One to One



Assessment  Reading

 Sample plan for VTS Communication course

Introduction to and beginning the consultation

10.00 - 4.45 pm

 Aims for leaders:

·      group forming

·      finding out where all the registrars are with their consulting

·      clarifying with the group what they would like to achieve by the end of the registrar year and matching it with what we can provide

·      explain the content and methodology of our teaching and why it is effective

·      give a demonstration of the method

·      tackle the beginning of the consultation; objectives and skills needed to achieve objectives

 10.00 am Introduction

Welcome and plan of the day, round of names


·        To explore together the structure and skills that we require to conduct an efficient, accurate  supportive and effective general practice consultation 

·        To look at the evidence that there are problems in the way doctors communicate with patients, that we can improve, and that these skills will be retained

·        To begin to use videorecording and rehearsal as a useful methods of analysing the consultation and  working out how we can improve our communication and consulting skills 

·        To explore what contributes to constructive and well intentioned feed back

 ·        To explore the beginning of the consultation, the objectives and skills needed to make this part of the consultation go well

 ·        To have fun


Pairs and feedback

you are all at different stages, but think back over the last few weeks and the patients you have either seen yourself, or consultations you have observed: 

·      What do you enjoy about consulting with patients in general practice?

what’s going well?

·      What are the difficulties?

            what would you like help with?

And specially for those who have just begun:

·      What have you noticed about the differences between consulting in hospital and general practice?

 Flip chart the difficulties and what they would like help with.

 Link with a quick mini-lecture on the issues of communication skills teaching

1.      why study the consultation

are there problems

are there solutions

2.      can communication skills be taught and retained

3.      what should we be teaching

4.      how should CS be taught

5.      is there a curriculum and what is it



Not just patient centredness but improved clinical competence.

Clinical competence = knowledge base, communication skills and problem-solving ability

The goals of effective communication: accuracy, efficiency, supportiveness - not just being nice

 Three questions to ask:

are there problems in doctor patient communication?

are their potential solutions?

can these solutions be taught and learnt?

If the answer to any one of these is no, we can all go home!!! Let’s start with the first two:

·        the evidence for there being problems in communication in the consultation (The Toronto Consensus Statement)

done as interactive lecture with questions and answers


1.      how many problems do people bring

2.      how many discovered

3.      which is the most important

4.      when do doctors interrupt

5.      what happens if doctors use closed questioning to hypothesis generation

6.      in what percentage of consultations do we underestimate our patients desire for info

7.      how many minutes spent in info giving

8.      percentage who do not adhere

9.      medico legal complaints related to communication


·        the evidence that communication skills make a difference to outcome, satisfaction and compliance

done as a few examples only again with interaction


The structure and skills of the consultation

Before we begin to consider your agenda any further, we think that it’s important to look at some models and frameworks of the consultation. We need ways of structuring our thoughts about the consultation and what is happening within it and to think about the tools of our trade, the communication skills that we use everyday and how they fit into the overall pattern of what we do as doctors, and how we combine them with our knowledge-base, clinical reasoning and problem-solving. We also need to develop some common language to help us as a group to look at this; how to analyse the consultation - and develop some mutually understood jargon.

What we’d like to do here is answer the two questions, can we define the skills that we are trying to learn and why we need some sort of structure to place them in.

·        a structure or framework or map

·        a list of skills

exercIse 3: In fours

From what you’ve read in the handouts and your own thoughts, and perhaps thinking of a recent fairly simple consultation if you like e.g. UTI or sore throat


Can you divide the consultation up temporally into 4 or 5 discrete sections - the landmarks of a consultation?

Use plain English without jargon

Try and work out a plan together

Can you further subdivide each of these discrete areas into up to 4 key objectives that both you and the patient are trying to achieve in each section? What broad areas do you need to consider to accomplish your needs as a doctor and also to help the patient achieve their needs in each section?

Try and work out a plan together in diagrammatical form on a piece of flipchart - be as inventive as you like

Feedback, compare models


What skills do you need to get there?

