The logic and chronology of consultations in general practice - Teaching consultation skills in medical school

Introduction Teaching consultation skills requires a structured description of consultations. The objective of this is to describe how consultation topics may be classified and ordered logically. Methods All our last semester medical students make video recordings of their consultations with real patients. The feedback method is systematically developed into a grading system that takes into account both structure and content. This includes the relevance of the topics handled, the extent to which they cover all aspects of the clinical problems of the patient, whether the goal of each step is reached, and the extent to which the topics are handled in the logical order. Results The consultation may be described in nine steps. The order of steps is based on the logic of clinical reasoning. Each topic can only be placed on one step. The steps and logic is shown in Table 1. Figure 1 shows the relationship between the theoretical logic and the actual chronological order of events in the consultation (Table 1, Figure 1). Conclusion and Practice Implications The analysis is straightforward and may be used when teaching. The system is being developed further for preand post-graduate use in research and quality development. Witt K, Jorgensen M MedEdPublish https://doi.org/10.15694/mep.2016.000111 Page | 2


Introduction
The authors have been teaching medical students at the University of Copenhagen Section Of General Practice for over twenty years. The department is currently in the final phases of a project to improve the teaching of consultation skills in general practice.
An important part of the teaching is a classification of the topics of the consultation for use when analyzing video recordings of consultations and to optimize the feed-back process in general. The method is based on the principles of patient-centered medicine as this is associated with improved patient satisfaction [3], and less use of health care resources [4].
The method is being developed further into a scoring system to compare the students' skills before and after the family practice course, DanSCORE (Danish Structured Consultation Observation, Recording, and Evaluation).
DanSCORE is currently being tested in a series of controlled trials to evaluate the effect of systematically adding different forms of e-learning to the usual teaching in the classroom and in clinical practice. Data from this part of the study comprising 554 last semester medical students have been collected and analyzed. (554 A and 414 B , in total 968 schemes from 12 different groups). All groups of medical students have the same distribution of scores the same at the start of the course.
Several rating scales are available [5] [6], but we think there is a need for a system that may be integrated into the total education from student to specialist in general practice.
We need to establish a classification of the topics handled in a consultation, establish a logical ordering of these, and develop a set of questions to demonstrate whether each topic has been treated adequately.
The aim of this part of the project is to describe a classification of the topics handled in the consultation process, test whether this classification is exhaustive and exclusive, and describe the logical order of the topics that may appear in a consultation.

Method
The system has been developed in the context of the medical school curriculum. Medical students in Denmark were first introduced to the specialty of General Practice medicine in the 1970s when classroom teaching in the last semester was offered along with a short, voluntary stay in a general practice clinic with voluntary tutors. General practice became mandatory in the last semester some years later, with each student having a 5 week individual stay at the office of a GP, and in 1992 the formal exam was introduced at the end of the course.

The course
During the course the students spend eight days in the office of a general practice tutor, sitting in on the consultations and later discussing what the GP did and why. Each day, the student is given the opportunity to conduct a couple of consultations with real patients on his own, working in the role of a GP. The GP finishes the consultation, including prescription, referral etc. and discusses the process with the student. The student-patient consultations are video recorded and later used in the group teaching at the department.
The eight days with the tutor are placed over a five week period and alternate with group sessions at the university. The students meet once a week in groups of ten under supervision of one of the tutors.
During the course, each of the ten students in the group shows at least one of their own videos from their tutor practice, discuss the case and get feed-back and guidance from their teacher and fellow students. This method to learn consultation skills has been described earlier and found to be effective 7 .
Other subjects of the group sessions are: General practice epidemiology, clinical problems from primary care, practical diagnostics, and consultation skills.
Since the start of the general practice course we have given much attention to developing the teaching program and updating the family physicians who are teaching at the university and/or in their own practice. We have discussed our experiences at meetings with teachers and regularly collected feed-back from the students. The program has been adjusted from course to course according to our experiences and to test new ideas.
From this process the teachers have systematically extracted the topics that together describe the content of a consultation. The U of C has been providing resources for the use of video equipment since the beginning of the course, and for an e-learning platform when it became available in 2007.

