What is a Good Consultation in General Medicine?

The General practitioner/Family doctor in his or her daily practice often has to make decisions on a multitude of subjects with no more support than his ability to judge and reason. In daily practice we continually have to decide the greatest good for the patient [1]. But, how we can define and identify the concept of the “good” for the patient? What are good and bad health behaviours? Where are the "gold standards" of good clinical practice? [2-4]. Evidence-Based Medicine, clinical trials and quantitative studies, which are indispensable for medical science, however they do not give us much information on what a good consultation is, since specifically that qualification refers to specific contexts, not general [5].


Editorial
The General practitioner/Family doctor in his or her daily practice often has to make decisions on a multitude of subjects with no more support than his ability to judge and reason. In daily practice we continually have to decide the greatest good for the patient [1]. But, how we can define and identify the concept of the "good" for the patient? What are good and bad health behaviours? Where are the "gold standards" of good clinical practice? [2][3][4]. Evidence-Based Medicine, clinical trials and quantitative studies, which are indispensable for medical science, however they do not give us much information on what a good consultation is, since specifically that qualification refers to specific contexts, not general [5].
So, what is a good consultation? First, it may be different for the doctor and the patient. The doctor-patient meeting is an expressive framework of relationships; there are two types of actions: technical and expressive, which are interrelated to each other. A "good consultation" does not mean eliminating the differences between the two sides, but rather that an agreement is reached on what to do (even if there is no cultural consensus on the "why" to do).
Good consultation can have several characteristics or nuances: a good decision implies that it has been built collectively; consultation and the "good" decision would be one that achieves patient satisfaction; the "good" decision is constituted from the awareness of the emotion; a clinical decision is good if it opens the way to a new decision (i.e. if it unlocks the path of the problem); a "good" decision also implies "empowerment".

A good decision implies that it has been built collectively
Decision making is complicated in complex systems, in contrast to the mathematical model approach of positivist science. When the context is turbulent, unstable, unpredictable, it is when the professional, in order to achieve the "good" for the patient, must be more flexible, autonomous, with more decentralized decision-making, involving other actors in them, and facilitating a broad participation. Many times there is not a single "good decision" for the patient, but several options and we must use contextualisation, decentralization, and strategic planning skills to select the best [6].
A good decision means a turning point; a time and a place in the patient's medical history where different factors collide, and may assume a pivotal point in history. It's like a battle whose outcome can change history. And that requires a strategy. Sometimes the battles are won by inspired leaders such as Alexander the Great, Julius Caesar, Napoleon, Nelson, Washington or Grant, other times they have been influenced by technology, but behind victors were always the ordinary soldiers who, through their courage, determination and sacrifice, changed the course of history [7]. The same is fully applicable to the "battle of the consultation". Thus, the collective construction of decisions would be a basic competence of the physician.
Decision-making is complicated by complex systems, like in family medicine, as opposed to the mathematical model approach of positivist science, by: • The more information about a system greater inaccuracy about it. • A change of scale to see an object does not always increase the precision: the closer we get the more blur we see. • Two identical systems can evolve very differently by varying some minimal characteristic of their initial state. • In decision-making -diagnosis, treatment, small fluctuations can cause the flow to evolve very differently, so that it is impossible to predict how the system will behave.
Communication is not a digital or algorithmic process, but it has a narrative form proposes themes that organize the response of individuals in their being and being. The focus must be on the richness of interactions, not on the outcome. The world is a complex of adaptive systems in which events are related by non-linear interactions of many parts [8][9][10][11].

Consultation and the "good" decision would be one that achieves patient satisfaction
It is a satisfaction because of reflective and human help. What helps people has nothing to do with the theories that are used. When a person feels seen, and we feel that they feel seen, and we feel seen by them, then, at that precise moment, it takes place as a friction of the spirit. And that's all. The query or decision "good" works as life works: no road map, no instruction manuals. What makes it "good" is what makes a good relationship work: to feel understood by the other. Achieve an interconnection situation. Maybe together -patient and doctor-they understand the problem. What is on the table in the consultation is not the doctor or the patient, but the two together. The physician's task is to achieve and maintain a connection with the patient. That is healing. That's what good doctors do: being with people at the crucial moments of their lives [12].

The "good" decision is constituted from the awareness of the emotion
Emotional experiences should not be viewed as undesirable intrusions, but must become a fundamental guide for the understanding and development of the therapeutic process. The clinician's accessibility to diverse feelings is the key to the situation [13]. In the end all decisions are emotional [14]. As Mahatma Gandhi said, "Everyday decisions are good to be taken with the head, but the really important ones must be let the heart take them."

A clinical decision is good if it opens the way to a new decision (i.e. if it unlocks the path of the problem)
The purpose of thinking in decision-making is to encourage our emotional reaction to go the "good way": a clinical decision is good if it opens the way to a new decision (i.e. if it unlocks the path of the problem). It is a question of assuming that uncertainty for decisions will always exist, even though its limits could be reduced. It is a question of trying to find "the system that defines the problem", which means the set of problems, situations and people affected or related by the problem, both in terms of the maintenance (cause) or in its changes (treatment) [15]. The one that, in doctor opinion, for that patient at that time and in that context, concentrates the greatest importance or significance for the patient's health/illness, and which allows us to "move forward" (open doors, change scenarios) [16].
To heal is to facilitate the unlocking of a situation, the passage from one stage to another with new perspectives. In our intervention, healing would be achieved when the patient may perceive that the situation is different from how he perceived it initially. By becoming aware of the problem globally, treatment can emerge. A healthy person is not the one who is free of problems but the one who is able to deal with them. Treatment includes having a device that prevents blocking of situations during health problems. The cure is not so much to favour a project of adjustment between the patient and his context, but to restore or reinforce the patient's ability to face his own problems, or to decide how to act in that situation here and now. The cure or resolution of the disease means more than achieving a homeostasis of the system: the patient and the doctor work cooperatively as people.
The role of the physician is not to try to adjust the patient's contextual system or lead patient to a standard of health, physical or mental, but to help him or her to learn how to do it or to stop doing so in the future [17].
The concept of curing the disease or trauma has to do with avoiding feeling overwhelmed and with interrupted connections. The cure is to restore interrupted connections. Healing involves in one way or another the return of the part to the whole. Even if the patient's stressful environment is not modified (because it is not always possible). The world that surrounds each one (the context of each one), is largely created by oneself, because we are interpreting what surrounds us. Therefore, if we vary the interpretation of what surrounds us, in a certain way, it is as if we vary our surroundings. The units of analysis of the consultation in family medicine are the relations/connections/links between actors. The healing (the treatment, the intervention of the professional) becomes possible through the participation of the therapist in the matrix of communications with the other people.

A "good" decision also implies "empowerment"
A "good" decision also implies "empowerment," and it means that marginalized people can take charge of their own affairs and improve their situation. From here develops a positive feeling of control over one's life. This feeling can be more than individual satisfaction, selfesteem or personal confidence, and lead to ideas of responsibility and social justice [1,18,19].

Conclusion
Traditionally, the physician assumes only the authority of the decision making in the consultation and he or she transmit it to the patient and occasionally to other professionals in his team. The style of clinical decision making that the doctor adopts depends largely on his or her beliefs about people (their abilities, rights, self-responsibility, creativity, resources, compliance ...). Generally, physicians who assume the capabilities and self-responsibility of others, consistently get better results than those who make all decisions personally, give orders, and threaten punishments. When the context is turbulent, unstable, unpredictable, as always happens in Family Medicine, it is when the physician should be more flexible, autonomous, more decentralized decision-making, and he or she should involve other actors in them, facilitating broad participation. In case the family doctor does the opposite (less flexible, less adaptable, more rigid and directive, limiting the panoramic view, reducing the communication with the relevant actors), will increases conflict with patients and reduces positive outcomes. In family medicine, the worst thing you can do with patients, when you do not know very well what to do, is to try to resolve things yourself and not ask for help. A clinical decision is good if it opens the way to a new decision (i.e. if it unlocks the path). In Family Medicine algorithms are needed for decision making based on interactions between elements and groups, with very simple rules, to solve complex problems.
What are the characteristics of a good consultation in family medicine?
• The one that achieves patient satisfaction • The one that is produced from the awareness of the emotion • The one that opens the way to a new decision (i.e. if it unlocks the path of the problem) • The one that restore or reinforce relations/connections/links between actors • The one that implies empowerment • The one that is flexible, decentralized, and involves other actors, facilitating a wide participation • The one that is contextualized • The one that involved strategic planning In short, the excellent consultation would be where the doctor finds significant things for him or her and facilitates that the patient also can find significant things for himself.