Patient Consultation Techniques

Initiating the Session

• Greet the patient and introduce yourself
• Ensure the patient is seated comfortably
• Show interest and respect
• Gain consent to proceed with the consultation

Identifying the Reason for Consultation

• Ask the patient why they are there today.
• Listen attentively to the patient’s response without interrupting.
• Check with the patient to confirm the reason for their visit.
• Set an agenda, considering both the patient’s and your own needs.

Gathering Information: Exploration of Problems

• Encourage the patient to tell the story of their problem(s).
• Use open and closed questioning techniques.
• Open questions encourage detailed responses.
• Closed questions elicit yes/no answers.
• Listen attentively to the patient’s responses, both verbally and non-verbally.

Gathering Information: Picking up on Cues

• Pay attention to the patient’s cues, expressions, and body language.
• Use appropriate language, avoiding medical jargon.
• Establish dates and sequence of events.
• Clarify if unclear information is provided.
• Summarise key findings, confirming your understanding and demonstrating attentiveness.

Identifying Ideas, Concerns, and Expectations

• Be aware of the patient’s:
  • Ideas: Beliefs about the cause of their problem.
  • Concerns: Worries about their symptoms.
  • Expectations: What kind of help they expect.
• Consider how the problem is affecting the patient’s life and daily living.

Providing Structure to the Consultation

• Ensure consultation flow with a logical structure and sequence.
• Summarise regularly before moving to the next section.
• Use signposting phrases, like "Now, I'd like to ask about your past medical history."

Building a Relationship with the Patient

• Pay attention to non-verbal behavior, including:
  • Eye contact
  • Facial expressions
  • Tone
  • Volume
  • Rate of speech
  • Posture
  • Position
  • Movement
• Reduce barriers, e.g., minimize computer use during the interview.
• Develop rapport through empathy, acknowledging patient views and providing support.
• Involve the patient, e.g., “Based on what we’ve discussed, my thoughts are… what do you think about that?”

History Taking Sequence

• Introduction and Consent
• Presenting Complaint
• History of Presenting Complaint
• Past Medical History
• Past Surgical History
• Medications
• Allergies
• Social History
• Family History
• Systems Review
• Summary
• Differential Diagnosis
• Management Plan

Past Medical History

• Use open questions to gain information about:
  • General health
  • Known medical conditions
  • Current or previous medical care
  • Past surgeries
  • Previous musculoskeletal, cardiac, respiratory, or gastrointestinal problems
• Use closed questions to confirm the presence of specific conditions.

Medications

• Identify current medications, including prescription, over-the-counter (OTC), and herbal remedies.
• Consider any recreational drug use relevant to the consultation.
• Document medications, including:
  • Name
  • Dosage
  • Frequency
  • Length of use
  • Reason for taking
  • Compliance
  • Side effects

Allergies

• Record any known allergies, including:
  • Medications
  • Latex
• Document the severity of the allergy and the reaction experienced.
  • Mild reaction vs. anaphylaxis

Social History

• Gather information about:
  • Home life
  • Living arrangements
  • Support network
  • Occupation
  • Stress level
  • Hobbies
  • Exercise habits

Social History (Continued)

• Assess the patient’s:
  • Smoking History:
    • Are they a current or former smoker?
    • How much did they smoke?
    • For how long?
  • Alcohol History:
    • Do they drink alcohol?
    • How often?
    • How much do they drink per occasion?

Family History

• Document the health history of:
  • Parents
  • Siblings
  • Include chronic conditions and their status (living or deceased).
• Assess for a family history of any known conditions, including:
  • Cystic fibrosis
  • Haemochromatosis
  • Diabetes
  • Heart disease
  • Stroke
  • Hypertension

Beyond the Scope of Year 1

• The following components of history taking usually fall outside the scope of the first year of medical training but may be covered in later years:
  • Systems Review
  • Summary
  • Differential Diagnosis
  • Management Plan

Small Group Tutorials

• Review lecture materials and relevant notes before a tutorial.
• A GP tutor will facilitate the session.
• Expect 10-12 students per tutorial.
• Students will form groups of three (patient, doctor, observer).

