By David Pendleton, Theo Schofield, Peter Tate and Peter Havelock. Oxford University Press, 2003, PB £19.95, 143 pp. ISBN 0-19-263288-4 The Consultation–An Approach to Learning and Teaching was first published in 1984. Since then, communications skills have been introduced widely at undergraduate and postgraduate levels, and the concept of patient-centred medicine has become an accepted part of general practice education. In this revised edition, Pendleton and colleagues provide an updated version of their earlier text, reinforced with evidence where available. The first half of the book has been extensively revised, with dedicated chapters on the wider context of the consultation, understanding the patient and understanding the doctor. The focus has shifted, with greater emphasis upon understanding the patient's concerns and enabling the patient rather than merely involving him or her in management decisions. The first six chapters of the book focus on understanding the patient, doctor and context of the consultation, and on describing the seven tasks to be achieved in effective consultations. The second half of the book is a very practical guide to teaching and evaluating consulting skills, and implementing new methods. The Consultation has two aims: to describe the authors’ model for effective consultations, and to describe their method for teaching consulting skills. The early part of the book makes the argument that patient-centred care is effective care. This is a challenging area because of the well-recognized difficulties in obtaining high quality evidence about the effectiveness of consultations. The evidence presented here indicates that patient-centred consulting is associated with higher levels of patient satisfaction and increased adherence to treatment as well as positive health outcomes such as symptom resolution, function, emotional health and pain control. These positive outcomes ground the book's main argument that doctors should be trained in the necessary skills to achieve these outcomes. Chapter 6 describes the seven tasks that the authors believe contribute to an effective consultation, contrasting these with similar lists from other consultation models. The key issues in the task list are to understand the problem and the patient, to share understanding, decisions and responsibility with the patient, to maintain the relationship, and to do all of this within the allotted time. I enjoyed the first part of the book, with its description of the cycle of care building over time and emphasis upon understanding the importance of patients’ beliefs and concerns. The material on understanding the doctor is welcome. This chapter explores how various doctor-related factors feed into the dynamics of the consultation, including the doctor's knowledge, values, skills, mood, health and style, and the physical environment and arrangements. The authors describe various outcomes of the consultation for doctors, including short-term rewards and punishments, and the lack of patient feedback. Doctors with an interest in understanding their own consulting will find this material useful and thought-provoking. There is discussion about the potential tensions involved in patient-centred care. On the one hand, there is a moral imperative to provide information, empower patients and maximize patient choice as part of respecting patient autonomy. On the other hand, there is the medical imperative to improve health outcomes. The authors argue that fortuitously, the same consulting style maximizes both simultaneously. I think this point is more complex, as well-informed patients do not always make ‘medically approved’ choices. In the area of screening for example, patients exercising their informed choice may lead to lower rather than higher levels of screening, thereby questioning what is meant by effective preventive care. The second half of the book provides a fairly comprehensive guide on how to implement the seven tasks of the consultation in practice. The authors describe their teaching philosophy (student centred, using principles of adult learning) and outline various strategies for teaching in a variety of settings. There is some discussion of the wider context of general practice, but this is limited. There is also limited discussion about involving patients in the task of defining and assessing patient-centred care. Most of the work on consulting derives from the medical side of the desk; I would have enjoyed some critical discussion of this phenomenon and greater exploration of ways to involve patients in assessing consultations and devising research to demonstrate the benefits of ‘effective’ consultations. The Consultation is a practical guide for General Practioners and registrars, based upon experiences in general practice and training in the UK. The tone is straightforward and the authors are quite candid at times about their experiences, for example, in describing their disappointment at the apparent lack of progress in teaching and learning communication skills over the past 20 years as judged by assessing GP registrars. This direct approach is one of the strengths of the book, marred slightly in places by a retreat to technicalities, such as in describing multiple models of the consultation, or the somewhat convoluted discussion of validity.
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