Add 3 or 4 skills in each section that you think are really important

What are the skills that doctors can use to enable the doctor and patient to achieve what they both need

Share the flip charts again

Discuss how these skills and the framework need to be added together to produce an overall guide and how structure and skills fit together

Describe a need for a temporal approach to describing the consultation

To enable all of this to occur for both you and the patient, the doctor has to take active control, it won’t happen just by chance - we are always in control of the structure. We need a temporal model or framework of the consultation, a structure that we can employ to allow it all to occur.

Show our exploded model on page one of the guide

Discuss how this fits in with the various models: all the same

Ours is a temporal approach to the consultation which helps put the theoretical models into practice by using the skills of the consultation

Explain how the all important disease-illness model and ours fit over each other.

Describe the theoretical importance of the collaborative partnership approach.

Need to have in mind an overall concept or model of the doctor-patient relationship.

Mention well backed by evidence: achieves better outcomes. Mutuality - major problems with the alternatives of paternalism and consumerism: skills would be different if paternalistic model.

Show the disease illness model - describe how helpful we find it is in our consulting - not commonly used in England: the central component of the collaborative approach - explains the unique role of doctors to explore both arms and the need to positively enable the patient to enter into the consultation: it won’t happen unless we engineer it.

However we need as doctors not just the collaborative model but also effectiveness within our time constraints

Not just to be supportive but also accuracy and efficiency

Clinical competence - knowledge, comm skills, problem solving

Need skills to enable you to take an accurate and efficient history and give information to patients as well as those needed to be supportive to the patient - need to consider the skills required for both the disease and illness arms of the model - fortunately the same!

 Introduce the importance of

·        structure

where am I - what do I want to achieve

what are my objectives/outcomes

·        skills

how do I get there?

·        behaviours

      how can I incorporate these skills into my personality?

 Skills are used at different times in the consultation, they are useful at particular times: Need to get down to a detailed skills level to analyse and learn - communication is a series of learned skills that must be split apart and then re-assembled into a seamless whole


A framework is useful for preventing aimless wandering (+ flexibility) e.g. disease/illness, or screening or repetition

Look at the first two pages of the guides again. Then refer to pages three and four of the guides.

Need to get down to a detailed skills level to analyse and learn - communication is a series of learned skills that must be split apart and then re-assembled into a seamless whole


As we will see, labelling the structure and the skills is still not enough: we need to explore exactly how you ask an open question or try to be empathetic. Later we can return to this and build on it. This is the third part, behaviour. Discuss personality: skills must be incorporated into our personality so that their use becomes natural - unconsciously competent.

11.30 - 11.45 break                      back to top

11.45 looking at a tape of a real consultation

 Analysis and feedback

In order for us to analyse a consultation and try to learn from it and improve, we need to have our  practice observed, we need to have some constructive feedback and the opportunity to try again.

(Briefly mention the research that experience is a poor teacher, and the research that supports the above).

The methods we can use in your registrar year are:

1.      videos of real consultations

2.      working with actors

3.      individual / paired roleplay

4.      cases and reverse roleplay

5.    observation of real consultations

Today we have the opportunity to look at a tape and do some roleplay

Brief paired exercise or brainstorm (depending on time) on having your own practice observed

·      in what circumstances has your practice been observed?

·      what happened?

·      what went well?

·      what was difficult?


Brainstorm and flip chart what the group would like in order to make being observed safe and constructive

Go briefly through ALOBA and link with their needs

 12.0 - (may be 12.15)  look at tape

 Hopefully an experienced registrar will have bought a tape! 

Fish bowl into two groups

Outside group to observe the process take notes and feed back in the last 10 minutes what interested them, and what they learned.

 Lunch 1.15 - 2.15 pm

2.15 pm split into two small groups to look in detail at the beginning of the consultation 

Round or pairs

Think back over the beginnings of consultations you have seen or done recently:

·      can you remember any specific problems?

·      what were they?

·      what would have helped?

·      what specifically did you notice in consultations that began well?

Flip chart

Objectives and skills in initiating the session

The beginning of the interview is a particularly rich area to explore in communication skills teaching. It sets the scene for all that occurs in the rest of the consultation.

