Consultation Models in General Practice

The consultation is the cornerstone of general practice and is a vital part of the doctor-patient relationship. Pendleton described the consultation as ‘the central act of medicine’, which ‘deserves to be understood’. It remains an integral part of most medical school curriculums and is taught in depth as part of most vocational training schemes for trainee General Practitioners.

The consultation also features in the MRCGP curriculum in ‘Contextual statement 2.01: The GP consultation in practice’:

For the competence area of Primary Care Management, Learning Outcome 1.1 lists the knowledge required of a GP. In particular, GPs should:

Understand the common models of the consultation that have been proposed and how [they] can use these models to reflect on previous consultations in order to shape [their] future consultation behaviour.

Use the skills typically associated with good doctor/patient communication

For the competence area of A Holistic Approach, Learning Outcome 6.4 describes some of the attitudes required of a GP. In particular, GPs should:

Show a holistic approach, and understand that consultations have a clinical, psychological and social component, with the relevance of each component varying from consultation to consultation (the ‘triaxial model’)

For the Essential Features of the GP, Essential Features 2.3 details the attitudinal features required; in particular, the ability to:

Recognise, manage and monitor [your] personal emotions arising from the consultation

Essential Features 3.5 describes the scientific features required of a GP; in particular:

Undertaking self-appraisal through things such as … video recordings of consultations, and seeking out opportunities for your educational development based on this.

The consultation has evolved considerably over the years, with several different models being proposed, each with its own merits.

Balint – ‘The Doctor, His Patient, and the Illness’

Balint published ‘The Doctor, His Patient, and the Illness’ in 1957, and this was a groundbreaking piece of work at the time that changed the landscape for consultation in the primary care setting. It gave an insightful view into the emotional aspects of the doctor-patient relationship.

Key points highlighted by Balint included:

The concept of taking a wider bio-psychosocial view in the history taking process.
The importance of active listening to enhance the understanding of the patient’s view.
The concept of a ‘ticket of entry’ being the key to discovering the patient’s ‘hidden agenda’.
The observation of the ‘doctor’s apostolic function’, which incorporates the doctor’s own beliefs about how patients ought to behave when ill, how they should behave with doctors and how they should co-operate with their cure.
The idea of the ‘doctor as a drug’ where the doctor themselves can be a powerful medication.

Berne – ‘The Games People Play’

Berne published ‘The Games People Play’ in 1964. One of the key concepts of this publication was a theory of social interchange called ‘transactional analysis’.

This theory proposed that anything that happens between two or more people can be broken down into a series of single transactions from a specific ego state. Berne named three ego states, the Parent, the Adult and the Child.

The Parent is an authority figure that can be critical and caring. The Adult is logical and autonomous and tends to regulate and mediate between the other two states. The Child demonstrates relics of childhood behaviour and is intuitive, playful and spontaneous.

At any one point during a ‘transaction’, a person will be acting as one of the three ego states, but they will shift through a spectrum of each ego states over a period of time.

Berne noted that many consultations are conducted with a Parental doctor and a Child-like patient, but that this transaction is not always in the best interest of either the doctor or the patient.

Byrne and Long – ‘Doctors Talking to Patients’

Byrne and Long published ‘Doctors Talking to Patients’ in 1976. It was based on research that took place in the General Practice setting analysing verbal behaviours in tape recordings of doctors in consultation with almost 2500 patients.

The study by Byrne and Long recognised six phases by the doctor in the process of the consultation:

Establishing a relationship with the patient
Discovering their reason for attending
Conducting a verbal and/or physical examination
The doctor, patient or both consider the condition
The doctor (and sometimes the patient) detail further investigation and treatment
Ending the consultation

Stott and David – ‘The Exceptional Potential in Each Primary Care Consultation’

Stott and David published ‘The Exceptional Potential in Each Primary Care Consultation’ in 1979. This was a theoretical framework in which they described four areas that could be profitably explored in routine surgery consultations and also used for teaching purposes.

These four areas were:

Management of presenting problems
Modification of help-seeking behaviour
Management of continuing problems
Opportunistic health promotion

Helmen – ‘Culture, Health and Illness’

Helmen published ‘Culture, Health and Illness’ in 1984.

He suggested that a patient with a problem comes to a doctor seeking answers to any number of the following six questions:

What has happened?
Why has it happened?
Why has it happened to me?
Why now?
What would happen to me if nothing were done about it?
What are the likely effects on other people if nothing is done about it?
What should I do about it?

Pendleton, Schofield, Tate and Havelock – ‘The Consultation – An approach to Learning and Teaching’

Pendleton, Schofield, Tate and Havelock published ‘The Consultation – An approach to Learning and Teaching’ in 1984. This is now widely referred to as the ‘Pendleton’ model of the consultation. It was updated and revised in ‘The New Consultation’ in 2003.

This model described seven tasks, which taken together form comprehensive and coherent aims for any consultation:

To define the reason for the patient’s attendance
To consider other problems
To choose an appropriate action for each problem with the patient
To achieve a shared understanding of the problems with the patient
To involve the patient in the management and to encourage the patient to accept appropriate responsibility
To use time and resources appropriately
To establish or maintain a relationship with the patient which helps to achieve other tasks

Roger Neighbour – ‘The Inner Consultation’

Roger Neighbour published ‘The Inner Consultation’ in 1987. He outlined an easy to remember five-stage model that was easy to remember and followed the natural flow of the consultation.

The five stages are:

Connecting
Summarising
Handing over
Safety netting
Housekeeping

Neighbour also identified a three-stage pathway to improve consultation skills:

Goal setting
Skill building
Getting it together

The Calgary-Cambridge Observation Guide to the ‘Medical Interview’

The Calgary-Cambridge Observation Guide to the ‘Medical Interview’ was published in 1996 by Kurtz, Silverman and Draper. It is commonly used in the education of both medical undergraduates and GP trainees.

This model is based on ‘a patient-centred approach that promotes a collaborative partnership’ and includes five main tasks within its framework: