GP training: Structuring the consultation in the CSA exam

This article should be read in conjunction with the article Preparing for the CSA exam.

The structure of your consultation is essential for a successful outcome in the CSA and also in real practice. Cambridge Calgary^1,2 is a widely accepted model of safe efficient consulting, so putting this into practice from an early stage of your rotation is essential.

Below are some tips on how to structure a consultation during the CSA exam.

Starting the consultation

• Introduce yourself.
• Use open question e.g. 'What are we doing today?' or 'Why have you come in today?'
• Allow the patient to 'tell their story'. Early interruptions could lead to missed cues and a catastrophic breakdown in the doctor-patient relationship.
• An empathetic statement after this (if appropriate).
• Summarise at this point.
• Agenda set. Check if patients have come about anything else at this point. This will hopefully avoid the dreaded 'oh and by the way, doctor'.
• Signpost as to how the consultation will progress.

Data gathering

• With the agenda set and your relationship with the patient having started, the history taking process can begin.
• Ensure a good mix of open and closed questions are used. One approach is to use an open to closed cone. Start with open questions i.e. 'you mentioned headache, tell me a bit more about that' and close it down as appropriate. This may be important for example when trying to establish the aetiology of a specific type of pain.
• Avoid leading questions.
• Echoing the patients’ own words shows that you have been listening.
• Ensure that red flag symptoms are covered.
• Risk assessment is critical for psychological cases.
• Ensure full exploration of patients’ social circumstances if relevant.
• Ideas concerns and expectations are vital.

Examination

• Conduct a focused physical or mental state exam

Explanation

• Find out what the patient already knows.
• Tell the patient what you think the diagnosis could be.
• Avoid jargon and use diagrams where appropriate.
• Chunk and check.

Planning

• Give the patient options if appropriate. This generates a shared management plan. The patient's ideas, concerns and expectations will be crucial at this point.

Final check and closing

• Ask the patient to recap the important points of the consultation.
• Appropriate safety net with specific red flag symptoms to look out for.
• Specify follow up.
• Provide any relevant patient information leaflets.

Learning points

• Ensure that the agenda is set early.
• Always be alert to verbal and non verbal cues.
• Good non-verbal communication is important.
• Familiarise yourself with a few consultation models.
• Try and avoid using the computer.
• Ensure you familiarise yourself with the patient's history, medication list, last few consultations and letters before you see them.

Dr Pipin Singh is a GP trainer in Northumberland

References

1. Kurtz SM, Silverman JD, Draper J. Teaching and Learning Communication Skills in Medicine. Oxford: Radcliffe Medical Press, 1998
2. Silverman JD, Kurtz SM, Draper J. Skills for Communicating with Patients. Oxford: Radcliffe Medical Press, 1998

Useful resources on GPonline

• CSA practice case - Patient smells of alcohol
• CSA practice case - Pruritus in pregnancy
• CSA practice case - Low mood in a menopausal patient
• CSA practice case - Patient requests specific medication
• CSA practice case - Patient presents with a list of problems

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