I.C.E. (Ice Baby)

Before I start on today's topic and wanted to dispel a myth that has appeared in the comments section and I want to stop it before it potentially escalates. Contrary to popular belief - now this may surprise most of you - I am not a 'lazy GP'. In fact, I'm not even a GP - I am a GP Registrar, which means I am in training to be a GP. I have a morning session from 8.30am to 11am, seeing patients with 20 minute appointments. After the morning session I spend an hour or so seeing extras and home visits. In the afternoon the session runs from 4pm to 6pm, again with 20 minute appointments. It is not my fault that I have a 4 hour gap during the afternoon. However, even with the 4 hour gap I have to update my training ePortfolio daily - filling in details of clinical learning that I experienced during the morning and previous afternoon sessions. After all of that, I have the time to blog and do other things - so I am anything but lazy!

Now that's all cleared up, we can move on. Yesterday saw the usual commotion about whether it was the 1st day of Ramadan. Generally it has been accepted that yesterday was in fact the 1st of Ramadan. Ayatullah Sistani's UK based website, stated that the moon crescent was visible on the night of 1st September, and the Greenwich Royal Observatory has also declared that the crescent was visible on the night of 1st September. It also states that the next moon crescent will definitely be visible on the night of 1st October, making Eid on the 2nd of October for everyone inshallah.

Yesterday was a day of tutorials as part of our training during the Registrar year. Being the first day of fasting made the day particularly tough, but I somehow managed to plough through. The morning tutorial was about consultation skills in General Practice. I thought it might be interesting to discuss the art of consultation with you all in an attempt to demystify the work of a General Practitioner - I am sure you all very interested to know!

There have been many books written on the subject of consultation skills in General Practice. (Apparently, I am not the only doctor who has a lot of spare time). GPs have taken the time to study how people consult and then come up with models for the consultation to ensure that they go as smoothly as possible.

A common theme from these various models is that the consultations need to be patient-centred. After all, like anything in the consumer trade - it's all about the customer, the patient. Ensure that the patient comes first and you can't go wrong. Simple. So why is there so much literature on the subject? It's not that simple after all.

Dr. Roger Neighbour has written The Inner Consultation and it seems to be the most widely used when teaching GP trainees about the skills of consultation. He talks about "5 checkpoints that need to be visited on the journey that is each consultation."

1. CONNECTING: Being able to see the world through your patient's eyes - building a rapport with the patient and attempting to appreciate their views/beliefs/ideas.
2. SUMMARISING: Telling the patient what you think is the problem - the patient has a chance to correct you if there has been a misunderstanding.
3. HANDING-OVER: Agreeing a management plan between the doctor and patient. The responsibility lies with both parties (unless the patient hands full responsibility to the doctor and vicer-versa).
4. SAFETY-NETTING: Considering what may go wrong and planning accordingly. Giving the patient the chance to come back if there is no resolution to their problem.
5. HOUSE-KEEPING: Ensuring that the doctor looks after his/her own needs and is satisfied with the consultation.

Neighbour's model is popular because it can be flexible when used with different patients. It is apparently easy to remember (can you name the 5 check points yet? I can't!) A lot of the above is taken as standard practice engaged by most doctors. Labelling them as checkpoints is a way of ensuring it is done all the time with each consultation. An additional benefit is that it's the first model to actually consider what occurs to the doctor after the consultation.

Another model discussed was the Pendleton New Consultation, which has 7 tasks.

1. To define the reason for the patients attendance.
2. Take into account the patient's perspective - achieve a shared understanding.
3. With the patient, to choose an appropriate action for each problem.
4. To enable the patient to manage the problem - encourage him/her to accept appropriate responsibility.
5. To consider other problems.
6. To use time and resources appropriately.
7. To establish and maintain a relationship with the patient which helps to achieve the above tasks.

Reading all the above (if you managed to keep your eyes open), the two consultation models are practically the same. From the tutorial I came to the conclusion that all these consultation models are essentially the same. They all focus on a patient-centred approach and all discuss with clever language about how to connect with the patient, establish their concerns and develop appropriate management plans.

It all comes to the fundamentals of general practice: I.C.E.

• Ideas
• Concerns
• Expectations

That is the simplest way of putting it. Talking to the patient to develop their ICE. From there all the rest follows. Once I've established what the patients ICE is I can discuss the problems, advice the patients appropriately and come to an agreement over the management plan.

I've been doing this since I qualified. I didn't need a 2 hour tutorial to go into the various minutiae details about how to do it - I already follow the correct principal. By following the ICE principal, my consultations are automatically patient-orientated. It's only through ICE that I am able to advise and treat patients.

So, why do I need all the other stuff that just expand on the same thing? One word - 'exams'! To qualify as a GP I have to take the MRCGP (Membership of the Royal College of General Practitioners) and part of it is the theory paper which goes into a lot of details about various consultation models. In order to qualify as a GP, I need to learn about the above (and other) consultation models, just so I can answer questions on them. Also, from these models come the performance criteria for my practical exams - I will be observed conducting a range of consultations and in order to pass the examiner will have a tick sheet with various principals of the consultation models which I need to display during the consultation.

However, without wishing to sound complacent, I am pretty confident about the practical exams. By following the ICE principal, I should achieve quite a few ticks because the nature of the consultation should lead me to cover the relevant points from various consultation models used in the exam. Of course over the year I am meant to steadily show an improvement in my consultations and hopefully by sticking to ICE that should be straight-forward. It had better be, as the exam costs over £1400 and there's no refund if you fail - it's another £1400 to re-take as well - so no pressure then!

Having bored you enough, it's probably time to finish. Looking on the bright side, a) this has taken 10 minutes or so to read - that's 10 minutes not thinking about food! b) when you next see a doctor, see if they look after your ICE!

Take care all,
Thoughts just flow, when do they have to make sense?