Consultation skills

https://www1.racgp.org.au/ajgp/2024/december/consultation-skill-tips-for-new-general-practice-r

🧱 STRUCTURED CONSULTATION FRAMEWORK

1. Preparing for the Consultation

Apply Neighbour’s ‘housekeeping’: look after yourself and mentally prepare.
Ensure physical space is clean and organised:
- Uncluttered desk
- Clean examination couch
Close electronic records of previous patients.
Review the appointment book at the start of the session.
Anticipate specific patient needs and prepare accordingly.

2. Connecting with the Patient and Building Rapport

Let patient speak uninterrupted initially.
Avoid distractions from the computer; signal when checking results.
Use Kalamazoo framework: prioritise “building the relationship”.
Employ core communication skills:
- Eye contact
- Active listening
- Open body posture
Use preferred name (ask and clarify pronunciation).
Identify and reference patient’s occupation and life events.
Overtly express empathy (e.g. “That must be really tough for you”).
Consider the BATHE technique for structured empathy.

3. Identifying the Patient’s Agenda

Use ICE (Ideas, Concerns, Expectations)

	Purpose	Key Questions
Ideas	Explore beliefs about the problem	“What do you think is going on?” “What do you think might be causing it?”
Concerns	Understand fears and anxieties	“What worries you most?” “Is there anything you’re particularly concerned about?”
Expectations	Clarify goals and agenda	“What were you hoping we could do today?” “What do you think might help?”

Listen for what is unsaid: tone, body language, facial expressions.
Be alert to hidden agendas through non-verbal cues.

4. Gathering Data (History and Examination)

Pause periodically to summarise what the patient said.
Rephrase to clarify understanding: “Let me know if I haven’t got this right…”
Clarify ambiguous terms (e.g. “dizzy”, “anxious”): “Can you describe what you mean by…?”
Use validated assessment tools (e.g. IPSS, DASS-21).
For physical exams:
- Ensure adequate exposure
- Consider checklists for specific encounters (e.g. baby checks, licence exams)

5. Managing Uncertainty

Use previously described techniques:
- Seek help
- Diagnostic pause
- Trust gut feelings
- Safety net
Use ICE questions to clarify ambiguous presentations.
Be alert to ‘uncertainty flags’ indicating when to seek supervisor support (e.g. ED referral, patient requests second opinion).

6. Explaining the Problem

Provide clear explanations of diagnosis and reasoning (‘the wrap’).
Use diagrams, lists, and patient handouts.
Consider health literacy:
- Use teach-back method to confirm understanding.

7. Management Planning

Engage in shared decision-making.
Use the ‘management pause’:
- Why this intervention?
- Risks and alternatives?
- Patient perspective?
Say: “I’ll have a quick think before we discuss a plan.”
Provide a written management summary (include meds, referrals, follow-up).

8. Follow-up and Safety Netting

Provide clear safety net advice:
- Explain purpose of tests and how to follow up.
- Warn: “No news is not necessarily good news.”
Reinforce when to return or seek further help.

9. Managing Time

Offer follow-up for unresolved issues.

Prioritise the agenda: manage ‘the list’.

Book appropriate length appointments; explain constraints.

Flag end of consultation (e.g. “As we’re nearing the end of the visit…”).

Consultation Stage	Practical Tips	Model Phrases / Notes
Preparing for the consultation	– Organise desk and room at start of day and between patients – Close all previous patient records – Review appointment book – Check patient history (previous encounters or parent of child)<br>- Review last visit, results, letters – Take a break after emotional consultations*
Connecting & building rapport	– Allow patient to talk for first minute uninterrupted* – Use appropriate expressive touch* – Minimise distractions from the computer — take intentional ‘time out’* – Use patient’s preferred name, and recall key personal details – Express empathy and connection	“Please excuse me while I look up your results” “That must be really tough for you”
Identifying the patient’s agenda	Ideas – Explore beliefs about the problem Concerns – Understand fears and anxieties Expectations – Clarify goals and agenda – Actively listen for key words (fear, frustration, expectations) – Observe non-verbal cues (hesitation, body language)	“What do you think is going on?” “What are you particularly worried about?” “Is there something else?”
Gathering data	– Summarise history to confirm understanding – Clarify vague or ambiguous terms – Use structured history tools (e.g., SOCRATES, COLDSPA) – Use validated assessment tools (e.g., DASS-21, PHQ-9) – Perform physical examination routinely* – Use physical exam checklists for specific complaints	“Please let me know if I haven’t got the story right …” “Can you describe what you mean by …”
Managing uncertainty	– Seek evidence or ask supervisor when unsure* – Use Murtagh’s diagnostic strategy (probable, serious, pitfall, masquerade)<br>- Take diagnostic pause to reflect – Use watchful waiting or follow-up for evolving symptoms* – Trust gut instinct (pattern recognition) – Document safety net clearly – Re-explore ICE in vague presentations	“I’m just going to take a moment to think this through”
Explaining the problem	– Discuss likely diagnosis and reasoning before offering treatment plan* – Address concerns raised in ICE* – Use diagrams, models or handouts to explain – Gauge and address health literacy – Check for patient understanding	“After listening to your story and examining you, I think that the most likely diagnosis is …” “I know you were worried about something serious…”
Management planning	– Use shared decision-making principles* – Involve the patient in treatment decisions – Use inclusive language (“we”) when discussing plans* – Pause to think before rushing into management* – Provide written plan if possible	“Where do you think we should go from here?” “I’ll just have a quick think before we make a plan”
Follow-up and safety netting	– Low threshold for review in unclear cases* – Call patient back if worried or unexpected result arises* – Document and communicate clear safety net advice* – Confirm receipt and review of investigations and referrals	“Please come back if you develop …” “Let’s review this in a few days to make sure it’s improving”
Managing time	– Identify and clarify the list of problems early* – Prioritise what is most urgent for patient and doctor* – Set expectations around time and number of issues – Offer a follow-up visit for remaining concerns* – Signpost time left in consultation	“What’s most important for us to focus on today?” “As we’re nearing the end of the visit…”

Telehealth-Specific Considerations

Subcategory	Best Practice
Confirm identity	Ensure you’re speaking with the correct patient.
Ensure privacy/confidentiality	Ask if patient is in a private space.
Use remote exam techniques	e.g., breathing sounds, movement tests via video.
Enhanced safety netting	Provide clear instructions on when to escalate or present in-person.
Face-to-face threshold	Be liberal with offering in-person review if clinical uncertainty exists.

📚 Consultation Models Referenced

Model	Description
RACGP 2022 Consultation Framework	Promotes structure, patient-centredness, safety.
Neighbour’s Five Steps	Connect, Summarise, Handover, Safety net, Housekeeping.
BATHE model	Background, Affect, Trouble, Handling, Empathy.
Roth’s ‘The Wrap’	Emphasises explanation of diagnosis and rationale before planning.

✅ Key Takeaways

Consultation skills are not intuitive—they need to be consciously developed and practised.
Structured frameworks help support consistency and safety.
Use model phrases, reflective pauses, and shared decision-making to enhance patient experience.
Ongoing feedback, supervisor support, and adaptation of consultation style are essential for registrar growth.

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