Navigating the consultation

At the core of general practice is the consultation. 

In its simplest form, the consultation can be regarded as the sharing of information between patient and doctor in order to facilitate both a common understanding and a plan of management.

It has been estimated that a full time GP will undertake over 200,000 consultations during their career! With the potential to encounter upwards of 10000 individual diagnoses. But while we will never know all the clinical stuff, an effective, organised, and time-efficient consultation will go a long way to delivering quality patient care.

 Over the years, a number of models of the general practice consultation have been written up in the literature. In 1979, for instance, Stott and Davis described the ‘exceptional potential in each primary care consultation’.[i] Personally, I always found this is a bit over-optimistic and, if it had been me, I would have written about ‘the exceptional potential in most consultations, except perhaps on a Friday before a long weekend.’

Roger Neighbour, in his seminal textbook ‘The Inner Consultation’[ii], theorised that the general practice consultation was ‘a journey, not a destination’. He proposed five ‘checkpoints’ along the way:

• Connecting – Have we got rapport?
• Handing over – Have we agreed on a management plan?
• Safety netting – Have I covered the ‘what ifs’?
• Housekeeping – Am I in good shape for the next patient?

More recently, Murtagh stated that the objectives of the general practice consultation are to:

• determine the exact reason for the presentation
• achieve a good therapeutic outcome
• develop a strong doctor-patient relationship.[iii]

But more recently I came across an article that described a new framework for the GP consultation – ‘the consultation hill’. [iv] In it, the author analogised the consultation as a hill to be climbed, (discovering the reason for attendance and defining the problem), summited (sharing understanding), and descended (providing an explanation and managing the problem). He mentions variable gradients and terrain, but, disappointingly, doesn’t recommend appropriate footwear or the need to carry an emergency beacon.

It made me think of the variety of other geographical landforms that could represent the navigational challenges of day-to-day general practice. 

How about the ‘Grand Canyon’ consultation, which commences from a vertiginous height while perusing the last consultation notes, and then a precipitous plummet into the patient’s issues (sometimes in the corridor on the way to the consultation room). The steep climb out the other side can be just as challenging.

I not infrequently experience ‘Jenolan Cave’ consultations. These speleological expeditions involve a lot of fumbling around in the darkness, encountering dead ends, and being overwhelmed by a sense of feeling completely lost. But usually the proverbial ‘light at the end of the tunnel’ eventually appears, and the patient and I emerge into the daylight at the other end, albeit with skinned knees.

While some consultations feel like crossing the Simpson Desert — featureless and exhausting — others can feel like an amble through a wildflower meadow. In truth though, especially with our patients with chronic disease, our consultations add up to a traverse of the Alps — a long journey of ups and downs, occasional scree slopes and impassable streams, but interspersed with long stretches of gentle terrain. 

So, I reckon the topological model of the general practice consultation could potentially catch on, but I would suggest the authors broaden their scope. That said, it’s a crowded market in the consultation framework business and not every GP is into hillwalking, even if the blisters are metaphorical.

[i] Stott N, Davis R. The exceptional potential in each primary care consultation. J R Coll Gen Pract 1979. 29; 201: 201–205.

[ii] Neighbour R. The inner consultation: how to develop an effective and intuitive consulting style. 2nd edn. Oxford: Radcliffe Medical Press, 2004

[iii] Murtagh J. John Murtagh’s General Practice. 5th edn. Sydney: McGraw-Hill, 2010.

[iv] McKelvey I. The consultation hill: a new model to aid teaching consultation skills. Br J Gen Pract 2010. 60; 576: 538-540.