Table Of ContentThe Inner Consultation
I offer this book to my trainer and partner
Peter Tomson
Who by his example has taught me many things – not least, to
follow my nose
The Inner Consultation
How to develop an effective and
intuitive consulting style
Second Edition
Roger Neighbour
MA,MB,BCHIR,DOBSTRCOG,FRCP,PRCGP
Boca Raton London New York
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Taylor & Francis Group, an informa business
Cartoons by Patrick Reade
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© 2005 by Roger Neighbour
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Version Date: 20151019
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Contents
Forewords to the first edition ix
About the author xii
Acknowledgements xiii
Guarantee xiv
Introduction to the second edition 1
Overview 13
Goal-setting
Skill-building
Getting it together
How to use this book
Section A: Goal-setting 21
A1 Problem? What problem? 23
Tutorial
Consulting skills: five case illustrations
A2 How have you been taught previously? 33
The Educational Paradigm
Models of skills training: simple, participatory and systematic
Assumptions in traditional methods of skills training
A3 Models of the consultation 45
Models in medicine: Cartesian dualism and the medical model
Models of illness
The role model
Task-orientated models of the consultation
Behaviour-orientated models
Models as transitional objects
A4 On having two heads 63
Internal dialogue
The Organiser and the Responder
vi Contents
A5 Keeping it simple: the consultation as a journey 75
Five checkpoints: connecting, summarising, handing over,
safety-netting, housekeeping
A left hand mnemonic
A6 Five ‘en route’ checkpoints 81
Case examples
Reaching and recognising the five checkpoints
Section B: Skill-building 97
B1 How people learn 99
Conscious and unconscious learning
The three stages of learning: instruction, imagination
and expression
B2 Checkpoint 1 (Connecting): rapport-building skills 113
What is rapport?
Gambits and curtain-raisers
Minimal cues: the physical signs of mental states
Representational Systems: Visual, Auditory and Kinaesthetic
The patient’s language of self-expression
Speech censoring, internal search and the acceptance set
Matching
B3 Checkpoint 2 (Summarising): listening and eliciting skills 143
Vernacular and medical language
Eliciting: what, when and how to elicit, and when to stop
Individual contexts
Maslow’s Hierarchy of Needs
Incongruities, non-sequiturs, deletions, distortions and
generalisations
Strategies for eliciting
B4 Interlude: the clinical process in general practice 169
The Ballad of Doctor Busy
Diagnostic strategies
Hypothesis-testing
‘Always make a management plan’
B5 Checkpoint 3 (Handover): communication skills 175
The handover process
The patient’s framework
Strategies for handing over a management plan: negotiating,
influencing and gift-wrapping
Contents vii
B6 Checkpoint 4 (Safety-netting): predicting skills 203
Three important questions to ask yourself
SOAP
B7 Checkpoint 5 (Housekeeping): taking care of yourself 211
Doctors have needs too
‘Time-stress’
The ‘red light’ quarter
Job stress, and what to do about it
Ebbing and flowing
Section C: Getting it together 229
C1 On having only one head 231
Improving by ‘trying’, and improving by ‘allowing’
Here-and-now awareness
C2 The Inner Consultation 239
Integrating conscious and unconscious learning
Timothy Gallwey
Listening, speaking and thinking
Distracting the second head
Minimal cues
Controlling your attention
C3 Zen and the art of the consultation 253
Intellect and intuition: two routes, one goal
Appendix 1: An ‘Inner Consultation’ training programme 261
Appendix 2: Annotated bibliography 265
Index 271
When at the first I took my pen in hand,
Thus for to write, I did not understand
That I at all should make a little book
In such a mode; nay I had undertook
To make another, which when almost done,
Before I was aware, I this begun.
And thus it was: I writing of the way
And race of saints in this our Gospel-day,
Fell suddenly into an allegory
About their journey, and the way to glory ...
This book will make a traveller of thee,
If by its counsel thou wilt ruled be;
It will direct thee to the Holy Land,
If thou wilt its directions understand:
Yea, it will make the slothful active be,
The blind also delightful things to see.
Art thou for something rare, and profitable?
Would’st thou see a truth within a fable? ...
This book is writ in such a dialect
As may the minds of listless men affect:
It seems a novelty, and yet contains
Nothing but sound and honest gospel-strains ...
Would’st read thyself, and read thou know’st not what
And yet know whether thou art blest or not,
By reading the same lines? O come then hither,
And lay my book, thy head and heart together.
John Bunyan
The Author’s Apology For His Book
‘The Pilgrim’s Progress’
Foreword to the first edition
Therehavebeenmanychangesingeneralpracticeinthelast15years;fewpeople,
be they doctors, practice staff or patients, have been unaffected by them. The
recent development of vocational training has brought considerable benefit to
patient care by defining the content of general practice, by promoting its emer-
gence as an academic discipline and by encouraging doctors to review critically
what it is that they are trying to achieve through their work.
Undoubtedly the content and organisation of general practice will continue to
change. In future, more people now cared for in hospital will be looked after in
their own homes by general practitioners and community-based nurses. Other
changes will result from the increasing specialisation in medicine as a whole, for
thiswillmean that thegeneral practitioner willhaveto takeonthe responsibilities
of the general physician to a greater degree than hitherto.
The philosophy of practice is changing. Now, many practices are beginning to
exploit the benefits of the registered list system which is a feature of the British
National Health Service and which enables practices to adopt a more population-
based approach to their work. More practices actively seek out the at-risk groups
within their populations and offer them a range of preventive services; the
application of computers in general practice helps in this.
Nevertheless, no matter how much general practice changes, nothing will ever
undermine the central role of the consultation. No matter how much the respons-
ibilities of general practice increase, and irrespective of more efficient practice
management,theconsultationwillalwaysremainthebasisforgoodqualitypatient
care. General practitioners will always need to develop and maintain their con-
sulting skills. The ability to find out and to understand why an individual patient
has sought help and advice, and together to be ableto agree the most appropriate
way forward, is an enduring attribute of the general practitioner. For this reason,
teaching young doctors consultation skills and how to understand people’s beha-
viour,includingtheirown,duringaconsultation,isanimportantpartofvocational
training for general practice. A range of teaching techniques directed towards this
has been developed. Most of these are based on small group work – on doctors
sitting in on each other’s consultations, on the review of audio and video record-
ings of actual consultations and on the analysis of role play, using professional
actors or doctors themselves playing their own patients.
Theliteratureonthissubjectisincreasing,withDoctorsTalkingtoPatientsbyPat
Byrne and Barrie Long published in 1976 as an early and important work. Roger
Neighbour’s book is a major contribution in this area. It sets recent literature on
theconsultationincontextandprovidesthebasisforgreaterunderstanding ofthe
content and interactions of the consultation, and the behaviour of its participants.
There ismuch inthis booktoguide the clinicianin any medical specialityand also
perhaps those in other professions, such as lawyers and politicians, who are
consulted by clients.
