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At the heart of general practice since 1960

The key to effective consulting

Dr Peter Tate discusses what influences successful outcomes of consultations

The consultation is the central act of medicine and as such it deserves to be understood1. In the UK alone it has been estimated there may be as many as a million consultations per day. Medical care is a part of life and each consultation has a context. Events leading up to a consultation influence its content. The consultation, in its turn, has an impact and influences subsequent events for both doctor and patient.

An effective consultation takes account of those factors that resulted in the consultation, such as the clinical history and the patient's interpretations of events. An effective consultation also results in beneficial outcomes, such as reduction in the patient's concerns, adherence to the action plan developed, and improvements in the patient's health. Not all good consultations can achieve ideal outcomes but those processes that regularly succeed are effective.

Antecedents on the patient's side of the cycle tend to be focused on the problem for which they are seeking help and the reasons why they choose to seek help at that time. These include their understanding of the possible nature of the problem, its meaning to them, and their expectations of what help the doctor may be able to provide, often based on their previous experiences of health care. All these factors will also be influenced by the patient's cultural background.

Doctors are likely to be influenced by some general factors including cultural, professional and personal issues. Cultural influences include the expectations held about doctors in our society and the roles we expect them to fulfil. Professional issues include ethical and other rules of conduct, and the current state of beliefs about appropriate medical care.

Personal issues will vary from the state of the practice (the organisation itself) and relationships within it, to the state of the doctor's home and family, and his or her personal health. In addition, there are personal issues that are bound up much more with the doctor's current workload and perceptions. These will include his or her mood, the current pressures of time, and the state in which the last patient left the room.

Other antecedents on the doctor's side are specifically related to the patient who is about to be seen. Since doctors are also human we can expect they will anticipate the arrival of some patients with delight and others with dread, and most with some reaction in between.

GP's and patient's understanding

The key concept for both doctor and patient is understanding: the result of formal and informal learning, general and professional socialisation, and the individual's upbringing and experience. It is a mix of cognition and affect: the thoughts and feelings that govern the doctor's and the patient's orientation to a consultation and help shape its contents.

There are very different types of outcomes that occur once a consultation has ended. For the patient, immediate outcomes include commitment to the management plan agreed, his or her satisfaction with the consultation itself, his or her memory for what was said, and any change in the initial level of concern.

One of the most widely researched intermediate outcomes is adherence to the proposed treatment (or management plan). Later, there is the longer-term outcome of change in the patient's health, which is to some extent governed by adherence to the proposed treatment. Finally, patients learn from their reflections on these experiences and so sustain or modify their understanding.

For the doctor, immediate outcomes include the pleasant and unpleasant consequences of certain aspects of their consultations. These form rewards and punishments that encourage or discourage certain consulting styles.

Longer-term outcomes for the doctor include the level of job satisfaction. This is a prime determinant of motivation and morale, and can affect decision-making. Values are also relevant and may change over time. There is much research to be done on the relationship between immediate rewards and punishments, consultation satisfaction, longer-term job satisfaction and the impact on the doctor's values and behaviour.

In summary

lConsultations take place in a broader social and professional context, which also fashions the dominant system of health care

lThere are antecedents and consequences of

all consultations for doctor and patient that

influence the consultation's content and

effectiveness

lOutcomes from consultations for doctor and patient can be placed in a sequence in which shorter-term outcomes influence later outcomes

lDoctors and patients make sense of their experiences of health and health care by developing their understanding. This forms

the primary link between consultations

This is the second of two articles based on

The New Consultation: Developing Doctor-Patient Communication (Oxford University Press, 2003) by David Pendleton, Theo Schofield, Peter Tate and Peter Havelock

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