Learning Outcomes

• Demonstrate understanding of communication skills within a consultation setting.
• Be familiar with the Calgary Cambridge Consultation Model.
• Described the first four headings of the Calgary Cambridge Consultation Model.
• Understand the structure of history taking and its relationship to the consultation model.
• Be aware of summarising findings, forming a differential diagnosis, and developing a management plan.
• Recognize the importance of addressing the patient’s ideas, concerns, and expectations during the consultation.

Calgary Cambridge Consultation Model

• Developed by Suzanne Kurtz and Jonathan Silverman in 1996
• Revised over time, based on research
• Many other consultation models exist, each aiming to structure the patient interaction
• It is helpful for students starting out seeing patients

Calgary Cambridge Consultation Model

• This model encourages the doctor to be aware of the patient's ideas, concerns, and expectations (ICE)
• It is valuable for creating a good relationship, listening to the patient, and understanding their perspective

Initiating the Session

• Greet the patient, ask their name
• Introduce yourself and explain your role
• Ensure the patient is comfortable
• Demonstrate respect and interest
• Gain consent from the patient before beginning the session

Identify the Reason(s) for the Consultation

• Use an open question to identify the main reason for the consultation
• Listen attentively to the patient's initial statement, without interrupting or directing their response
• Check if you understand the problem correctly
• Negotiate an agenda with the patient, addressing both their needs and your own, to focus the consultation

Gathering Information

• Use a structured approach to explore the patient's problems
• Encourage the patient to tell their story
• Use open and closed questions to gather information
• Pick up on verbal and non-verbal cues
• Use clear and appropriate language, avoiding jargon
• Establish a timeline of events and clarify anything that is unclear
• Regularly summarise information back to the patient to ensure accuracy and show attentiveness

SOCRATES

• Useful to systematically gather information about symptoms
• Stands for Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating factors, Relieving factors, Severity
• Should be used for the presenting complaint and any other patient-reported symptoms

Past History

• Divided into Medical History, Surgical History, Medications, Allergies, Social History and Family History
• The aim is to learn about past experiences

Past History: Medical History

• Open questions:
  • Focus on their overall health
  • Ask if they have any known medical conditions
  • Enquire if they have any regular visits with a doctor or clinic
• Closed questions:
  • Aim to cover specific conditions, such as those related to the presenting complaint
  • Helpful to prompt the patient if they have forgotten about a history
  • If the patient reports having such conditions, be sure to explore the details

Past History: Surgical History

• Open questions:
  • Explore if they have had any previous operations
  • Ask about any investigations done in a hospital setting
• Specific to the presenting complaint:
  • Ask about previous musculoskeletal, cardiac, respiratory, gastrointestinal problems
  • Ask about any other relevant procedures they have had

Medications

• Current medications prescribed
• OTC medications
• Herbal remedies
• Recreational drug use (relevant to the consultation)
• Record what the medication is for, when it was prescribed, and if the patient is compliant with the medication
• Ask if the patient tolerates the medication or experiences any side effects
• Ensure there are no interactions between medications

Allergies

• Any allergies to medication or latex (especially if the patient is undergoing an examination)
• Explore the extent of the allergy, including what happened when exposed
• Record specific details of the reaction

Social History

• Explore factors related to the presenting complaint, like lifestyle or environment relevant to their health
• For example, if the patient complains of back pain, enquire about their job.
• If the patient presents with chest pain, ask about smoking and alcohol consumption

Family History

• Explore the patient’s family history to identify any relevant conditions, either by asking about specific diseases or using a family tree with an outline of those diagnosed
• It is best practice to ask about parents, grandparents, siblings, children, and other close relatives

Systems Review

• Ask about other systems that may be related to the presenting complaint
• Example: if the patient has chest pain, review the cardiovascular system (including shortness of breath, palpitations, chest pain, leg swelling) and respiratory system (cough, sputum, wheezing)
• Ask simple open questions regarding each system, and use closed questions to clarify

