Communication in this setting is further complicated by the fact that GPs are generalists. That is, they focus on health promotion and disease prevention, as well as diagnosis and treatment of patients of all ages, ethnicities and social status. Nowadays, they frequently work in teams (the primary care team) and many have specialist interests in certain areas of practice.

Introduction

One of the distinguishing features of consultations in general practice is that the patient may bring any problem or query to the doctor. Thus we say that such interactions involve patients with undifferentiated problems or complaints. The wording here is from the traditional biomedical model in which a patient has a ‘presenting complaint’ and the doctor then takes a ‘history of the presenting complaint’ (HOPC). The first part of a consultation usually involves the GP gathering information and the second part involves the GP sharing information about the possible diagnosis and the management plan. The plan may include investigations and treatment. The GP may also take the opportunity, if there is time, to talk about health promotion and disease prevention. Such activities may include checking if the patient is up to date with immunisations and health screening, if a recent blood pressure reading has been recorded, and discussing risk factors for cardiovascular disease and cancer. GPs frequently refer patients to other healthcare professionals such as hospital specialists (for example, a medical doctor), allied health professionals (for example, a physiotherapist) and mental health professionals (for example, a psychologist). Patients referred for certain conditions and for team-based care under Medicare arrangements are eligible for a reduction in the usual fees charged by some healthcare practitioners. It is important for shared care arrangements that relevant information is exchanged between all the professionals involved with the permission of the patient.

Components of a general practice consultation: information-gathering

Information is gathered about the following:

• the presenting complaint;
  
• the history of the presenting complaint (for example, when and how the symptoms started, how severe, where, and so on);
  
• previous medical history (particularly if the GP has no previous medical records – physical and psychological);
  
• medication history (past and present medications including over-the-counter and prescribed);
  
• family medical history;
  
• social history (including employment, smoking, alcohol use, illicit drug use, exercise, and so on).

Of course, not all consultations begin with a ‘presenting complaint’ or a set of symptoms. The patient may have a very specific agenda such as a sexual health check, a prescription renewal or a screening procedure (for example, a cervical ‘Pap’ smear test). Patients may also use one problem as a way of initiating a consultation on something entirely different once rapport has been established.

There is a danger with the traditional history-taking that the patient is bombarded with a set of closed questions requiring only a ‘yes/no’ or minimal response – for example, ‘Have you had blood in your urine?’; ‘How often do you get up at night to go to the toilet?’ Such a bombardment of questions may reduce the opportunity for the patient to speak about their specific concern. The doctor should use a mix of open and closed questions. For example, the GP may start with a very open invitation: ‘Tell me about the pain’. The doctor can monitor the effect of such questions and whether they encourage the patient to tell the story in the patient’s own words. The doctor may need to follow this up with more focused questions to gain a better understanding of the symptom and its effect on the patient.

There are three models of communication, each distinguished by the degree of patient involvement. The biomedical approach to patient problems involves the application of science to clinical medicine. It aligns with a doctor-centred or paternalistic model of communication. Here, the disease and not the patient is the focus, and the aim is a physical diagnosis and potential cure frequently through issuing a prescription. The patient is not involved in the process after the initial ‘complaint’. The GP adopts a ‘fatherly’ (‘paternal’) manner and provides for the patient’s perceived needs without giving them any responsibility.

By contrast, the biopsychosocial model takes into account not only physical symptoms but also the patient’s psychological and social factors: the patients’ understanding of their problem and their emotional response to that problem (Pendleton et al., 2003).

Then we have the patient-centred model, in which the patient’s agenda (involving both explicit and initially hidden components) is paramount. The GP explores the patients’ ideas about what is wrong, their concerns about their symptoms and possible diagnoses, the effect of the problem on their daily life, and their expectations of coming to the doctor – what they hope to achieve in the consultation (Stewart et al., 2013). Each approach may benefit a particular patient and their complaint, and may be more or less suitable given the time available for the consultation.

Consultations with a GP in Australia may last from under five minutes to over half an hour. The length and complexity of a consultation determines how much a GP is paid. Medicare reimburses doctors for their time. If the Medicare fee is the same as the fee charged by the practice to the patient (that is, the practice ‘bulk bills’), then there is no gap fee for the patient to pay. However, GPs may charge patients above the Medicare price and thus the patient is ‘out of pocket’ depending on the gap.

