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Regardless of how much knowledge the RCGP curriculum requires GP trainees to have, good consulting skills continue to be a vital part of general practice. It is our communication with patients that allow them to build a rapport and trust us as clinicians.
There are many historic consultation models and individual trainees will probably have their preference on which one they tend to favour.
RCA exam
There are, however, probably some key generic skills that trainees need to be able to demonstrate to do well in their RCA exam.
The consultations need to be fluent despite the potential of uncertainty through lack of knowledge of undifferentiated symptoms, relevant to the presentation of the patient, and interactive i.e., adopting a shared consultation style with the patient as a partner. The doctor should be able to monitor the feel and direction of the consultation as it progresses.
Identifying strengths and weaknesses
The best way to prepare for the RCA is by experiencing general practice and seeing patients. Using evidence and feedback from previous workplace-based assessments (including CBDs and COTs and audio COTs) and general feedback from hot reviews from the educational supervisor can be a good starting point.
Recording videos of consultations and reviewing with GP trainers is a very good way of judging consultation skills and observed clinics can also be useful. This allows GP trainers to give feedback on specific areas which are likely to be assessed as part of the RCA.
Key skills to focus on
Although the marking scheme for the RCA might be specific to ensuring GP trainees have covered areas to pass the exam, it is a good reminder of the elements of a good consultation. Being divided into 3 areas, the skills required are:
- Data gathering – takes a focussed and safe history eliciting relevant information, rules in or out significant disease and considers appropriate diagnoses, explores the psychosocial context of the problem, explains, and performs examinations where needed, and recognises the priorities in the consultation.
- Clinical management skills – makes safe diagnoses and offers appropriate and safe management options, any prescribing or referrals are evidence-based, uses time and resources well, provides realistic safety netting and follow up advice depending on the nature of the consultation.
- Interpersonal skills – encourages contribution by the patient by exploring the patient’s agenda, health beliefs and preferences and responds to any cues, conducts examinations sensitively and with consent, provides explanations in a patient-centred way that are understandable and allows and encourages patient’s to be involved in management decisions to reach a shared understanding.
Other generic considerations are use of open questions initially followed by closed questions, building rapport, using a holistic approach to care, showing signs of active listening, allowing the initial ‘golden minute’ for the patient to speak, and allowing space and time for that.
Tips on remote consultations
When consulting remotely, we need to be aware that there is a higher element of risk as we do not have the ability to ‘eye-ball’ the patient or take observations or examine them. We should therefore be extra diligent to listen for any cues.
Anecdotally, a patient who makes comments like ‘I’m not sure I can wait until then’, or ‘I’m very concerned’, or I’m not sure it’s easy to explain over the phone’, or ‘I feel quite unwell to be honest’ are probably hints that they’d prefer to be seen face-to-face.
We need to be more cautious about covering all red flags and in more detail than we might if we were seeing the patient face to face.
A good introduction to check who they are and whether they’re able to talk is important. Sometimes, offering to see a patient or making sure they’re content with just a phone call can be a good way of compromising.
It is very important to make sure patients are satisfied with the consultation at the end of the phone call and allowing them to end the phone call ensures that they felt in a position to finish.
Tips on face-to-face consultations
Having spent such a long time dealing with many consultations remotely, it is important sometimes to remind ourselves of certain examinations and to continue to keep our skills updated. Even if we’re likely to see the patient in-person, taking the history over the phone in its entirety allows the face-to-face appointment to be focussed just on examining the patient.
Plans can be changed if needed once the patient has been examined but as we know, the history will often give us most of the information we need to decide a management plan. Face-to-face appointments can either be offered on the same day or into the future (allowing flexibility for the patient can be helpful).
- Dr Anish Kotecha is a GP and GP trainer in Gwent, south Wales