The exam
By the end of the course the students are evaluated in an individual exam based on the student showing one realpatient video of their own choice. The student analyzes and discusses the patient's clinical problems from a general practice perspective and discusses the relevant actions. This is supplemented by a clinical textbook question . The communication with the patient is discussed separately as part of the examination.
The need to formally grade the student's performance also stressed the need for a systematic analysis of the consultation process.
This forms the basis of the description of a student video in both the teaching sessions and at the final exam. To observe the flow in the consultation we combine the method of conversation analysis [8] ( Fig. 1) with the consultation logic (Table 1).

Ethics
Patients are only included after having given written consent to participate in the video recordings and having accepted the use of these in the general practice course within one year. The patients are anonymous. The recordings are kept under lock and key, and the patient may have the recording deleted at any time by contacting the department of general practice.

Results
The analyses and discussions during and after the teaching sessions led to the following definitions and descriptions of the elements of a general practice consultation. The consultation When is a conversation a consultation? We define a consultation in general practice as a meeting between two people, the one seeking the help (the patient role) of the other (the doctor role) for something that the patient at the start of the consultation considers a health problem (regardless of type or possible cause), and where the two agree on these being their roles.

The roles
The consultation takes place between two equals, but it is an asymmetrical conversation. This is a consequence of the purpose of the consultation: The doctor has knowledge and skills that the patient lacks, and the patient seeks the help of the doctor because of this. This makes the relationship asymmetrical and so requires mutual respect of the participants, and that they honestly seek a shared understanding of the problem and the possible solutions. The relationship has also been described as a power imbalance. To limit this, the patient has a free choice of doctor. The doctor may have the upper hand in the consultation, but the patient may go somewhere else if she is dissatisfied.
It is part of the role of the doctor to be responsible for guiding the process, making sure that the plan is realistic, and obtaining informed consent. It is characteristic that during the consultation decisions and contracts must be made on the basis of shared understandings of problems and possible solutions.
The doctor's role is that of a consultant. This means, that the patient is not required to follow the advice of the doctor. Provided there is mutual trust, the physician-patient relationship may be preserved in spite of the patient on occasions choosing something else than the doctor has suggested. The patient has autonomy. The function as consultant also means that the doctor is not a merchant, selling as many services as possible for his own gain, or selling any service only because the patient wants it. The doctor must be able to say no like other in similar roles, for example the architect, who draws the house according to the owner's wishes, but must say no to illegal or technically poor constructions. And the architect must listen to the clients and build a house that corresponds to their wishes and not just build his own dream house.
The steps and the topics The model consultation may be described in three parts in this sequence: The patient's part, the doctor's part and the shared part. Our model subdivides each part into steps based on each step having one distinct goal. We realized that each topic of the consultation may be placed on one of nine steps. The topics of each step have the same type of goal, and the goal must be reached before moving to the next step. Otherwise a return to the step becomes necessary and so breaks the logic of the process.
We have found the list of steps exhaustive and exclusive.
A topic can only be classified onto one step, so when two or more topics cannot be arranged in a logical order, they belong on the same step.

The goals
For each step in the consultation all topics have the same type of goal.
A Decision is the result of deliberations. The doctor or the patient decides how to act after considering the I.
pros and cons, facts and emotions. A Contract is a mutual agreement between two or more parties that something shall be done or abstained II. from by one or both. It is characteristic that the content of the contract is adjusted in the process leading to it. An Operational Shared Understanding of the patient's problem has been reached, when the following III.
conditions have been met: The doctor has decided, that he has got sufficient information from the patient, and that he has reason 1.
to believe that the patient has heard and understood what he wanted to tell her, and The patient has decided that she has got sufficient information from the doctor, and that she thinks that 2.
the doctor has heard and understood what she wanted to tell him.
So the patient does not need to know everything the doctor knows about her and her disease, and the doctor does not need to know everything about the patient and her life. The phrase "operational" denotes that the limit of the shared understanding is inherent in the purpose of the consultation and in the situation at hand. It is the responsibility of the doctor to make sure that a shared understanding has been reached.
By summarizing what he has heard the patient say, the doctor ascertains that he has understood the patient correctly, and the patient can make sure that the doctor has been sufficiently informed. This may be illustrated by comparing the consultation to the physical examination: A complete physical is not expected in every situation, just what is relevant. Any examination chosen must be performed professionally.