Analysis and reflection

The consultation between John Baxter and Dr Malik illustrates a number of points about the nature of such interactions. In this case Dr Malik has access to John’s previous medical records, though these may not be complete. In Australia people are able to consult at any general practice surgery at which they can obtain an appointment. Thus, records, which are frequently computerised, may be held on several different computer systems over the course of a patient’s life. At the present time computers are not linked between practices. Nor are hospital records accessible in the community, though this may change in future once the electronic patient record (EPR) held centrally becomes more widely used.

Patients may request that their records be transferred from one practice to another if they move house, for example, but it is rare for any one GP to be able to see a full medical history. Letters following hospital admissions and clinic visits should be sent to the referring GP, but these are not always timely or received by the correct person. This can lead to fragmented care if important medical events are not accessible at the time of a consultation. It also means that each GP or practice may have to ask similar questions such as family history, with the repetition annoying the patient.

Moreover, we all know that past events in our lives can be forgotten or our memories become distorted over time. Patients may not remember the exact details of their past medical histories or what drugs they have taken (or even the names of their current medication). Thus, in this scenario Dr Malik cannot assume that he has all the details about John Baxter’s medical history. In fact, he has no idea what John may be consulting about.

In general practice one of the challenges for doctors is that patients may present with any type of problem: undifferentiated problems or complaints. The GP may just have had a very difficult and emotional consultation with a person, such as breaking bad news, and then the next patient may request a sexual health check. The GP should be able to change communication style in response to each patient’s problem and needs, and give undivided attention to the person being seen.

Let us return to the consultation seen above. As John Baxter enters the consulting room, the doctor will be forming an impression: does John look ill, is he in discomfort, is he anxious? Dr Malik begins with an open invitation to John to present his reason for consulting. As the pair have not met before Dr Malik might have considered introducing himself, but he has probably assumed that the receptionist has informed John of his name. John states his problem: a ‘pain in the chest’. Chest pain is a common symptom and it can have many causes from the serious (for example, heart attack) to the self-limiting (for example, pulled muscle). Dr Malik will already be considering the possible diagnoses in this case. He will take into account the patient’s age and history (if available). He will also be making an assessment of John’s physical status. Having decided that John is not acutely ill, he uses another open invitation or question to elicit more details about the pain, and then focuses down into a standard ‘pain history’, followed by an appropriate examination.

For Dr Malik the consultation appears to be going well. He has excluded serious causes for chest pain and suggested a management plan. However, the patient has another agenda; he is not reassured by the doctor’s conclusion. John’s query about whether the pain may have a more serious medical cause or ‘aetiology’ is interpreted by Dr Malik as a concern about cardiac problems.

In Dr Malik’s experience, patients often worry they are having a heart attack if they have chest pain. John, though, has another anxiety. He is able to express his concern about his colleague’s diagnosis. However some patients may not have been able to share their worries without an explicit invitation to do so. If Dr Malik had adopted a patient-centred approach, he would have asked John earlier in the consultation, while gathering information, about his ideas and concerns about the pain. He would still have to exclude other causes, but he could specifically allay the anxiety about lung cancer. If John had not raised the question about cancer he would have left the consultation with his anxiety unresolved and, perhaps, sought another opinion elsewhere.

Implications for practice

The ‘first half of the consultation’

Conducting consultations in a patient-centred manner has long been shown to improve healthcare outcomes (Stewart et al., 2013). Certainly a patient’s anxiety is reduced if a health professional explores the patient’s understanding of the problem and any ideas and concerns about its cause and diagnosis (Evans et al., 1987). The patient-centred approach involves considering patients as ‘experts’ in relation to their own health. In a classic study titled ‘Meetings with experts’ (Tuckett et al., 1985), in which the experts are the patient and the doctor, the authors defined a successful consultation as one in which a shared understanding was reached.

When a person makes a GP appointment they have an agenda that they wish to be dealt with. This may be a diagnosis of a new symptom, or it may involve a repeat prescription or advice about a continuing problem or lifestyle issue. The patient’s opening remarks, in response to the doctor’s invitation, are the only part of the consultation over which they have much control (Neighbour, 1987). Some patients rehearse what they are going to say before they enter the consulting room. Many are anxious and indeed this is a potent cause of ‘white coat hypertension’: a person’s blood pressure is raised above their usual reading when they consult a doctor (Pickering et al., 1988).

