CHAPTER 1
The Consultation

Frank Coffey and Dianne Bowskill

LEARNING OUTCOMES

By the end of this chapter the reader should be able to:

• recognise and analyse the important elements of a consultation
• identify the components of the traditional medical history
• appreciate the diagnostic process and distinguish between the treatment of symptoms and the treatment of a disease or condition
• identify the elements of the consultation essential for safe prescribing (bottom liners)
• refine their professional assessment/consultation for the prescribing role
• have insight into the impact of technological advances on assessment, diagnosis and treatment.

As you begin your prescribing education you already have a wealth of professional experience in your own area of practice. The assessment and consultation skills learnt as part of professional registration are well practised but may need to be refined as you take on prescribing. We are not suggesting that you need to adopt a new or medical model of consultation, although this might be desirable in certain advanced practice roles. For the majority of new prescribers, the focus will be on analysing their current framework of assessment or consultation and identifying adaptations required to support prescribing decisions. In this chapter we will ask you to think about the elements of the consultation that you may need to adapt or work on. We will give practice tips and point out common errors that can affect the quality of a consultation.

Prescribing inherently brings with it a greater requirement to make a diagnosis. This responsibility may be new and quite daunting. Prescribers need to understand the diagnostic process. In most circumstances, the key factor for accurate diagnosis is eliciting a good history. For this reason, we will look in detail at the elements of a history. Examination and investigations are directed by and supplement the history. The depth and focus of the history and examination will vary depending on the setting and your role. Wherever you work, however, it is essential to be thorough and systematic, and above all to know the bounds of your competence. History taking, examination and clinical decision making are skills that need to be continuously practiced under expert supervision.

Ideally your prescribing will be effective, but above all it should be safe. The primary dictum of all healthcare practice is 'primum non nocere' (above all do no harm). We will outline the elements of the consultation that are essential for safe prescribing, the 'bottom liners' of a prescribing consultation.

In the final part of the chapter, we will explore the potential impact of technological and scientific advances on assessment and clinical decision making and outline the increasing emphasis on health improvement and prevention in consultations.

THE CONSULTATION

The consultation is a two-way interaction between a healthcare practitioner and a patient. Your role will influence the types of patients you treat, the environment in which you see them and your approach to the consultation. As a non-medical prescriber your focus is on diagnosis. Assessment for diagnosis in a typical consultation comprises the history, examination and investigations. Factors to consider include the urgency and seriousness of the presentation, time constraints and the personalities, culture, language and medical knowledge of both the patient and the clinician. Previous contact with the patient, autonomy, and confidence are further influences on the consultation. Communication and consultation skills are inextricably interlinked. There are many excellent textbooks available for prescribers who wish to enhance their communication skills (Brown et al. 2016; Silverman et al. 1998; Berry 2004).

ELEMENTS OF A CONSULTATION

Although consultations differ in specifics, there are common elements and generic skills that are applicable in varying degrees to any given situation. Numerous consultation models have been developed over the years, for example Neighbour (2005), Pendleton et al. (2003) and Calgary Cambridge in Silverman et al. (1998). Rather than dwelling on the theory underpinning consultations, we will describe a practical framework for the consultation (see Box 1.1). This includes an assessment component (see I to (j) in Box 1.1) and other elements which can be applied in varying degrees to all consultations.

It is important for consultations to have a degree of structure. The skill in consulting is to maintain a structure and system that includes all the vital elements and yet does not feel like a straitjacket for the patient or clinician. In the following section we will analyse the different elements of the consultation in more detail and highlight those that are likely to change or need more emphasis for you as you take on prescribing.

BOX 1.1 ELEMENTS OF A CONSULTATION

1. Preparing for the consultation and setting goals for it.
2. Establishing an initial rapport with the patient.
3. Identifying the reason(s) for the consultation.
4. Exploring the patient's problem(s) and ascertaining their ideas, concerns and expectations about it.
5. Focusing questions to obtain essential information.
6. Gathering sufficient information relating to the patient's social and psychological circumstances to ascertain their impact.
7. Coming up with a diagnosis or a number of differential diagnoses in order of likelihood.
8. Performing a focused physical examination and near-patient tests to support or refute the differential diagnoses.
9. Reaching a shared understanding of the problem with the patient.
10. Interpreting the information gathered and re-evaluating the problem.
11. Considering further investigations if necessary.
12. Deciding what treatment options, pharmacological and non-pharmacological, are available.
13. Advising the patient about actions needed to tackle the problem.
14. Explaining these actions and the time of follow-up if required.
15. Inviting and answering any questions.
16. Summarising for the patient and terminating the consultation.
17. Making a written record of the consultation.
18. Presenting your findings to another health professional.

STOP AND THINK

Using Box 1.1 as a framework, reflect on your current consultations and identify elements you are less confident with. Make a note of these to inform learning and development needs.

(A) PREPARING FOR THE CONSULTATION AND SETTING GOALS

Take time to study all the information available to you about the patient prior to the consultation. Study referral letters and available medical records for vital information, including the patient's past history, medications and allergies. Set goals for the consultation and ensure that the environment is set up appropriately with adequate lighting and privacy.

(B) ESTABLISHING THE INITIAL RAPPORT

First impressions are especially important and will influence your subsequent relationship with the patient. If you have not encountered the patient before, introduce yourself by name and explain your role. Check the patient's details (name, date of birth, address). Observe the patient's demeanour and physical appearance. The patient will invariably be feeling nervous. Put them at ease by projecting confidence and warmth, and they are more likely to open up to you during the consultation.

(C) TO (G) HISTORY TAKING/DIAGNOSIS HYPOTHESIS

Elements (c) to (g) in Box 1.1 are primarily concerned with the taking of a history and the consideration of differential diagnoses. The importance of the history cannot be overstated. In the vast majority of cases (>70%) the history will provide an accurate diagnosis or differential diagnosis even before the examination and investigations are performed. A good history will therefore facilitate effective prescribing. Certain minimum information must be elicited to ensure safe prescribing,

The history is a two-way process. In reality, we do not 'take' a history. Rather, we 'make' a history with the patient. The result is influenced by both the practitioner's and the patient's prior knowledge, experiences and understanding of language. Where understanding of language is a barrier, clinical risk is significantly increased and an interpreter should be considered. There are psychodynamic processes at play during any consultation which the practitioner needs to be aware of. These are explored in detail in other publications (Berry 2004).

The scope and depth of the history will depend on the role of the practitioner and the circumstances surrounding the consultation. Whatever the nature of the history, it is essential to be systematic and as far as possible follow the same sequence of questioning each time. In this way vital information will not be overlooked. This becomes particularly important when the patient has multiple symptoms and/or a complicated medical history.

Most patient histories will contain some or all the elements of a traditional medical history. This structure has limitations and has been criticised for being practitioner...