Consultation skills - Managing three-way consultations

If an extra person is involved in the consultation, it can hinder communication, says Dr Tillmann Jacobi.

An additional person in the room with you and the patient creates a three-way consultation. GPs can sometimes not even be consciously aware how often this happens every day and the implications it can have on the consultation. The extra person might act as an important facilitator or enhancer, but can also become a barrier to communication.

The most obvious cases are when parents bring a small child as the patient.

But other patients might also arrive with a family member, a carer or a companion when they have one of a range of disabilities, or have problems speaking or understanding English. This can be confusing when you are unsure of the relationship.

Clarifying the precise relationship between the patient and the third party is important because it may have a considerable impact on how you proceed and what you can and cannot say. This includes awareness of conflicts of interests or confidentiality.

There are two types of three-way consultations: planned and unplanned or unexpected.

A planned consultation means that the attendance of the additional person is foreseeable or was specifically arranged by you in special circumstances - for example, when you are going to break bad news to the patient.

An unplanned consultation means that it is not clear why there is someone else with the patient.

Confidentiality

A common example of this is when young adults, particularly those who are under 16, come in with a friend rather than a family member. It is important to establish the relationship in these cases or you could become drawn into very awkward and potentially legally problematic scenarios regarding confidentiality.

You must be clear who any third party that you might share information with is, especially if they are not the legally responsible parent or next of kin.

Similar caution applies if vulnerable patients come in with a friend, neighbour or colleague. It can be very difficult fully to understand the interests and intentions of all the parties in this case. Be aware that you cannot even be sure if the other person is coming in with the full and free consent of the patient.

Parent and child consultation

A challenging situation frequently faced by GPs is when fairly mature teenagers, who are still aged under 16, are accompanied by a parent.

This is likely to restrict your chances to explore complicated but common teenage issues, such as contraception, drugs, depression, suicidal thoughts and conflicts with other family members.

If an adult brings a child in with them for their own consultation, this may block any open discussion of serious or difficult issues in front of the child. You might suspect that an adult is purposefully using a child to protect him or herself from being challenged by you or to prevent difficult subjects being raised.

Assertiveness

When faced with an unplanned three-way consultation, there will be four main actions you could consider. You could try to integrate the other person, ignore him or her as much as possible, verbalise the challenge the situation poses to you or simply ask the extra person to leave the room.

You can also compromise by requesting to speak to the patient alone for the second half of the consultation.

However, sometimes it can be necessary for you to be assertive and prevent a three-way consultation before it starts. For example, some family dynamics, cultural understandings or other perceptions can result in more than one person trying to attend the consultation with the patient. This is guaranteed to become intimidating and highly impractical.

Try to be clear, relaxed and authoritative when you explain that the consultation cannot go on in those circumstances. Be honest about what, who and how many people you are willing to accept and when you want to set clear boundaries.

If a situation seems inappropriate to you, you should trust your instincts - you are most probably right in your assessment. An appropriate intervention from you will help to reach the most useful outcome for the patient.

- Dr Jacobi is a salaried GP in York. He qualified as a GP in February 2005

LEARNING POINTS

GPs must stay on top of three-way consultations

Clarify early on the precise relationship of the people in the consultation room and what information it is appropriate to share.

If a vulnerable patient comes in with a friend or neighbour, it can be very difficult to understand the interests and intentions of all the parties.

Parent-teenager consultations can be awkward as they may block open discussion or may prevent the child from being open about common teenage issues.

Parent-child consultations can block open discussion of grave or difficult themes in front of the child.

Remain in charge of the situation and be clear and relaxed when asking somebody to leave the room.

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