The logic
The steps and topics are shown in Table 1. The logic of the numbering may be checked by reading through the table, taking the last step and checking that none of the previous steps need information from the last step.
Step no. 8 does not require information from step 9, step 7 likewise not from step 8 or 9, and so on. By this reasoning, some topics may end up on the same step, e.g. two topics may fulfill the criteria for step 8 ("necessary for step 9, not necessary for step 7"). This means that they may be handled in any order on step 8 without damaging the logic in the consultation process. Table 1 shows the steps arranged in the only logical way.

The chronology
The consultation process is based on the logical line of thought, so it follows that in real time the process should follow the sequence of the logic. To describe and clarify the significance of this we are using the principles from conversation analysis. When the video is shown, it is paused every 30 seconds, and the topic(s) that have been handled are checked in the corresponding boxes in the diagram. When a goal has been reached it is indicated separately. If the topics are handled in the logical order the checked boxes show a descending pattern. If a topic is handled before its logical position this result in a steep jump down and if a topic is returned to later the result is a jump upwards to the proper step.

Conversation analysis
The consultation logic and the conversation analysis are used for observational and descriptive purposes, and to create structure for reflections and feed-back after the consultation. The consultation logic is not an absolute recipe for behavior in the consultation, but it has been found useful to let students check the chronology of their own video against the logic. During the consultation it should not take the attention away from the contact with the patient, and not prevent the patient presenting her case in a personal way.

Parallel activities
The communication often continues while the general practitioner is making the physical examination, taking blood samples, preparing an injection etc. These activities affect the contact between doctor and patient, so they may be registered on the time line below the table.
Pausing the consultation During the meeting, the consultation may be put on standby while doctor and/or patient talk about things outside the agenda and their roles (i.e. they go outside the consultation steps and the topics). This is registered by the conversation analysis and so can be discussed and evaluated.
DanSCORE is currently being used in a series of controlled trials of the effect of systematically adding different forms of e-learning to the usual teaching in the classroom and in clinical practice. Data from this part of the study comprising 554 last semester medical students have been collected and analyzed. When entering the course all groups of students show the same distribution of answers, so the questionnaire is usable and valid.

Discussion and Conclusion
Some topics may be directly irrelevant to the problem on the patient's agenda. This takes time from the consultation process but need not be a waste of time, e.g. if the doctor learns about other matters important to the patient's life or the patient needs. Or it may be plain small talk. In the long run it is important to a GP to have some background knowledge of the patient's workplace, family economy, home, family members, etc., so opportunities for this should not be missed when time allows.
The students' earlier experiences all come from training in University Hospital settings, where they meet a highly selected group of patients. The patient's reasons for encounter are specified in the referral letter.
In the family medicine course they meet unselected patients, and patient centered medicine becomes essential. We teach the students as a minimum to get a contract for the content of the encounter, explore the patients function, feelings, expectancies and ideas, and to reach a mutual agreement.
We think we have developed a useful tool for teaching and evaluating communication skills for undergraduate students. The next step is to develop a grading checklist (DanSCORE) to measure their analyzing skills before and after the course and learn how different teaching methods succeed.

Conclusion
We have established a classification of the topics handled in a consultation and shown that they may be arranged on steps in a logical order and chronologically handled. This forms the basis for systematically making sure that each topic has been treated adequately in the consultation and the objective of each step reached.

Reason for encounter
Contract about the consultation topics.

The professional filter
The doctor's decision: Is it a medical problem and a task for the doctor?

The diagnostic process
Diagnostic interview,

Conclusion/diagnosis
Shared understanding of the condition and its consequences if left untreated

Options
Shared understanding of the possibilities for treatment or for further examinations and tests -or for watchful waiting.

Plan
Shared understanding of division of tasks and responsibilities between doctor and patient

Informed decision
The doctor's decision: Is the plan professionally/ethically correct; a.
The patient's decision to follow the plan or not. b.

Safety net
Contract about what to expect, what to observe, and how the patient should react.