Abstract
Summary box
An experienced clinician can end a consultation in good time – complete with an agreed management plan and without loss of safety by:
Following a clear structure with successful summarising and signposting Effective listening Reflecting on their own consultations to avoid time wastage and maximise efficiency
Introduction
The duration of a consultation is only a partial representation of its quality or effectiveness. It is possible to consult smoothly and quickly without loss of safety. Following a clear structure that is shared with the patient allows for efficient exploration of the issues while strengthening rapport and maintaining appropriate boundaries in the consultation. Effective summarising and signposting to the next phase avoids time wastage from misunderstanding and allows for a good flow throughout the consultation. These skills take time to develop and benefit from reflective practice. Where a trainee may take 30 minutes and be unable to achieve a management plan, an experienced clinician can employ highly effective consultation skills to achieve a mutually acceptable plan without a sense of hurry (TALC (Teaching and Learning Consultation Skills) module 7).
Summary of the skills you need
Effective time management skills include:
Structuring a logical sequence to the consultation Active and effective listening to avoid repetition and blind alleys Summarising effectively at the end of each phase and progressing to the next by signposting and using transitional statements
Clear structure, successful summarising and signposting
Following a consultation structure that is patient-centred is time efficient as it focuses on what matters to the patient and avoids going down a blind alley. Effective consultations result from clinicians moving smoothly from one phase of the consultation to the next in a structured manner (TALC module 3). For example, during information gathering, beginning with open questions, moving on to open directed questions and then closed questions allows maximum information flow. A physical examination may follow, or a discussion of any test results. This generally leads into the explanation phase, planning of appropriately personalised care and the closing and safety-netting stages.
Summing up each section and signalling the next direction ensures a shared understanding of the patient’s needs, helps structure the clinician’s thoughts and allows the patient to feel more secure in how the consultation will flow (TALC module 4). For example, ‘So, your chest symptoms sound pretty bad at the moment, and you are concerned you might end up in hospital again, so I would like to do a full examination now and then we can decide how best to treat things’.
Skills to pick up cues can help reassure patients that they have been heard, while maintaining an efficient flow. For example, ‘You mentioned your concern about X a few moments ago … can I ask you to tell me more about that now? I am keen to understand your point of view’. Further exploration of the patient’s thoughts, hopes and worries will then flow easily.
Using embedded commands can help keep up with administrative elements while maintaining rapport. For example, ‘While you get your coat on, I will concentrate on getting your prescription sorted’.
Effective listening
Active listening saves time as key issues are recognised and addressed without dwelling on irrelevant questions or repetition (TALC module 7). Patients may repeat something several times if they feel they have not been heard, their concerns not understood or that the clinician does not appreciate the significance of their problem. This can be avoided by summarising and repeating back to the patient. It is important to acknowledge concerns highlighted to reassure patients that these will be addressed. For example, ‘So I know what’s been happening with this rash that’s been bothering you; you mentioned wanting to talk about a lump on your leg too, can you tell me all about that now?’
Reflecting on your own practice
Reflecting on recorded consultations is an effective way of improving the skills outlined. It allows identification of areas of time wastage from repetition, blind alleys and time spent on issues that are clearly irrelevant. Paradoxically, speeding up consultations sometimes means learning to do them slowly at first. Learning new skills is awkward and needs repeated practice and feedback. If skills are developed and embedded slowly and systematically, the tasks of the consultation are achieved effectively and this naturally leads to consultations becoming shorter but more efficient.
Putting these skills into practice
Carla M comes for a medication review but is concerned about recent palpitations. The clinician starts with setting the agenda to address both problems; proceeds with a full assessment of the main concern (palpitations), signposts to a discussion on medications and then moves to explanation, planning, closing and safety netting. Carla feels at ease, the clinician’s thoughts are organised and they share a respect for the structure to achieve all needs efficiently.
Investing in active listening skills and conducting every consultation with a clear structure results in efficient consultations, improving satisfaction in both patient and clinician.
