BJGP Long Read: How to enjoy your consultations

Julian Marsden has been a GP in Luton for 33 years. He is FRCGP, Provost of the Beds & Herts Faculty, and is a retired Training Programme Director for the Luton GPSTP

I’ve been a GP for over 30 years, but I still enjoy what I do. As others around me take early retirement, I sometimes ask myself why I still enjoy the job and keep doing it. For me, it’s the interaction with patients, getting to know them, forming and developing a relationship where we can feel comfortable, doing something useful and sharing some humour where I can.

The GP consultation is at the heart of what the GP does. It’s the best bit, sitting with and getting to know your patient and their problems and trying together to find a way forward. Anything and everything can come the way of the GP, which makes it all the more interesting, and we have the opportunity to see our patients again and get to know them, even if only a little, and this is fun and rewarding for both; continuity of care is much valued and a strength of general practice.

It helps, of course, to be able to consult effectively, and I learned from Roger Neighbour’s Inner Consultation, the Calgary-Cambridge Guide by Silverman, Kurtz and Draper, and others, such as The Anxious Patient by Bendix and Peter Tate’s The Doctor’s Communication Handbook. Listening to the advice of many GP luminaries such as Roger Neighbour himself, Jonathan Silverman, David Haslam and others helps reinforce important messages.

Developing consultation skills goes on throughout one’s career and if you didn’t make time to read those consultation texts during your training, why not make time afterwards? The last textbook I read on the subject was Neighbour’s Inner Physician, an excellent and thoughtful book giving rich insight into how we consult but at a deeper level than a consultation guide, exploring some of the perceptual skills and developing an awareness of what we are thinking and feeling and how this might be useful during the consultation.

There is so much good advice out there and it can seem daunting to distil this into a simple guide. This isn’t a consultation guide; instead it encapsulates some of the things I have learned over many years; it is what I do. There might be one or two ideas that may be useful to you.

Simple advice is easier to remember, however. David Haslam spoke about his four rules: Shut Up, Listen, Do Something Useful, and Care. I love that, so simple, succinct and so true. Roger Neighbour talks about the patient’s bit, then the doctor’s bit, then the shared bit. Again, so simple but so true; the shared bit reminds me about shared understanding and shared management plans.

Before I start, I try and look at the patient record. This may take less than a minute so it’s perfectly feasible. Patients will often assume that you know everything in their records even though in reality you haven’t had 20 minutes to read all the letters! But a brief look at the summary and problem list and the previous consultation is time well spent. The repeat prescription list gives a quick clue and if full of cardiac meds then you know they have a cardiac problem, for instance. I like to put something personal about patients that is easily seen, such as in the reminders section. This might be only visible to you, so you can mention the name of their spouse, if they have children, what they do for a living, what they do at other times such as sport or other hobbies, or what they are studying or hoping to do in their future career, or their favourite football team.

I add this stuff after the consultation and it can be read with a second’s glance before they come in. The personal details might be relevant in the consultation, but if not can be a basis for friendly conversation at the end of the consultation, which is fun and all part of developing rapport which helps next time you see them. It is difficult to achieve the continuity that GPs had in the past, as we usually work in teams nowadays and not necessarily full-time, but a brief mention of something in the personal section helps the patient feel known as a person. This helps with the “Getting to know your patient” and I think it makes a big difference.

Rapport is so important. The initial smile and greeting are crucial. With small children, I usually focus on the parent with my best attempt at a warm smile, as if Mum is happy and welcomed and at ease, the child will sense this and hopefully relax a little. Expressing delight in a coloured pair of socks or the design on a T shirt is a helpful distraction though this is reserved for small children as adults might give me a funny look! I still wear cartoon ties, even though they went out of fashion 20 years ago; but it is one way I have of not taking myself too seriously and helping my younger patients feel a little more relaxed, especially if they’re two years old and frightened of doctors.

We have all heard about the golden minute, whereby, if you allow the patient, most of the relevant information will emerge, so long as they are not interrupted. Or will it? Actually, we generally only elicit half the patient’s complaints and concerns. And the main concern may not be the first mentioned. Listening and watching carefully with full attention is key.

Listening carefully is crucial, and showing that you have listened equally so, whether for a complicated history or minor illness as subsequent reassurance will be more effective if the mother of a toddler with a cough and a temperature who ran smiling into the room may be worried nonetheless that something is really wrong. I once heard at a trainers’ seminar that as we have two ears but only one mouth, we should listen twice as much as we talk.

Caring, or compassion, and showing it, is so important for patients. We can be forgiven for a multitude of errors if we are nice about it. How to show compassion? That you care?

There are some simple things that I have found to help. After the patient has told you about their problem, acknowledge what they have said, so they know you have understood, then say something empathic. For example: “She’s been coughing all night and been burning up.” You might say something like: “That must have worried you?” or “And you’ve had no sleep either then?” it might be tempting to ask if her child is well-cooked, having been burned to a frazzle, but this doesn’t work.

I know a GP who welcomes his patients into his consulting room by standing up and, with arms wide, proceeds to hug them. I don’t do this. Touch can be powerful of course, and a light hand on your patient’s forearm can say a thousand words, but I don’t do this much either. Perhaps in a bereavement situation. David Haslam once said at a conference that elderly patients he saw on home visits appreciated it if he sat down. This sounds simple, but of course it shows clearly that he has the time and inclination to listen and not rush, as opposed to standing there and appearing impatient to get on.

