Life in ten minute slots: A review of The Inner Consultation

One day I see myself telling the next generation of medical students how in the olden days we used to only have ten minutes to see patients and often to have deal with multiple complaints in that same slot. On average most GPs will see at least forty patients in a day (some considerably more). In the early 1950s this would have been closer to a hundred [1] as shown in an early David Dimbelby documentary. It’s hard to comprehend why such a system exists and how it serves either patients or doctors best interests. Hopefully in forty years people will be disbelieving that medicine could ever have been delivered in this way much in the same way I was almost disbelieving of my cousin (less than ten years my senior) who told me about her first day of work. We did our house jobs in the same hospital, my first day finished at 6pm. She was told she would finish at eight, “eight this evening?” she asked. “No” came the reply. “Eight tomorrow morning?” she asked again. “No, eight the following evening” was the answer she was given.

How ten minutes came to be accepted as the time for a consultation I have not been able to find, thankfully opposition to it seems to be growing. In my meaner moments I wonder what would happen if it were patients that were forced to conform to it rather than their doctors. What if we told patients this is your ten minutes, you can use it how you will. Would that change the consultation if it was the patient had the pressure to get their story out, be examined and get treatment all within ten minutes.

As a trainee when you start in general practice you are normally given thirty minutes for a consultation though this rapidly moves down towards ten. Sometimes ten minutes is easy, a pill check, a fungal nail or a runny nose. Sometimes ten minutes is impossible, a broken marriage, attempted suicide or an unwell diabetic. Many times patients’ finish the consultation and I can be left mystified as to why they attended at all, whether they had a medical problem I missed or whether I was their only human contact for the week. Learning to manage the consultation is not a skill taught neither in medical school nor the relatively luxuriously paced interactions we experience during our time in hospital medicine.

Chief amongst the consultation bibles is Roger Neighbour’s The Inner Consultation. A combination of oriental wisdom and psychoanalytic theory it can at times feel almost New Ageish. Yet the key to surviving in ten minutes is self-awareness and structure and The Inner Consultation helps with both. Neighbour divides the consultation into five parts; connecting, summarising, handing-over, safety-netting and housekeeping. These five components can be applied to nearly every medical interaction yet seem only touched upon in General Practice. It is nearly impossible to stick to the structure, yet I wonder how many patients would recognise the steps as being something that their GP goes through during the consult. The five parts are as follows [2]:

  1. Connecting, the first point to aim for in a consultation. It usually doesn’t take very long, is just quickly building enough of a working rapport with a patient for you then to be able to take things further. That involves just setting the patient at ease and preparing the ground for effective communication.
  2. Taking the sort of focused history, listening to enough of the patient’s narrative to get a feel of what today’s agenda is. Being able to confirm to the patient that you’ve got that gist of today’s agenda by being able to summarise it to them very succinctly. So that they can recognise in your summary the fact that you’ve understood what they’ve come for.
  3. Handing over. At some point in the consultation you reach a point where a management plan or a way forward has been discussed and considered and agreed between you. But you have to make sure that the patient is happy with that. That involves you, as the doctor, systematically taking steps to hand over, to the patient, the management plan in a way that they’re totally happy with it and understanding of it.
  4. Safety netting means just thinking ahead. Anticipating what might go wrong. What might happen and having, in your own mind at least, prepared some next moves. So “What would I do if . . . ?” situations.
  5. Housekeeping. That’s to do with keeping oneself in good lick. Housekeeping means making sure that you don’t carry forward leftover feelings from one consultation to the next. Making sure that you’re in the right frame of mind. Looking after yourself to keep yourself both mentally, physically, and psychologically in good lick from one patient to the next. From one surgery to the next. From one week to the next.

Whilst the structure provided is useful, the books ability at helping the trainee (or practitioner) develop self-awareness is its greatest strength. Sometimes a consultation is doomed from the start. A careless word makes the patient clam up; a reprimand may stop further revelations. Whilst there is no cure for clumsiness with words since reading The Inner Consultation I have been more aware of what I say. There are techniques which seem to work well in eliciting further information but understanding what the patient wants from the consultation can still at times be a challenge. It can at times feel that The Inner Consultation is aimed at those that have a predominantly English speaking and relatively affluent demographic to deal with, alternatively my lack of success with some if its techniques may be my own inexperience.

Neighbour’s writing style is engaging. Whilst the Confucian* homilies can sometimes be laid on a little thick we are given a bird’s eye view of the consultation. Our own blunders are often cringingly illustrated in what not to do but the book is invaluable to any GP. Indeed anybody who wants to know what their GP may be thinking or why they are seemingly ignored would do well to read this foundation stone in the art of General Practice.

*Poetic license, I am aware a lot of the quotations are form other schools

References

[1] Enquiry: Potrait of a GP, BBC website.URL: http://www.bbc.co.uk/archive/nhs/5144.shtml

[2] An amended version of “Transcript of learning module Advanced communication skills 1: beginning the consultation – with Roger Neighbour”, BMJ Learning, URL: http://learning.bmj.com/files/pdf/ACS1.pdf

Item Reviewed

Title: The Inner Consultation second edition
Author: Roger Neighbour
Publisher: Radcliffe Publishing Limited (2005)

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