Consulting Skills

The general-practice consultation is the cornerstone of primary healthcare in Australia. Australians make approximately 160 million GP visits annually, with an average of 6.2 consultations per person per year (AIHW 2023). The quality of the consultation directly influences diagnostic accuracy, patient adherence, health outcomes, and medicolegal risk.

Consulting skills are not innate — they are learnable, practisable, and assessable competencies. The Royal Australian College of General Practitioners (RACGP) mandates consulting skills as a core component of fellowship training across all five domains of the RACGP curriculum. Competency in consulting skills encompasses communication, clinical reasoning, physical examination, shared decision-making, and cultural safety.

A structured approach to the GP consultation — incorporating models of the consultation, systematic history-taking, targeted examination, and evidence-based management — provides a reliable scaffold that protects both the patient and the clinician. This article outlines the key phases and techniques that underpin effective consulting in Australian general practice.

Consultation models provide conceptual frameworks that guide the clinician through the structure and process of the medical encounter. No single model is universally superior; experienced GPs often blend elements from multiple models depending on the clinical context.

The Calgary–Cambridge Framework

Developed by Kurtz, Silverman, and Draper (1998, updated 2005), the Calgary–Cambridge model is the most widely taught consultation framework in Australian GP training. It provides a skills-based approach with five clearly delineated stages:

Pendleton's Rules (1984)

David Pendleton's feedback model focuses on what went well and what could be improved, and is widely used in GP registrar supervision and clinical teaching. The seven tasks of the consultation are:

• Define the reason for the patient's attendance (including symptoms, ideas, expectations, and the effects of the problem).
• Consider other problems (including continuing problems).
• Choose an appropriate action for each problem.
• Achieve a shared understanding of the problems and their management.
• Involve the patient in the management plan and encourage self-management.
• Use time and resources efficiently.
• Establish and maintain an appropriate doctor–patient relationship.

Patient-Centred Clinical Method (Stewart & Brown)

Stewart, Brown, Weston, McWhinney, McWilliam, and Freeman's Patient-Centred Clinical Method (5th edition, 2014) identifies six interactive components:

• Exploring both the disease and the illness experience.
• Understanding the whole person (contextual factors including family, work, culture).
• Finding common ground (shared understanding of the problem and goals of treatment).
• Incorporating prevention and health promotion.
• Enhancing the doctor–patient relationship.
• Being realistic about time, resources, and limitations.

The Bio-Psychosocial Model (Engel, 1977)

George Engel's bio-psychychosocial model expanded the biomedical model to include psychological and social determinants of health. In Australian general practice, this is particularly relevant given the burden of mental health presentations (approximately 1 in 7 GP encounters involve a mental health component — BEACH study data, Britt et al.), the impact of social determinants of health on Indigenous communities, and the increasing recognition of chronic disease management as a bio-psychosocial endeavour.

Balint's Approach (1957)

Michael Balint's work on "The Doctor, His Patient and the Illness" introduced the concept of the doctor as a therapeutic instrument. Balint groups (small-group reflective practice) remain a component of GP training in Australia and focus on the unconscious dynamics of the doctor–patient relationship, including "collusion of anonymity" in patients with medically unexplained symptoms.

The history remains the most powerful diagnostic tool in general practice. Studies consistently demonstrate that 70–80% of diagnoses can be made from the history alone (Hampton et al., 1975; Peterson et al., 1992). In the Australian GP context, where consultations are time-limited (typically 15–20 minutes), efficient and skilled interviewing is paramount.

Structure of the Medical History

Core Interviewing Techniques

• Open-ended questions: Begin each new topic with an open question (e.g., "Tell me more about the chest pain"). This maximises information yield and respects the patient's narrative.
• Focused/clarifying questions: Progressively narrow the differential using specific, closed questions (e.g., "Is the pain worse on exertion?").
• Reflective listening: Mirror the patient's language and emotion (e.g., "It sounds like that was really frightening for you"). Builds rapport and validates the patient's experience.
• Facilitation: Non-verbal cues (nodding, eye contact) and verbal cues ("Go on…", "Uh-huh") encourage the patient to continue their narrative.
• Signposting: Orient the patient to transitions in the consultation (e.g., "I'd now like to ask you a few more specific questions about the headache, if that's OK").
• Empathy statements: Explicitly acknowledge the patient's feelings (e.g., "I can see how worried you are about this").

Motivational Interviewing (MI)

Motivational interviewing (Miller & Rollnick, 3rd edition, 2013) is an evidence-based, patient-centred communication style designed to strengthen personal motivation for change. It is particularly relevant in Australian general practice for smoking cessation, alcohol reduction, weight management, medication adherence, and chronic disease self-management.

