The Consultation Model

Introduction

A consultation model is a structured framework describing the tasks that make up a medical consultation and the skills needed to carry them out well. Models exist because the consultation is the core unit of clinical work - it is where history is taken, a relationship is built, information is exchanged and decisions are made - and because doing it well is a learnable, assessable skill rather than an innate talent.¹

In UK undergraduate and postgraduate assessment, consultation skills are marked explicitly, usually against a structured model. OSCE stations for history-taking, explanation and consent, and breaking bad news are all scored partly on process - did the candidate structure the consultation, elicit the patient's perspective, and check understanding - not only on content.

Several models exist, but the one taught throughout UK medical schools and general practice training is the Calgary-Cambridge Guide, developed by Kurtz and Silverman. It is popular because it is comprehensive, evidence-based, and maps cleanly onto how a consultation actually unfolds in time.

Why structure matters

Unstructured, doctor-led consultations are efficient at gathering biomedical facts but poor at identifying what actually matters to the patient. Studies going back to the 1980s show that when doctors interrupt early and pursue their own agenda, they miss the patient's main concern in a substantial proportion of consultations, generate more complaints and litigation, and achieve worse adherence to treatment plans.²

Patient-centred, structured consulting is associated with better diagnostic accuracy, better symptom resolution, higher patient satisfaction and improved adherence - it is not a soft skill bolted onto medicine, it is part of what makes medicine effective.

The Calgary-Cambridge Guide

The guide breaks the consultation into five sequential stages, with two further tasks - providing structure and building the relationship - running throughout rather than occupying a discrete slot.¹

Initiating the session

The opening sets the tone for everything that follows. Confirm the patient's name and, where relevant, their date of birth. Introduce yourself by name and role. Establish rapport before moving to business - a purely transactional opening reads as cold and can make patients less forthcoming.

Identify the reason for the consultation with an open question ("What has brought you in today?" rather than "I see it's your knee?", which presupposes the agenda) and then screen for further problems ("Is there anything else you wanted to cover today?") before diving into the first one. Patients frequently mention their most important concern last if not asked explicitly, a phenomenon sometimes called the 'doorknob' problem.

Gathering information

This stage moves from open questions ("Tell me more about the pain") to closed questions ("Does it radiate anywhere?") as the picture narrows - the funnel technique. Jumping to closed questions too early constrains the patient's answers to your own hypothesis and risks missing information that does not fit it.

• Facilitation: encourage the patient to continue with verbal ("go on", "okay") and non-verbal cues
• Picking up cues: patients often signal concerns indirectly through word choice, tone or body language - naming the cue ("You mentioned you were worried, can you tell me more?") is a marked skill
• Clarification: ask the patient to explain vague or jargon terms ("What do you mean by 'dizzy'?")
• Internal summary: periodically reflect back what you have heard, both to check accuracy and to signal you have been listening
• Avoiding leading questions: "The pain doesn't go anywhere else, does it?" invites a fitted answer rather than an accurate one

Understanding the patient's perspective: ICE

Eliciting Ideas, Concerns and Expectations is the single most examined patient-centred skill, because it is what separates a disease-focused consultation from one that addresses the whole person.³

ICE is not a checklist to run through verbatim - asking all three mechanically, out of context, sounds stilted and is easy for examiners to spot. Woven naturally into the conversation, it frequently surfaces the real reason for attendance: a patient presenting with a headache who is actually worried about a brain tumour because a relative died of one needs that fear addressed directly, and a plan that only covers analgesia will not resolve the consultation.

Explanation and planning

This is where the balance of talking shifts from the patient to the clinician, and where most information is lost if done poorly. Studies of recall show patients retain a minority of what is said in a typical consultation, worse when a lot of information is given at once.⁴

• Chunk and check: give information in small pieces and check understanding before continuing, rather than delivering a monologue
• Avoid jargon: or explain it immediately if used - "myocardial infarction, that's a heart attack"
• Categorise information: signpost explicitly ("There are three things I want to cover: what I think is going on, what tests we need, and what we can do about it")
• Use the patient's own words and ideas as a starting point, correcting misunderstanding gently rather than dismissing it
• Check reactions, not just understanding - "How does that sound?" rather than only "Does that make sense?"

Shared decision-making

Where more than one reasonable option exists, present them together with their respective risks, benefits and the option of no treatment, and involve the patient in choosing. This is distinct from simply informing the patient of a decision already made, and it is what NICE means by shared decision-making: 'no decision about me without me'.⁵

Closing the session

Closing has three components: summarising what has been agreed, safety-netting, and checking the patient has understood and has no further questions.

End by confirming next steps in plain terms - what happens now, who will contact whom, and by when - and thank the patient.

Providing structure and building the relationship

These two tasks run throughout the consultation rather than occupying a stage of their own.

Providing structure

• Signposting: telling the patient what is about to happen and why ("I'd like to examine your chest now, is that alright?")
• Sequencing logically: moving through the consultation in a coherent order rather than jumping between topics
• Summarising at intervals, not only at the end, to check accuracy and keep both parties oriented
• Attending to timing: keeping the consultation to time without appearing rushed

Building the relationship

• Non-verbal behaviour: eye contact, posture, and appropriate use of notes or a screen without breaking engagement
• Empathy: naming and validating emotion explicitly ("That sounds like it's been really difficult") rather than moving straight past it
• Involving the patient: sharing your thinking ("I'm thinking about a few possibilities here...") rather than working silently
• Sensitivity: to discomfort, embarrassment or distress, adjusting pace and language accordingly

Other consultation models

Calgary-Cambridge is the most examined model, but you should recognise others referenced in the literature and occasionally in exam questions.

Neighbour's concept of housekeeping is worth knowing specifically: it is the deliberate practice of clearing your head after a difficult consultation before starting the next one, recognising that unprocessed emotional load degrades the quality of subsequent care.

Special situations

Remote consultations

Telephone and video consultations, now routine in general practice, remove non-verbal cues and make explicit safety-netting and clear structuring even more important. Confirming identity and a safe location, and having a low threshold to bring the patient in for a physical assessment when something does not add up, are standard safeguards.

Working with an interpreter

Use a professional interpreter rather than a family member wherever possible, particularly for sensitive or safeguarding-relevant content. Speak directly to the patient, not the interpreter, use short sentences, and allow extra time - the consultation will typically take twice as long.

Breaking bad news

A specific application of these skills, commonly taught via the SPIKES framework: Setting, Perception (what does the patient already know or think), Invitation (how much do they want to know), Knowledge (give a warning shot, then the information in small chunks), Emotion (respond to it explicitly), and Strategy/Summary. The same core skills apply - open questions, chunk and check, empathy, safety-netting - but the pace is slower and silence is used deliberately.

Common pitfalls in assessment

• Premature closure: narrowing to closed questions before the patient's agenda has fully emerged
• Doctor-centred consulting: pursuing a pre-formed hypothesis and ignoring cues that do not fit it
• Checklist ICE: asking ideas, concerns and expectations as three rote questions rather than integrating them naturally
• Jargon without explanation
• Vague safety-netting with no specific symptoms, timeframe or destination
• Failing to check understanding, especially after giving a diagnosis or complex information
• Ignoring emotional cues and proceeding directly to the biomedical agenda