Yet we know from research that many problems in doctor-patient communication occur in this initial phase of the interview. We also know that doctors tend to underestimate the potential difficulties and opportunities of these brief first minutes. In almost every communication course that we have run, the participants’ own communication concerns at the start of the course emphasise problems in ending the consultation and in keeping to time. But so often it becomes apparent as the course proceeds that it is the beginning rather than the end of the interview that is the root cause for many of their difficulties.

The specific communication skills that doctors choose to demonstrate at the beginning of the consultation are not merely social niceties: they have an important impact on the accuracy and efficiency of the interview and on the nature of the doctor-patient relationship. Initiation is therefore best considered as a separate task, even though it will take at most only a few minutes to achieve in real time.


Work together as a small group. It might help us to think of a recent fairly simple consultation to help guide our thinking

 1. Use a single piece of flipchart paper to construct a model just for the initiation phase of the consultation this time, that part of the consultation that occurs prior to the doctor starting to explore any one problem in depth.

 Look again at what we did in the first exercise when we tried to construct a model of the whole consultation, do we want to add any objectives for both us

and the patient : what are we both trying to achieve in this part of the consultation? What broad areas do we need to consider to accomplish our needs as a doctor and also to help the patient achieve their needs in this section?

Use plain English without jargon

Try and work out a plan together in diagrammatic form on a piece of flipchart - be as inventive as you like

 2. Again, what skills do we need to get there?

What are the skills that doctors can use to enable both doctor and patient to achieve what they would like in this section of the consultation

Add as many specific skills as you can to your flipchart to create an overall plan for initiating the session

Try to work out the specific phrasing and behaviour that you might use for each skill

Discuss the findings and refer to what the guides say about initiation

3.0 pm - 4.30 pm with a break for tea at some point

 options are:

·      roleplay / reverse roleplay cases where there has been a problem or scenarios which regs think that there might be a problem; we could get each reg in the group to practice on the same scenario

·      look at beginnings of tapes ( see below)

·      use a trigger tape eg immunisation tape

·      show one of your own tapes

·      roleplay a “bad” beginning

beginnings                                    back to top

 Suggest here that one way of looking at a part of the consultation, and to help with the  structure, would be to look at the beginnings of everybody's tape.

This can be helpful to registrars partly because it seems to be a reasonable way to "chunk" the consultation, but it is also a good part of the consultation to serve as a model for getting the registrar or a group to offer and list ideas, strategies, and phrases which work. Particularly good at practising descriptive feedback 

Explain the process; that we can all share together quickly our consultations, our styles, which after all are very personal.

Show each tape until clearly into the beginning of the story, until asked first closed question. 

Sell as a gift to the group, that we are all going to learn from each other, ? including the leader, who has no hidden agenda. This is not a competition. We all begin differently and how we begin depends on many factors.

Try to think about it from the patients view as well and get one to be the patient for rehearsal

Let’s start off with the person whose tape has been shown and we’ll ask them how they felt about it;

what they thought went well

and where the problems were.

Make sure that when we open it to the rest of the group, that what you say is descriptive,

well intentioned and non - judgmental.

 Possibly rehearse one suggestion

 (Problems for leaders about doing “beginnings” are  that it is comparative,and can become repetitive.)

 You could add in here a brief exercise to get them to be patient centred, by asking them to imagine themselves as a patient going to see their doctor; How would they like him to begin?

 Identify good practice, and the main goal of identifying why the patient has come.

 Flip chart good practice and check back with our framework and skills

May need to point out the point of “screening”. Back it up with the research, e.g. Beckman and Frankel. Add in that prioritising is important.

Note that the building relationship skills are important throughout the consultation.

Add lessons into our rolling model of the consultation, by summarising with "What are we trying to achieve here - in this part of the consultation, how do we get to where we and the patient wants to be?"

 Distinguish between structure and skills, concepts and specific skills

 Look at what can get in the way of a good beginning;

and how to make sure that the docs attention is focused correctly and the patient feels safe. (interruptions, records, wrong patient, computer, closed questions, not listening, no eye contact, no problem list identified) 

4.30 pm both groups together

feedback round

tasks to practise in the coming weeks

Read Chapter 2 of the Skills book

Next consultation pm gathering information   read chapter 3 first ? actors

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