The consultation in 7 steps: Performance and review of consultations in Family Medicine

Abstract

This article presents a model to practice and to critical analysis of consultations in general practice/family medicine. It is a proposal to be adapted to each particular clinical situation. It begun to be developed in 2005 as a small exercise to support training in consultation skills for the family medicine vocational trainees / residents in the Cascais Health Centre, in Portugal. This exercise was further developed and became a working book, edited in Lisbon in September 2008. The model proposes a consultation structure with three phases and seven steps. The starting phase includes two steps: preparation and the first minutes: 1 - Preparation - with a self-evaluation on how the doctor feels for the next consultation; who is the next patient with a brief review of the clinical records; and a brief appraisal of the physical environment of the consultation office (comfort, cleanness, good order, etc.). 2 - The first minutes - this phase is dedicated to the initial listening and attentive observation to the called patient. It is when doctor and patient meet each other and get the first signs and impressions and when a caring and therapeutic climate begins to be prepared. In this phase doctor pays a special attention to patients expectations and motivations (here and now). An intermediate phase follows, with three steps: exploration; assessment; and plan (EAP) always actively involving the patient in the decision making process: 3 - Exploration and contextualization - a step for the anamnesis, physical examination and contextualization of the approached health problems, understanding the patient, his illness, their worries and their problems, without forcing or deforming the patient narrative. 4 - Assessment (interpretation; diagnosis; prognosis) - the step when data and information are collected, interpreted, inter-related and integrated in a coherent explanatory framework, which make sense both for the doctor and for the patient, including quality of life impact assessment. 5 - Plan for action/care - to propose, negotiate and agree on actions and aims, including, if appropriate, preventive activities. A final phase to close the consultation and to reflect on it: 6 - Closing the consultation - with the confirmation that there are no remaining doubts and that the main expectations were met. It is also the time to accept feed-back from the patient about the consultation, namely his/her immediate satisfaction before closing the consultation warmly and formally. 7 - Final reflection - a reflexive moment on what happened during the consultation. It is also a step for «house keeping» on cognitive and emotional aspects before passing to the next patient. This phase may be useful to complete or to reformulate clinical records of the patient.