Abstract
Summary box
Effective preparation before consulting replenishes energy and saves time – there are two key skill sets: ○ Preparing yourself to consult effectively ○ Preparing your understanding of the next patient Some clinicians plunge straight in, omitting these processes – this can lead to poor focus or concentration, misunderstandings, duplications or forgotten information
Introduction
How do some consultations start off badly? ‘What if’ questions or intrusive second thoughts (‘Did I get that wrong?’) may result from uncertainty. Feelings about distressed or angry patients may ‘hang over’. Perhaps you were not aware of a recent new diagnosis. It always takes more effort to put something right. Such issues build up and the day becomes draining. An effective beginning to the consultation sets the tone, builds trust and ensures the right direction overall, improving clinical accuracy and saving time.
Summary of the skills you need
Prepare yourself to work effectively before the consultation by
‘Letting go’ of the previous consultation Specific breathing methods Specific thoughts Physical actions Being ready for the next patient with a systematic examination of their notes Situational awareness skills
Preparing yourself to consult effectively
Effective consultation skills, combined with good self-management skills, mean consultations require less effort. These ‘housekeeping’ skills enable clinicians to care for themselves and maintain composure (Neighbour, 1987). Adequate sleep, good food and healthy exercise are essential, as are sustaining personal interests and social relationships. However, unwinding after every consultation ‘resets’ the mind and prevents the emotional drain when things ‘hang over’, so that clinicians maintain energy and can fully listen and respond to their next patient (see TALC, Teaching and Learning Consultation skills).
Possible unwinding methods
Identify one good thing that happened in the previous consultation and then decide to ‘let go’. Note anything you need to look up or reflect on, to do later, clearing the way for the next patient Other basic strategies include pausing for refreshment, connecting with colleagues in positive ways, varying tasks and pacing yourself Try a calming breathing exercise such as ‘box breathing’. Breathe in for a count of four, hold the breath for a count of four, breath out for a count of four and hold the breath again for a count of four. American soldiers do this in stressful situations because it activates the parasympathetic system, with a calming and refreshing effect on the mind Find something of exquisite beauty to notice every day, perhaps a child’s smile, or something personally meaningful like a piece of jewellery or a treasured photo Note something that you are grateful for today; ‘Thank goodness I work indoors instead of outside in this storm’ Stand up and move around, shake your arms and stretch; all movement helps to regenerate energy Remember the deeper meaning and purpose of our work; the core values that drive us, help maintain focus and energy
Preparing your understanding of the next patient
Reading the notes fully before the consultation might seem time consuming when busy. However, being prepared inevitably saves time in the long run, especially if you are new to the patient. In primary care, there is always useful information available. All patients have interpretable demographic information, previous notes, prescriptions or summaries. Reviewing this information avoids obvious traps, for example, a major health condition or social issue. ‘You must complete this course of Amoxicillin’ … ‘actually I had a bad allergic reaction to that 3 months ago’.
Develop a system for checking the patient’s problem lists, medication, recent consultations, letters and results to avoid this kind of awkwardness, which also wastes time. Practice doing this with every patient. Develop the skill-set called ‘situational awareness’ (Danczak et al, 2016; Parush et al, 2011), which includes:
‘Monitoring the baseline’ – what is usually happening? What is different now? What pre-existing conditions and medications are present? ‘Being aware of our bias towards normality’ – instead of assuming all is fine, highlight subtle alerts, for example, a second or third consultation about an apparently uncomplicated upper respiratory tract infection. ‘Avoiding excessive focus lock’ – we attend to selected aspects, ignoring others, for example, noting a history of tiredness and depression, ignoring the chronic loose stools
Being prepared impresses patients, reduces errors and releases energy and confidence for the clinician with increased satisfaction for both parties.
Putting these skills into practice
Dr Ripon’s first patient was furious about a recent outpatient visit, struggling with their secondary cancer and wanted better pain relief. Dr Ripon felt a bit overwhelmed so afterwards did some box breathing, noting a learning need about handling angry patients. A holiday photo highlighted gratitude for their own excellent health. After reading the next patients notes, they were ready to explain the implications of a recent chest X-ray result.
What about the end of the consultation, if the patient says, ‘thank you, now there are some other important things I need to discuss’? The skills of agenda setting help here. The article in this series ‘How is a consultation like a business meeting?’ will outline the skills needed to plan consultations effectively.