Cookie policy notice

By continuing to use this site you agree to our cookies policy below:
Since 26 May 2011, the law now states that cookies on websites can ony be used with your specific consent. Cookies allow us to ensure that you enjoy the best browsing experience.

This site is intended for health professionals only

At the heart of general practice since 1960

Simon and Garfunkel taught me my most useful consultation tool

  • Print
  • Comments (14)
  • Rate
  • Save

’Hear my words that I might teach you.

Take my arms that I might reach you.

But my words like silent raindrops fell

And echoed in the wells of silence.’

…so sang folk-rock duo and inadvertent pioneers of GP training Paul Simon and Art Garfunkel in their song ‘The Sound of Silence’. Because I am still ‘dipping my toes’ into general practice, I am developing consultation skills and techniques and, to paraphrase, learning to be a decent GP. One of the most useful skills I have practised over the last few months is the sound of silence.

Silence is the most useful tool I use

Throughout medical school, we learn to take a history using whats, whens, wheres, hows and whiffs. Ask any medical student who SOCRATES is, and they will snort and call you an old-fool for asking a trick question.  As a result, students have a habit of barraging patients with questions in an effort to come to a diagnosis. This isn’t a criticism – it is an essential part of medical training. This habit is reinforced in foundation years, where pressures of quick clerking result in rapid-fire questioning, which often feels more efficient but generally is less so than a more open questioning style.

In the transition to general practice training, the consultation becomes an experience in itself which has structure and direction. We are introduced to consultation models. I’m going to declare a conflict of interest here and explain that I hate consultation models. I can’t get round the idea of taking something fluid and natural and personable like the human to human interaction of a patient and GP and reducing it to something that is anything close to scientific. Consultation models contain some essential titbits – safety netting (Roger Neighbour’s Checkpoint Model of Consultation Skills), collecting all the information before coming on to the management plan (Damien Kenny’s Consultation Navigation Tool) – but this all seems like common sense to me.

However, a recurrent theme in learning to be a good GP is the use of silence.

Mark my words (oh, the irony!), silence is the most useful tool I use. The more comfortable I feel sitting in complete silence with a patient, the more useful it is becoming. Silence will always need to be broken and if you don’t do it, your patient will. And that moment, that first thing that is uttered, is more golden than the silence itself. I sometimes start a consultation with silence and an encouraging nod of the head and smile, and find that this a much more effective icebreaker than, ‘How can I help?’ or ‘Why won’t you leave me alone?’ If you’ve never done it – try it. Just don’t start snoring.

Let me tell you a real story.

A few weeks ago, an elderly man came in to see me. He sat down, I smiled. He explained that he ‘just didn’t feel right’. Six years ago he wouldn’t have been able to finish his sentence before I asked him how long he had been like this and how he defined ‘not right’. This time, I said nothing. He started to cry. He opened up about how his wife had passed away three years ago, around the time of their 57th wedding anniversary. That week would have been their 60th wedding anniversary, and he missed her so much. He talked about how this was making him feel so awful. At the end, he thanked me and said he felt a lot better.

During this consultation, I said nothing.

So when you next discuss consultation skills with a registrar or some other poor soul, don’t forget to use the most useful consultation model that exists. Hellman’s Folk Model is dead. Long live Simon and Garfunkel’s.

Dr Danny Chapman is a locum GP in east and south Devon

Rate this blog  (4.71 average user rating)

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Readers' comments (14)

  • I also use simon and garfunkle to look back on my career

    all my past comes back to me with shades of mediocrity

    Unsuitable or offensive? Report this comment

  • I haven't felt groovy in a long time

    Unsuitable or offensive? Report this comment

  • After a long day, I just want to be Homeward Bound , driving over the Bridge over Troubled Water, back to My Old Town and see Old Friends. Sorry for this Dangling Conversation

    Unsuitable or offensive? Report this comment

  • Don't misbehave with Mrs Robinson.

    Unsuitable or offensive? Report this comment

  • That whole verse is this. Silence eh?

    “Fools” said I, “You do not know
    Silence like a cancer grow
    Hear my words that I might teach you
    Take my arms that I might reach you”
    But my words like silent raindrops fell
    And echoed in the wells of silence

    Unsuitable or offensive? Report this comment

  • A good tip is to maintain silence even when your patient stop talking and watch their eyes
    If they are not looking at you they have'nt finished you must only talk when their eyes look at you
    Even if there is a long silence till the patient looks at you keep silent

    Unsuitable or offensive? Report this comment

  • It's called 'don't interrupt internal search'
    in Roger Neighbour's 'The inner consultation'

    Unsuitable or offensive? Report this comment

  • Noddy!
    See GP is not so bad if ex Rock group members are joining us.

    Unsuitable or offensive? Report this comment

  • Silence is golden

    Unsuitable or offensive? Report this comment

  • horses for courses. one needs to decide what will be most appropraite consult technique for certain patient.

    Unsuitable or offensive? Report this comment

View results 10 results per page20 results per page

Have your say

  • Print
  • Comments (14)
  • Rate
  • Save