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2005 Radcliffe Publishing Limited Teaching exchange 597

The consultation: a juggler's art divides the consultation into three pro-cesses that are active simultaneously. Thethree processes are termed:J annie Hugo and Ian Couper

.facilitation

.clinical reasoning.collaboration.

Keywords: consultation skills,international, teaching

INTRODUCTION

The practitioner needs to be aware of andresponsible for all three processes through-out the consultation.

We take the patient-centred approach tohealthcare. Thus the wealth of literatureabout patient-centred care.. its theory,practice and outcomes form the basis ofour understanding. Each of the three pro-cesses can be linked to the concept of agen-das highlighted by the patient-centredapproach; each process requires specificskills and leads to particular expected out-comes (~ee Table I). However, the greatestvalue lies in the interplay among the pro-cesses. The emphasis on process enablesstudents and practitioners to become moreaware of, and give more attention to, thisaspect in the consultation.

The metaphor we use is a juggler whokeeps three balls in the air at anyone time(see Figure I). To be able to do that, hehas to be aware of each ball and can onlykeep juggling as long as all three aremOVIng.

Consultation skills are central to being aphysician. Without competence in consul-tation skills, all the other skills of a clini-cian become almost irrelevant. I What hap-

pens between the doctor and the patientfor that short time of the consultation dic-tates to a large extent the rest of patientcare and illness outcome. For this reason,medical teachers are constantly challengedby the teaching and assessment of consul-tation skills.

Many models of the consultation havebeen described and are used, while newones surface from time to time. This initself may indicate the complexity of theconsultation and how difficult it is to cap-ture its essence sufficiently to teach andassess.

The purpose of this article is to describea model of understanding, teaching andassessing the consultation in family prac-tice that we have found useful.

We practise and teach in southernAfrica, a context with a very wide varietyof patients from different demographicbackgrounds, ranging from sophisticatedurbanites to traditional rural people. Wehave experience of a range of practicesituations, in private and public health-care, involving both doctors and nursepractitioners. There are often major cul-tural and language differences between thepractitioner and the patient, and the timeavailable for the consultation is alwayslimited. The model has been developed in,and found to be relevant to, this context.

Our model uses the angle of process andinteraction to describe the consultation. It

FACILITATION

The first ball the juggler picks up is facilita-tion. Facilitation is 'making somethingeasier or less difficult,.2 This is the processthat aims at uncovering the patient's story,by making it easier for the patient to openup the problem with the doctor.

Facilitation has been described byEnelow and Swisher as a technique in basicinterviewing, which involves encouragingcommunication by manner, gesture orwords in a way that does not specify thekind of information sought.) However, wesee it as something broader. It is an essentialelement of the consultation that enables

598 Teaching e.~change

Table 1 Linking agenda. process. ski lit and expected out Imes in the consultatiol

SkillsAgenda Process Expected outcomes

Patient's agenda Facilitation .Patient satisfaction

.Relationship

.Cost-effective care

.Quality care

.Safety

Doctor's agenda lical reasoning

.Improved adherence.Patient satisfaction.Continuity of care.Improved disease

outcomes

aborationared agenda

.Rapport.Active listening

.Focused history taking

.Physical examination

.Comprehensiveassessment

.Focused investigation

.Rational decision

making.Hypothesis formation

and testing

.Evidence-based

practice

.Explanation 01

assessment.Explanation 01

management options.Involving patient in

decision making

.Negotiation

.Comprehensive plan

.Integrate processes

.Use 01 time.Integrated

understanding bypatient and doctor

.Comprehensive patientcare

tegratlonJendas Integration and synergybetween processes

patients to express their agendas, theirfears, their expectations and their needs inrespect of any aspect of their illness or life.

Facilitation assists the patients to describetheir problems in ways that they may nothave thought about before.

Barry and colleagues ask whether quali-tative research methods can assist doctorsand patients to 'encourage patients to bemore present,.4 The method that wedescribe here has been influenced by ourtraining and experience in conducting qual-itative research interviews, where the mainaim is to uncover and describe complexphenomena (see Box 1).

The first step in facilitation is to estab-lish a rapport and connect with the patient.Rapport is achieved differently in differentcultures and situations, but universally it isthe process that ensures that a patient is atease and is able to talk about the illness,issue or problem. The basis of rapport isrecognising the patient as the most impor-Figure 1 The juggler

Teaching e_~change 599

Box 1 F ac.ilitation steps

1 Rapport2 Open questions3 Recognise cue(s.)4 Reflect cue(s)5 Summarise patient's story

starts very early in the consultation and isalso triggered by a cue. Sometimes it mayeven start when the doctor sees the patientin the waiting area or the name on theappointment list or, more typically, whenthe patient enters the consulting room witha specific gait, facial expression or bodylanguage (see Box 2).

With clinical reasoning the doctor'sagenda comes to the fore, The natural wayto change the focus from facilitation toclinical reasoning is with a link statementsuch as: 'Now that I've heard your story,may I ask some specific questions andexamine you to understand more?', Thedoctor already has formed an idea orhypothesis, The aim of the focused historyand examination is to fill the gaps in theinformation needed to develop and testhypotheses further, in order to reach acomprehensive assessment, The three-stageassessment or triple diagnosis are usefultools to include biological, psychologicaland social dimensions in the assessment, 1.5

The purpose of the comprehensive assess-ment is to lead to a comprehensive man-agement plan.

Clinical reasoning may include the so-called 'routine search' (systems enquiryand physical examination). This aims toprompt alternative hypotheses by bringingto light cues that have not emerged in thedirected part of the search, to collect base-

tant person in the consultation and show-ing unconditional respect towards them.The doctor aims to meet the patient wher-ever they may be, rather than drawingthem into where the doctor is. How thishappens depends also on previous encoun-ters and an ongoing relationship.

Once rapport is established, the practi-tioner moves towards active listening. Thisstarts with an open question, the nature ofwhich depends on the individual practi-tioner, the patient, the culture and the lan-guage, e.g. 'What brings you here today?'or 'What is troubling you today'r. Thenthe practitioner waits for cues from thepatient. A cue is any piece of information,verbal or non-verbal, which comes fromthe patient: a word, a sigh, a shrug, even asilence.

The safest response to a cue is to reflectit back to a patient in a neutral, non-judg-mental manner, and then give time andspace to go further with the story. Infamily medicine, particular care is given torecognising emotional cues, includingthose about fears, beliefs and expectations.The process in which cues are reflectedback and discussed with the patient con-tinues until the doctor thinks that the storyis complete enough to proceed. Then theysummarise the story for the patient toassess whether they have heard and under-stood the story correctly. or whether thestory is different or incomplete.

CLINICAL REASONING

The second ball the juggler uses is clinicalreasoning. This is naturally a process that

600 Teaching exchange

line and background data on the patientand to screen for symptomless conditions.6

Clinical reasoning, which assumes theapplication of evidence-based medicineand rational decision making, is fundamen-tal to sound medical practice. Decisionshave to be made constantly throughout theconsultation and these decisions need to bebased on sound reasoning.7 Successfulfacilitation is dependent on clinical reason-ing, which gives substance to facilitation;without clinical reasoning, the consultationis no more than a conversation. We havefound that an overemphasis in family med-icine teaching on patient-centredness andlistening can diminish the importance ofsound clinical reasoning in the eyes of stu-dents. Clinical reasoning requires thedoctor to know enough about the patho-physiology of the illness and its clinicalcourse, as reflected in signs and symptomsto be able to evaluate the relevance of theinformation they obtain.3 It requires thedoctor to apply clinical skills expertly inorder to elicit signs and symptoms thatmay be present.

Effective clinical reasoning enables effec-tive management, which in patient-centredcare means a mutual decision betweenpatient and doctor. This is the next ball.

Collaboration can be built in from veryearly in the consultation. 'May I ask yousome questions?' and 'Do you mind if Iexamine you?' already indicate that thedoctor wants to work in a collaborativeway. These questions can change anauthoritarian consultation into a colla-borative one (see Box 3).

The natural way to move the focus fromclinical reasoning to collaboration is tomake the assessment clear to the patient, ina way that invites comment and discussion.Once there is agreement about the assess-ment, the different management options areexplained to the patient. The patient isdrawn into the decision-making processtowards a mutual comprehensive plan. Thisis where the different agendas become ashared one. The practitioner must be awareof what common ground exists between thepatient's ideas and expectations, and theirown ideas, plans and management goals.Mutual decision making involves a processof sharing management options with thepatient and deciding together on the wayforward, with both parties participating inthe process.12 It is also important for thepractitioner to aim for the level of partici-pation that the patient would prefer or isable to cope with.

The practitioner has to look out for dif-ferences in opinion, conflict or other com-plications in the relationship. The doctor'sagenda and the patient's agenda may notoverlap enough for mutual participation.Then the doctor needs to draw on negotia-tion skills. Negotiation is an important

COLLABORA TION

The third ball that the juggler keeps in theair is collaboration, which is an essentialpart of any productive process involvingpeople and includes meaningful participa-tion and enablement.

Ways to involve patients more in theconsultation and in decision making areimportant concepts in the literature. Someof the terms used are participation, enable-ment, agreement, shared decision makingand equipoise, partnerships and mutualagreement.7-10 All describe the collabora-tion between the patient and the doctor.We choose the term collaboration as itcommunicates a more focused, outcome-based participation.

Teaching e,~change 601

ence between an ordinary doctor and asuccessful one may lie in their negotiationskills. Good rapport and functional facili-tation build the kind of relationship thatcan cope with differences and enable nego-tiation.

Collaboration is the most active processtowards the end of the consultation andleads to a functional conclusion of the con-sultation.

INTEGRATION OF THE THREEPROCESSES

Integration is where the juggling metaphoris most useful. The success of the consulta-tion depends on how the doctor can keepthe three aspects in balance and active.The three elements carry equal importancebut do not necessarily require the sameamount of time. This will depend on thenature of the problem, the issues raised bythe patient, the context of the consultationand the relationship between the doctorand the patient. Each consultation is differ-ent, and the art of the juggler is to knowwhich ball to catch and which to throw upagain, without ever losing focus on theinterplay of the three balls. A patient maypresent with a 'straightforward' clinicalproblem, but if the doctor does not facili-tate the patient to share their understand-ing of that problem, the evidence-basedtreatment plan may come to naughtbecause the patient sees the problem in adifferent light. For example, a traditionalZulu patient presenting with pulmonarytuberculosis will not benefit from the doc-tor's clinical reasoning if their understand-ing of the illness as a kind of poisoning(idliso) is not explored and dealt with inthe negotiated management plan.

We recognise, as noted by McWhinney,that there is no predetermined order in theconsultation; it does not flow in a uniformfashion from history to presenting condi-tion through to systems inquiry and exami-nation, but is guided by the patient's pre-sentation and the doctor's response.6 The

aspect of successful collaboration. It isimportant not to confuse negotiation withconvincing the patient. The currency ofcollaboration is information, whereas thecurrency of coercion is power. We teachnegotiation as a specific skill, which maybe essential to collaboration (see Box 4).

We teach negotiation skills as requiringa series of steps (see Box 4). Recognisingthe difference between the agendas is thefirst step. Missing the difference leads to adysfunctional consultation. The secondstep is to recognise the value of the differ-ence and learn from it. There is a lot ofinformation in difference, and this may bethe key to understanding and addressingthe patient's problem. The third step is toverbalise and clarify the difference for boththe patient and the doctor, and then to tryto understand the difference. During thisprocess, one looks for the areas of overlapin ilgend.ls between the doctor and thepatient. Often. at the very le.lst, both wantthe best solution to the p.ltient's problem,Focusing on the are.l of agreement andtrying to broaden that area often brings asolution to the difference. Agreeing to dis-.lgree is also an option. Agreeing to dis-agree and giving each other time to reflectmay make an ultimate solution easier.Therefore it is vital for the doctor to main-tain their relationship with the patient,while maintaining their own integrity. Thelast step is to make a specific plan for

follow-up.Fortunately most consultations do not

need negotiation, but negotiation skillsoften make a major difference. The differ-

Box 4 Negotiation steps

.Recognise difference

.Value difference

.Verbalise and clarify difference

.Understand difference

.find areas of agreement

.Find solution

.Maintain relationship

.Arrange follow-up

602 Teaching exchange

image of the juggler keeps in tension thedynamic interplay of the various factors.

used the story of a patient with a sexuallytransmitted infection who refuses to let hisspouse be informed or treated. As long asthe student tries to convince the patient, itleads to resistance, but going through thenegotiation steps usually leads to uncover-ing important relationship issues, openingthe way for much deeper understandingand involvement.

TEACHING CONSULTATION SKILLS

ASSESSMENT

The model provides a useful frameworkfor assessment of the consultation. An easyscoring system allocates 30% for each ofthe components, highlighting their equalimportance and value. and 10% for theintegration. The different skills in eachprocess are used as elements for assessmentand feedback. (See 'Skills' column in Table1.) The student is usually good in at leastone of the three processes and thus can beencouraged, and then helped to master theother skills and processes.

Using a learner-centred approach topostgraduate training (which reinforces theissue of collaboration), this model enablesregistrars to identify specific areas of weak-ness and to develop learning plans toaddress these.

The 'P-R-A-C- T -I-C-A-L' frameworkfor the consultation has been offered as anaid to understanding the different phasesof the consultation and provides a check-list which can be used for assessing theconsultation, but it is difficult to rememberand arguably too cumbersome to use.12,13The Leicester Assessment Package is verylogical and has been found to be reliableand valid, but it relates more to specificactions and competences than to pro-cesses.14.1S

Describing the consultation in the jug-gler model also proves functional in inter-disciplinary discussions on the consulta-tion. Most specialist disciplines canidentify with the clinical reasoning section,but nevertheless agree that the other twoaspects are important. On the other hand,

We find this way of understanding the con-sultation particularly helpful in teachingconsultation skills to both undergraduateand postgraduate students. We often takethree different co loured balls to a discus-sion with the students. Usually one of thestudents can juggle and that is then used asa metaphor for teaching the consultation.

The model brings together familiar con-cepts from everyday life for students andregistrars, who discuss it easily in seminarsand often come to a unique understandingof the concepts and processes, teaching usin turn. The concepts are open enough toallow discussion of other models and the-ories within this framework, and to inte-grate much of the theoretical basis of theconsultation and relationships. Studentsalso find it easy to grasp, practical to useand relevant to their experience.

Dividing the consultation into these pro-cesses makes it possible to teach and prac-tise specific skills without having to do thewhole consultation at a time. The studentcan first understand and practise the skillsof facilitation (rapport and listening), stop-ping, for example, at the question: 'Nowmay I ask you some more specific ques-.?'tlons. .

Students find it helpful to see the differ-ence between facilitation and clinical rea-soning, including focused history taking.History taking is traditionally taught asinterviewing, so that there is often confu-sion between the need to listen and theneed to ask closed questions. In thismodel, the difference is clear, making iteasy to understand when to ask open ques-tions and when to ask closed ones. In thesame way, clinical reasoning and colla-boration can be taught and practised.

Practising negotiation skills in role-playis usually very intense, but can be greatfun. For example, in role-plays we have

Teaching exchange 603

a discipline such as psychiatry may placemore emphasis on the process of facilita-tion without neglecting the others. Thusthe allocation of marks in the assessmentmay vary in different disciplines.

of excellence: expanding the patient-centeredclinical method: a three-stage assessment.&!!Jiry Practice 10: ~

CONSULTATIONS IN PRACTICE

We have found the model to be useful inour own practice. Thinking about theseaspects throughout everyday consultationshas helped us to be reflective in our work.While recognising that the consultation iscomplex and varied, this model provides asimple and logical framework for review-ing it. Very often when a consultation isdys1unctional, the problem can be found inone of the three processes.

6 McWhinney IR (1997) A Te.~tbook of Famil.~'Medicine (2e). Oxford University Press: NewYork.

7 Britten N. Stevenson FA. Barry CA. Barber Nand Bradley CP (2000) Misunderstandings inprescribing decisions in general practice: a qua-litative study. British Medical Journal 320:484-8.

8 Howie JGR. Heaney OJ. Maxwell M andWalker JJ (1998) A comparison of a patientenablement instrument against two establishedsatisfaction scales as an outcome measure ofprimary care consultations. Fclmily Practice 15:165-71.

CONCLUSION

Thc method that wc describe offers a rela-tively easy way to understand and teachthe complex processes and skills involvedin a consultation while leaving space forother models and theories. The methodneeds to be systematically tested and to becompared with other methods in teaching,assessment and practice situations.

9 ElwynG, Edwards A, Kinnersley P and GrolR (2000) Shared decision-making and the con-cept or equipoise: the competencies or invol-ving patients in healthcare choices. ~journal or Gl!nl!ral Praclic,' so: 892-7.

10 Stewart M, Brown JB, Donner A, McWhinneyIR, Oates J and Weston W (1996) Thl! Impactlif Palient-Centrl!d Carl! on Patient Oulcoml!s inFamil.,,' Praclicl!. Filial Reporllo Ontario Mini.l.-Iry or Hl!allh. Centre ror Studies in FamilyMedicine, University or Western Ontario:

London, OntarioII De Villiers M (20()() The consultation -a dif-

ferent approach to the patient. In: Mash B (ed)Halldhook of Falnil.I' Medicine. Oxford Univer-sity Press: Cape Town, pp. 42--66.

12 Blitz J (2()()O) Communication skills. In: MashB (ed) Handbook of Family Medicine. OxfordUniversity Press: Cape Town, pp. 67-87.

13 Larsen J, Risor 0 and Putnam S (1997) P-R-A-C- T -1-C-A-L: a step-by-step mode! for con-ducting the consultation in general practice.Family Praclice 14: 295-301.

References

15 McKinley RK. Fraser RC, van der Vleuten Cand Hastings AM (2000) Formative assess-ment of the consultation performance of medi-cal students in the setting of general practiceusing a modified version of the LeicesterAssessment Package. Medical Education 34:~ -

Correspondence to: Jannie FM Hugo, Departmentof Family Medicine, University of Pretoria, PO

I Fraser RC (1999) The consultation. In: FraserRC (ed) Clinical Method: a general practiceapproach (3e). Butterworth Heinemann:Oxford. pp. 25-35.

2 Hornby AF (1989) O.~ford Advanced Diction-ar}' of Current English (4e). Oxford UniversityPress: Oxford.

3 Enelow AJ and Swisher SN (1986) Interviewingand Patient Care. Oxford University Press:New York.

4 Barry CA. Bradley CP. Britten N. StevensonFA and Barber N (2000) Patients' unvoicedagendas in general practice consultations: aqualitative study. British Medical Journa/320:1246-50.

5 Fehrsen GS and Henbest RJ (1993) In search

604 Teaching exchange

fessor, Department of Family Medicine, Universityof Pretoria and Ian Couper, BA MBBCII MfamMed, isProfessor of Rural Health, Department of FamilyMedicine, University of the Witwatersrand.

Box 53. De Wildt 0251. South Africa. 'rei: + 27 123541430: fax: +27 12 3541713; emai1: ~hugoCcyup.ac.za

lannie Hugo. MBChB MfamMcd, is Associate Pro-