• Spirit of MI: Partnership, acceptance, compassion, evocation.
• Core skills (OARS): Open questions, Affirmations, Reflective listening, Summarising.
• Processes: Engaging → Focusing → Evoking → Planning.

Ask–Tell–Ask Method

An information-sharing technique used in the explanation and planning phase:

• Ask: "What do you already know about [condition]?" (assess baseline understanding).
• Tell: Provide targeted information at the patient's level of comprehension (chunk and check).
• Ask: "Does that make sense? What questions do you have?" (confirm understanding).

Working with Interpreters in Australian General Practice

Approximately 21% of Australians speak a language other than English at home (ABS Census 2021). Best practice for interpreter use includes:

• Use professional interpreters (TIS National — Translating and Interpreting Service, funded by the Department of Home Affairs) rather than family members, especially for sensitive topics.
• Speak directly to the patient in the first person (e.g., "Where does it hurt?" not "Ask her where it hurts").
• Allow additional consultation time (MBS Level C or D consultation items for longer consultations).
• For Aboriginal and Torres Strait Islander patients in remote communities, use Aboriginal Health Workers or community interpreters where available.

Physical examination in general practice differs from hospital-based examination in several important ways: it is typically hypothesis-driven (guided by the history), performed within time constraints, and conducted in a consulting room with limited equipment. The RACGP curriculum requires competency in a comprehensive range of examination skills, but clinical efficiency demands targeted, focused examination in most consultations.

Principles of Physical Examination in General Practice

• Informed consent: Explain what you intend to do and why; obtain verbal consent. For intimate examinations (breast, rectal, genital), written consent may be appropriate and a chaperone should be offered (RACGP Position Statement on Chaperones, 2020).
• Exposure and dignity: Expose only the area being examined; use draping; maintain a warm environment.
• Inspection first: Observe before touching. Up to 80% of clinical signs can be detected by careful inspection.
• Compare sides: Where applicable (e.g., neurological examination, joint examination), always compare with the unaffected side.
• Narrate your findings: Explain what you are doing and what you find, in language the patient can understand.

Essential Equipment for the GP Consulting Room

The Mental State Examination (MSE)

The MSE is a structured assessment of a patient's current psychiatric state. It is analogous to the physical examination for mental health presentations and is essential for mental health care plans (MBS items 721, 723) and risk assessment. The MSE should be systematically documented across the following domains:

Cognitive Assessment Tools in General Practice

• MMSE (Mini-Mental State Examination): 30-point screening tool; score <24 suggests cognitive impairment. Takes approximately 10 minutes. (Not freely available — requires purchasing a licence.)
• GPCOG (General Practitioner Assessment of Cognition): Validated, free, designed specifically for Australian general practice. Takes 4–5 minutes. Includes an informant component.
• MoCA (Montreal Cognitive Assessment): More sensitive than MMSE for mild cognitive impairment (MCI). Score <26 suggests impairment. Free for clinical use.
• 7-Minute Screen / TYM (Test Your Memory): Alternative tools with varying sensitivities.

Focused Examination by System

The following table summarises key examination approaches for common presentations in Australian general practice:

The management phase encompasses explanation of findings, shared decision-making, prescribing (where indicated), safety-netting, referral, and follow-up planning. This phase closes the loop of the consultation and directly influences patient outcomes and adherence.

Explanation & Shared Decision-Making

• Use plain language: Avoid jargon. Check understanding using the "teach-back" method ("Can you explain back to me what we've discussed today?").
• Provide written information: Use reputable patient resources such as healthdirect.gov.au, RACGP patient handouts, or condition-specific fact sheets.
• Shared decision-making: Present options (including watchful waiting), discuss benefits, risks, and alternatives, and elicit the patient's preferences. The Ottawa Decision Support Framework is a useful tool for preference-sensitive decisions.
• Decision aids: For common preference-sensitive decisions (e.g., prostate cancer screening, knee osteoarthritis management, antidepressant initiation), patient decision aids can improve knowledge and reduce decisional conflict (NHMRC-endorsed).

Prescribing Principles in Australian General Practice

• Prescribe generic medications where possible (PBS policy); note brand names where patients are established on a specific brand.
• Check for drug interactions (use the AMH Drugs app or MIMS Online).
• Consider PBS restrictions and authority requirements (Services Australia PBS Online).
• Use real-time prescription monitoring (SafeScript VIC, ScriptCheck NSW, QScript QLD, NT Check, etc.) for Schedule 8 medicines and high-risk Schedule 4 drugs.
• Discuss potential side effects and expected duration of treatment.
• Address antibiotic stewardship: do not prescribe antibiotics for viral upper respiratory infections; use the NPS MedicineWise "Choosing Wisely" recommendations.

