Five cards: a simple guide to beginning the consultation

Abstract

Although it is widely accepted that the doctor should allow the patient to speak freely at the start of the consultation, many doctors find it difficult not to interrupt, and tend to medicalise the patient’s presentation prematurely. To help overcome these tendencies we use a simple description of the consultation as consisting of three parts, according to who should be leading the dialogue at the time (Figure 1).1–3 The consultation begins with the ‘Patient’s part’, during which the patient has the freedom to express their pre-consultation experience (symptoms, problems) and thoughts (ideas, concerns, and expectations [ICE]). Next comes the ‘Doctor’s part’, when the doctor selectively gathers information relevant to the task of translating the patient’s narrative from ‘lay’ language into ‘medical’ constructs. Finally, in the ‘Shared part’, doctor and patient cooperate to arrive at plans and decisions acceptable to both of them. Figure 1. The three parts of the consultation. The patient will usually open with a condensed account of what the consultation is about, often including cues to associated feelings and latent agenda. However, because of time pressure and our wish to find a medically solvable problem as quickly as possible, we are tempted to interrupt with questions about, for example, symptoms and duration: questions that belong in the Doctor’s part. This disrupts and distorts the prepared story, to which the patient will try to return having dealt with the interruption. Moreover, asking about the patient’s own thoughts and anxieties is often reduced to a few cursory and formulaic questions. In studying nearly 3000 GPs’ video-recorded consultations in residential workshops over 20 years (www.kalymnos-kurser.dk), we have noticed that two patterns of behaviour frequently recur: 1. When the doctor clearly acknowledges what the patient has said by giving a verbal ‘receipt’, the patient listens and is prepared to let …