The best way to use consultation models is to read them all, see which you like and take the best out of each to develop your own model.
Consultation models are not rules; they are learning aids to help you develop your own consultation skills. Having your own model ensures you have an internal guide to draw on during the consultation to achieve the best outcome for your patient. It also means you have a range of different techniques to use in difficult consultations.
Consultation models are also a great way to help prepare for the clinical skills assessment (CSA). One of the six blueprint areas tested in the CSA is a person-centred approach using recognised communication techniques that enhance understanding of a patient's illness and promote a shared approach to managing problems.
The following summary includes the models that I believe are the most useful with a brief explanation, highlights and questions to use in consultations.
Helmann's Folk model, 1981
This model sees the consultation entirely from the patient's perspective using a series of questions such as: 'what has happened?' and 'why me?'
- This model centres on the patient's story using empathy to address the patient's questions.
- Empathy is first recognising the patient's distress and secondly expressing the empathy. Statements to demonstrate empathy include: 'I can see how sad/frustrated/angry/frightened/upset you are.'
Pendleton et al, 1984
This seven task patient-centred model consists of defining the patient's true agenda, considering other problems, choosing an appropriate action for each problem, achieving a shared understanding, using time and resources appropriately and establishing and maintaining a relationship with the patient.
- Pendleton advises drawing out whether there are any other problems early on in the consultation.
- This model introduced the concept of eliciting the patient's ideas, concerns and expectations.
- Questions to try include: 'Was there anything else you were hoping to discuss today?', 'What is your main fear/worry/concern about this problem?' and 'What were you hoping to get out of today?'
Neighbour (The Inner Consultation), 1987
This uses the five checkpoints of connecting, summarising, handing over, safety netting and housekeeping alongside an awareness of 'minimal cues' (verbal and non-verbal) to help discover the unspoken agenda.
- Summarising is a useful tool to clarify your understanding of the problem. It can be an effective strategy if you feel that the consultation is stalling. Summarising both the events and the emotional content is a useful way to demonstrate empathy.
- This model outlines safety netting where the doctor and patient plan together to manage uncertainty. Use a specific time frame, for example 'come back in two weeks if it doesn't get better'.
- Questions to check understanding include: 'Could you tell me what you understand the problem to be so I can check I have explained it okay?'
Calgary-Cambridge Guide (Kurtz and Silverman), 1996
This model looks at the process of the consultation from initiating the session, gathering information, providing structure to the consultation, building a relationship, giving information by explanation and planning, and closing the session.
- A 71-point model and a useful template with lots of different consulting strategies.
- The section on explanation and planning is particularly helpful for looking at shared understanding and shared decision making.
- A question to aid shared decision making could be 'There are different management options you could try, these are... Which are you interested in?'
Using models in practice
To see what works for you try adding in a different question each week. I used a Post-it note with my 'question of the week' stuck on to my monitor so I would not forget, and the results were amazing.
I once said to a patient 'What do you think is wrong?' He was so impressed that I had asked him for his opinion that he sent all of his family to see me.
Another way to improve your consultation skills is to video your consultations and watch them. Ask your trainers and colleagues for feedback to identify what is working and what is not. In addition, watching others consult allows you to pick up questions they use to elicit information.
When you feel you have a system of questions that are working, memorise them so that you can use them if a consultation stalls or in your CSA exam. The more you practice, the more your model will become automatic so you can concentrate on what the patient is saying. If a consultation does become difficult you will have different strategies ready to get things back on track.
- Dr Carter is a GP in Lancashire and Yorkshire
1. Take the best out of the existing models and incorporate into your own model.
2. The Helmann's Folk model centres on the patient's story using empathy to address the patient's questions.
3. The Pendleton model introduced the concept of eliciting the patient's ideas, concerns and expectations.
4. The Inner Consultation suggests summarising throughout the consultation to clarify that your understanding of the problem is the same as the patient's.
References for Consultation Models
- Helmann CG. Diseases versus illness in general practice. J R Coll Gen Pract 1981; 31: 548-52.
- Pendleton D, Schofield T, Tate P, Havelock P. The Consultation: an approach to learning and teaching, Oxford, Oxford University Press, 1984.
- Neighbour R, The Inner Consultation, Lancaster, MTP, 1987.
- Kurtz SM and Silverman JD. The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organising teaching in communication training programmes. Med Educ 1996; 30: 83-9.
- www.skillscascade.com - A communication skills website
- http://e-lfh.org.uk/projects/egp/index.html - E-learning for general practice consultation skills modules.