Safety-Netting

Safety-netting is a critical risk-management strategy in general practice, especially for undifferentiated symptoms and conditions with diagnostic uncertainty. Effective safety-netting involves three components:

• Information: Tell the patient what to watch for (specific red-flag symptoms).
• Time frame: Provide a clear time frame for expected improvement (e.g., "If the cough has not improved in 3 weeks, come back").
• Action: Specify what to do if symptoms worsen (e.g., "If you develop fever or difficulty breathing, go to your nearest emergency department or call 000").

Referral

Referral is appropriate when a diagnosis is uncertain, specialist treatment is required, or the patient's needs exceed the scope of general practice. In Australia:

• GP referral letter: Should include presenting complaint, relevant history, examination findings, investigations performed, provisional diagnosis, reason for referral, and urgency.
• Urgency categorisation: Use the urgency grading system required by the receiving service (Category 1 — emergency, Category 2 — urgent, Category 3 — routine, Category 4 — information). Public hospital outpatient wait times are often 12+ months for Category 3 (AIHW data).
• MBS referral items: Specialist attendance requires a valid GP referral (MBS items 99, 104, 105, 110, etc.). Chronic disease management plans (MBS 721, 723) and team care arrangements facilitate access to allied health (up to 5 services per calendar year).
• My Health Record: Upload shared health summaries and event summaries to facilitate continuity of care during referrals (with patient consent).

Follow-Up & Continuity of Care

• Arrange follow-up based on clinical need — sooner for acute/emerging problems, regular intervals for chronic disease management.
• Use recall systems (automated in most Australian practice software) for chronic disease monitoring (HbA1c, BP, cervical screening, etc.).
• Document the follow-up plan clearly, including who is responsible for each component of care (GP, specialist, allied health, patient).
• Ensure the patient knows how to contact the practice for urgent concerns between appointments.

Documentation & Medico-Legal Requirements

Good documentation protects the patient and the clinician. The RACGP recommends the following standards:

• Contemporaneous (recorded at the time of or immediately after the consultation).
• Legible and attributable (include date, time, clinician's name and designation).
• Include clinical reasoning — not just findings, but why decisions were made.
• Document any refusal of recommended treatment or deviation from guidelines, including the patient's reasons and that risks were explained.
• Comply with the Australian Privacy Principles (Privacy Act 1988) and state-based health records legislation.

MBS Billing for GP Consultations

Effective consulting with Aboriginal and Torres Strait Islander Australians requires cultural safety, an understanding of historical and ongoing impacts of colonisation, and the use of culturally appropriate communication frameworks. The health gap between Indigenous and non-Indigenous Australians (life expectancy gap of approximately 8 years for males and 8.6 years for females — AIHW 2023) is driven by social determinants of health, barriers to accessing healthcare, and historical distrust of mainstream health services.

Cultural Safety in the Consultation

• Acknowledge Country: Recognise the Traditional Owners of the land on which the practice is located. Many practices display a formal Acknowledgement of Country.
• Ask, don't assume: "Would you like to tell me about your mob and where your family is from?" is more respectful than assuming identity or making assumptions based on appearance.
• Use of the term "Aboriginal and Torres Strait Islander": This is the respectful, inclusive term. Avoid "Aboriginal" alone (which excludes Torres Strait Islanders) or outdated terms.
• Yarning: Yarning is a culturally grounded communication style characterised by storytelling, circular rather than linear narrative, and relationship-building. Incorporating yarning into the consultation — especially during the rapport-building and history-taking phases — can significantly improve patient engagement and information disclosure.
• Silent pauses: Extended silence is comfortable and valued in many Aboriginal and Torres Strait Islander communication styles. Do not rush to fill silences.

Barriers to Healthcare Access

The Aboriginal and Torres Strait Islander Health Assessment (MBS 715)

MBS item 715 provides a comprehensive annual health assessment for Aboriginal and Torres Strait Islander people of any age. It is available once per 9-month period and is a critical entry point for preventive healthcare and chronic disease management. Key components include:

• Physical examination (including eyes, ears, cardiovascular, respiratory, musculoskeletal, skin).
• Screening for chronic disease risk factors (smoking, alcohol, nutrition, physical activity, obesity).
• Pathological investigations (FBC, EUC, LFTs, lipids, HbA1c, urine ACR, STI screening, hepatitis B serology where indicated).
• Immunisation status review.
• Social and emotional wellbeing assessment (use the SEWB tool or the Kessler-5/K10 for psychological distress screening).
• Follow-up plan with appropriate referrals, including to Closing the Gap programs and Indigenous-specific services.

Key Health Disparities

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