I do know some doctors who stand throughout the consultation to encourage speed, but I don’t do this. I have heard that some doctors have a chair for the patient with a slope on the seat to encourage the patient to get up sooner, but I don’t do this either! At the beginning, I stand up, find the patient from the waiting room and smile and greet them. I usually say: “Hi, How can I help?” as I ask them to sit down, or after they have sat down. I try and observe the patient as they come in and a limp with a wince is a good clue or a worried expression will raise my antennae, for instance.

. If you allow the patient to talk, they will usually tell you why they have come to see you, what their problems are and why they may be concerned. Let them tell their story. Allow them to voice concerns and volunteer ideas. Open questions facilitate this. It is important to let your patient know that you have heard and understood what they have said, and a simple summary spoken back to them helps. If you don’t, they may keep repeating themselves and feel frustrated. A simple summary allows the patient to feel understood and then allow the consultation to progress; or it may allow the patient to mention something else which may be important.

This is part of agenda setting and where appropriate, a negotiation about what can be covered first, second etc and what can be deferred if need be. “X sounds important and Y also so shall we deal with those first and see how we get on?” is better than “I only have 10 minutes, so may not have time to deal with….”. Then I ‘go with the flow’, where the consultation goes naturally, exploring and clarifying, sharing thoughts. Structure of the consultation is important but so is flexibility. Drilling down to clarify issues can involve closed questions but avoid these early on. Some local knowledge helps: the word ‘flu’ in Luton means a runny nose, nothing more, nothing less. Eye contact, posture and facial expressions are some of the non-verbal techniques we use to facilitate communication and staring at the computer does nothing to promote engagement with the patient.

Exploring ideas, concerns and expectations is a mantra distilled into us as trainees and of course is important; but this can be done naturally rather than in a formulaic way, if and when it feels appropriate. Being curious about the patient’s experience is key. How their symptoms affect them, what they mean to them, gives a deeper understanding. Patients are often just as interested in what the problem is, why it has happened and what is likely to happen, as any solutions I might try to suggest.

I usually examine my patients whenever this is clinically appropriate. I don’t know how I am supposed to know if someone’s pain is lumbar, hip or trochanteric for instance, if I don’t examine them. It surprises me when patients say that this is the first time that they have been examined in such a situation. The laying-on of hands is something we are allowed to do in our privileged role as doctors, and it can be a powerful way of reassurance, and helping the patient feel that they are being taken seriously and it may be clinically useful too, of course.

Has examination of the patient gone out of fashion? I usually explain what I am doing as my patient might not realise. A close relative had to be examined by a Professor in London, and he lifted up her top without warning and exclaimed: “It’s hard to tell anything through this flab!” She was not impressed. In fact, she felt humiliated. Any kind of examination is an invasion of privacy and potentially embarrassing for the patient. They’ve probably decided to wear their best underwear if they think they need to be examined, and it’s important to be respectful and considerate and put them at their ease.

A bit of humour is fine. “You can take alcohol with those antibiotics if you wish, but no lager, it must be real ale!” Or if you support Arsenal you might need a stronger antibiotic! Nowadays, more often than not, the patient says they don’t drink alcohol. Or, when doing a urine dipstick test, I might comment that it looks like a chardonnay. I suppose others might suggest a darjeeling tea.

Summarising is important as it draws issues to a close, and it also allows the patient to feedback their ideas and concerns, particularly if I have missed something. This is part of shared understanding and a mutually agreed way forward can follow. Summarising is a useful technique if I feel lost as it allows me to collect my thoughts openly and the patient or I might choose to change direction. If the patient doesn’t buy into the plan, then they won’t agree to follow the plan.

The consultation may last only ten minutes and I am there to help my patient and they will decide at the end of the day whether they choose to take the tablet I have prescribed, or engage with a counsellor, or make lifestyle changes or whatever we have agreed. The patient is a partner in the consultation and they need to be involved in decisions. If I were in my patient’s shoes, would I follow my advice? A shared management plan involves respecting the patient’s autonomy. Sometimes I find some personal disclosure helpful. I don’t try and force statins on patients, but I might say that I take them myself and the conversation becomes more adult to adult than parent to child as we look together at the computer’s 10-year risk estimation and weigh up what it really means.

One of the fun bits of general practice is getting to know your patients as people. This fosters some brief conversation beyond what they came about. If I know my patient follows Arsenal, for instance, I might bemoan the fact that they always seem to win against my team, Everton. If they follow Watford or Southampton, then the reverse applies; all good fun. Knowing that a young person is embarking on a degree course, previously recorded in the reminders section seen only by me, then I can enquire about their progress. The little bit of informal conversation may help them to see their doctor as a human being who has a genuine interest in them and that seems to me to be a good thing.

Closing the consultation seems to be a challenge for some trainees. This is problematic if you haven’t dealt with the patient’s problems and an unwillingness to leave the room is a sure-tell sign. Sometimes the patient might not leave because the prescription is still sitting on the printer and they have to remind me to sign it and give it to them. Memory lapses can affect doctors too.

Building rapport, connecting, establishing a relationship, knowing your patient as a person, all this sounds like jargon, but it is at the heart of being a GP and the bit that I enjoy. Trying to understand what it feels like to be a distressed teenager, a young parent with an ill child, or someone who has been bereaved. Knowing that my patient was widowed a year ago allows me to make a gentle enquiry as to how they are getting on, sometimes almost unsaid but communicated simply, that reaching out from one human being to another, is the stuff of general practice.

Featured photo by Natasha Kasim on Unsplash