The New Consultation: Developing Doctor-Patient Communication

Abstract

Those of us who conduct numerous consultations every week of our working lives may well consider ourselves as experts. But how good are we, in reality? Do we satisfy the wants and needs of the patients? Do these consultations afford us any satisfaction? Meetings between doctors and patients are the bedrock of any healthcare system, and the manner and efficacy of these meetings are principal determinants of the system’s success. Since the end of World War II, there has been a lot of interest in the analysis and improvement of consultation skills. Balint was one of the first to explore this subject in The Doctor, His Patient and the Illness (1957), and Pendleton and colleagues published the first version of their book in 1984 (The Consultation: an Approach to Learning and Teaching), which proved to be very influential. Consultation skills are now an established part of every medical school curriculum, usually taught early in the course and considered as important as traditional subjects such as anatomy and pathology. A second edition of Pendleton’s classic 1984 text has been a long time coming. It is timely, in that it deals predominantly with the manner in which we might provide more patient-centred consultations, and patient-centredness has become somewhat of a mantra of the 1990s and the new millennium, in the face of the rise in consumerism and ‘patient power’. It is quite a short book, aimed at ‘practitioners and their teachers’. Summaries at the end of each chapter enable the book to be ‘read’ very quickly, but they do not offer an adequate picture of the breadth of content. To my mind, the most interesting chapters are those which deal directly with understanding the doctor, the patient and the consultation process, and this new edition has put more emphasis on factors influencing the doctor’s performance, which is illuminating. The later chapters on how to put knowledge into action will be of especial benefit to trainees (e.g. specialist registrars in hospital specialties as well as general practice) and to their teachers. The writing style is clear and much of the content is authoritative (as one might expect) and thoroughly grounded in the knowledge gained from running courses on this subject, which have been attended by over 1000 doctors in the past 20 years. The difficult of dealing with this sort of subject in a book is that, in many ways, it is much more suitable for a discussion group where the concepts are mulled over and bounced off colleagues. However, this book is ideal as the fodder for such a discussion, and I can see why the courses run by these authors have been so successful. There is no denying that the subject deserves close attention, and the book offers tools for the analysis and assessment of consultation skills which could be readily used by any practising doctor who was prepared to take the trouble. Such tools deserve to become more widely known, in view of the advent of appraisal and reaccreditation. We should all ask ourselves why patient-centred consultations still are not the norm (e.g. 85% of candidates for the MRCGP exam espouse patient-centred consultations, but only 10% demonstrate the techniques in their video’d consultations). More fundamentally, researchers should address the questions as to whether more enabling consultations do, in fact, lead to better health and more appropriate use of health services. Surprisingly, there is little evidence to support or refute this basic contention: although it may seem a socially desirable modus operandi, this will not convince all doctors in an age of evidence-based medicine. Nevertheless, much of the book is plain common sense, and it deserves to have a wide readership.