To minimise the chance of inducing ‘white coat hypertension’ in their patients, GPs are advised during their training not to interrupt a patient during their opening remarks. Studies have shown that people are unlikely to speak for more than 30 seconds without prompts, but many doctors ask questions before the patient has finished speaking, and may miss important cues about the agenda (Rabinowitz et al., 2004).

As noted, patients often have a ‘hidden agenda’ as well as their more overt one. This is another reason for the GP needing to consider the possibility that the patient’s real motive for consulting is not mentioned straight away (McKinley & Middleton, 1999). The hidden agenda may be revealed when discussing ideas and concerns, but it is advisable for doctors to ask before closing a consultation: ‘Is there anything else I can help you with today?’ Sometimes the patient brings up their additional agenda only when they are about to leave – the ‘doorknob’ comment (Weston, Brown & McWilliam, 2002). The danger is then that the doctor disregards the comment due to time pressures and the patient leaves with an unresolved problem.

There is also a risk, however, that overzealous doctors, particularly inexperienced GPs, try to uncover a hidden agenda in every consultation (Thistlethwaite & Morris, 2006). Sometimes consultations are straightforward. It is also possible the patient has a second concern but one which they are not yet ready to raise in the first consultation.

Finally, some patients may not be used to doctors who adopt a patient-centred approach. Many, particularly older patients who are used to paternalistic GPs, may feel they are wasting a doctor’s time with their concerns, especially if they perceive them to be not medical (Bensing, 1991). Many people are unable to share their own ideas and may not be used to discussing their health problems. However, patients with psycho-social problems have been shown to appreciate the patient-centred approach (Little et al., 2001).

The ‘second half of the consultation’

The second half of a consultation in general practice is frequently concerned with information sharing and management plans. After the GP has gathered information, doctors have to decide how much information to share with patients about their diagnosis, prognosis and treatment options. A patient-centred approach in the first half of the consultation may change into a paternalistic approach in the second half. In fact the patient-centred approach should also include the patient and the doctor finding common ground regarding management (Stewart et al., 2013). Management includes lifestyle changes, such as advice about smoking and weight reduction, as well as options regarding pharmacological treatments, referrals, surgery and so on.

Many health professionals still talk of patient ‘compliance’ – the patient needs to comply with the management plan otherwise they are labelled ‘non-compliant’. A vast amount of research has shown that many patients do not ‘comply’ with their prescribed treatments, with average adherence rates for patients with diabetes being between 36% and 93% across various studies (Cramer, 2004). There are many reasons for this, most of which are due to poor communication in the consultation, patients not being involved in decision-making, their different interpretations of risk, and the complexity of the treatment regimen (Claxton, Cramer & Pierce, 2001). Cost may also be a factor in those countries where there are no ‘free’ prescriptions.

Patients have been shown to want the following information from their GPs: clear information about what is wrong; a realistic idea of prognosis; what they can do to help themselves (that is, self-care); sources of help; what to tell their family; and how to prevent further illness or worsening of their condition (Coulter, Entwistle & Gilbert, 1999). In addition, in relation to any recommended medicines they want to know what the medication does and what it’s for; possible and common side effects; dos and don’ts such as whether they can take other medication and whether they can still drink alcohol; and how to take it (Dickinson & Raynor, 2003).

Theoretical links

The process of information sharing and the dialogue between patient and professional in regards to management is called shared decision-making. The process has the following characteristics: both the patient and the doctor (in this case) are involved; both parties share information; both work together to agree on preferences for treatment; and both reach an agreement on the treatment to start (Charles, Gafni & Whelan, 1997). In addition it is important for the patient and doctor to discuss their values: ‘values-based practice aims to support balanced decision-making within a framework of shared values, based on a premise of mutual respect’ (Fulford, Peile & Carroll, 2012, p. 24).

shared decision-making

the interaction process between the healthcare practitioner and the patient who come together to devise treatment plans. Shared decision-making becomes possible when there is mutual listening and shared dialogue.

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