Summary

• Before moving onto the next section, summarise the information collected using the patient’s own words
• For example, “So, the chest pain that brought you here started yesterday, is worse when you breathe in deeply, and eases when you take ibuprofen.”
• This also demonstrates that you have been listening to the patient’s story

Differential Diagnosis

• Form a list of possible conditions that could be causing the patient’s symptoms
• This should be based on your interpretation of the history and examination
• Use the information gathered to rule out or support certain possibilities

Management Plan

• Create a plan of action for treating the patient, based on your assessment and diagnosis
• This may include investigations, treatment, or further consultation
• The final plan should be discussed and agreed upon by both patient and the doctor

Introduction and Consent

• Greet the patient, ask their name
• Introduce yourself and say what you do
• Make sure the patient is seated comfortably
• Show interest and respect
• Gain consent to proceed

Initiating the Session

• Identify the reason(s) for the patient’s consult
• Listen to the patient’s opening statement without interrupting
• Check with the patient to confirm the problem(s)
• Negotiate an agenda with the patient

History of Presenting Complaint

• Encourage the patient to tell the story of the problem(s)
• Use open and closed questioning techniques
• Listen attentively to facilitate the patient's responses verbally and non-verbally
• Pick up on cues, expressions, and body language

Gathering Information for Pain

• Use SOCRATES for pain:
  • Site: Where is the pain?
  • Onset: When did the pain start? Was it sudden or gradual?
  • Character: What does the pain feel like? (e.g., dull, sharp, throbbing, burning)
  • Radiation: Does the pain radiate anywhere?
  • Associated symptoms: Are there any other symptoms present?
  • Timing: How long does the pain last?
  • Exacerbating/Relieving factors: What makes the pain worse? What makes it better?
  • Severity: On a scale of 1-10, how severe is the pain? What impact does it have on daily activities?

Past Medical History

• Open questions:
  • How is your health generally?
  • Do you have any known medical conditions?
  • Are you attending a doctor or clinic regularly?
• Closed questions:
  • Do you have asthma? High blood pressure? High cholesterol? Diabetes? Depression? Epilepsy?
  • Rheumatic fever or heart disease? Stroke?

Past Surgical History

• Have you had any previous operations or investigations done in hospital?

Medications

• Current medications: Prescribed, over the counter (OTC), herbal remedies, recreational drug use
• List of medication:
  • What are they for?
  • When prescribed?
  • Compliance?
  • Tolerated/side effects?

Allergies

• Any known allergies to medications or latex
• Extent of allergy:
  • What happened when exposed? (e.g., nausea/vomiting/rash/swelling/collapse/hospitalisation)
  • Mild reaction vs anaphylaxis

Social History

• Home:
  • Who do you live with?
  • Do you have any dependents/children?
  • Do you have good support from family and friends/neighbors?
• Occupation:
  • Stressful?
  • Sedentary?
  • How do you manage work/life balance?
• Hobbies:
  • Sport?
  • How much exercise per week?
  • Other hobbies?

Social History (Continued)

• Smoking History:
  • Do you smoke?
  • Have you ever smoked?
  • How many?
  • For how long?
  • One pack year = 20 cigarettes/day/year
• Alcohol History:
  • Do you drink alcohol?
  • Would you drink every day?
  • How much?
  • How often?
  • Glass of beer - 1 unit
  • Pint of beer - 2 units
  • Glass of wine - 1-2 units
  • 1 measure of spirits - 1 unit

Family History

• Parents/Siblings:
  • Living or deceased?
  • Chronic conditions?
• Any known conditions that run in the family? (e.g., cystic fibrosis, haemochromatosis)
• Any conditions that can occur frequently in families? (e.g., diabetes, heart disease, stroke, or high blood pressure?)

Beyond the Scope of Year 1

• Systems Review
• Summary of findings
• Differential Diagnosis
• Management Plan

This quiz covers essential techniques for initiating and conducting a patient consultation. You will learn how to greet patients, identify their reasons for visiting, and gather comprehensive information through effective questioning and active listening. Mastering these skills is crucial for building rapport and ensuring a successful consultation.