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 Calgary1,2 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
- Kurtz SM, Silverman JD, Draper J. Teaching and Learning Communication Skills in Medicine. Oxford: Radcliffe Medical Press, 1998
- 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
