Consultation and Counselling Skills in Primary Care

A concise and complete history is key to success in managing patients in primary care. During consultations, always start by introducing yourself and your lecturer or collegues who happen to be in the same room. Even if the patient starts off the consultation by telling you why he/ she came to the Klinik Kesihatan today (e.g. pakcik datang hari ni sebab batuk), you still have to introduce yourself before continuing with the history taking.

The second most important element of history taking is clarifying your patients identity to avoid writing notes and prescribing for the wrong patient. At the same time, it is best that you ask him/ her the occupation (name, age, occupation). 

At the same time you should attempt to establish a good rapport with the patient so that the he/ she is more willing to share all the informations about himself/ herself with you. Amongst the strategies that you can use to establish this is by being cool and calm, confident, smile and have a good eye contact, comfortable sitting posture, not to fiddle with your pen too much, not to concentrate too much on writing notes, use the correct intonation and most importantly is to speak loud and clear.

Always be transparent (tell the truth to your patient) and non-judgemental in your consultation. Remember to ask sensitive questions SENSITIVELY (for example when asking about smoking, alcohol intake and taking a sexual history). When asking questions never assume anything. Start off with open ended questions then proceed to close ended question as necessary. For example, rather than say "pakcik duduk dengan anak isteri ke", it is better to ask whether he is married or not in the first place eventhough he is 50 years old, as for all you know he might still be single. Another example is, rather than saying to a patient who comes for diabetic/ HPT routine follow up, "pakcik datang untuk follow up kencing manis ye", it is better to ask him "pakcik datang follow up untuk apa hari ni". By this way you can assess whether the patient knows what disease he have. 

It is very important to be focused when taking history. Do not repeat the same questions many times as this may irritate the patient. A patient may come with more than one agendas. It is important that you address the patient's agenda otherwise the patient will feel unsatisfied when they leave the consultation room. As you go along, write down all the patient's agenda and prioritize your list. You don't have to deal with all the agendas in one consultation. You may ask the patient which is troubling him/ her the most and deal with that one first. Inform the patient that you will look into the other problems in the next consultation.

Always personalize your history taking. For example, a patient with Hypertension and Diabetes under the Klinik Kesihatan follow up, comes to see you today for a 1 year history of reduced vision in the left eye requesting for a referral letter to see the opthalmologist. Your main focus today is the reduced vision in the left eye. So you don't have to spend too much time asking about the hypertension and diabetes. Just do a general screening on the hypertension and diabetic control by looking at the FBS/ RBS and BP taken on that day.

During the consultation, it is always a good idea to summarize the problem lists and agendas with the patient as you go along so you don't miss anything important. Problem lists/ agendas are not only the clinical aspect of the illness but also includes th non-clinical aspects. An example of a problem list is as follow. It should be written in such a way so that the most important/ troubling problem be on top of the list and the least important/ troubling one at the bottom.

Problem list:
1) Uncontrolled Type II Diabetes
2) Poor compliance
3) Poor injection technique
4) Poor competency in managing illness due to forgetfulness
5) Poor self monitoring
6) Poor family support
7) Poor understanding of the Diabetes in terms of control and complications


Last but not least, it is a must that you have your own structured and systematic way of conducting a consultation. It is best to formulate two separate systematic approach of obtaining the following elements of history taking for ACUTE and CHRONIC cases; History of presenting illness, Systemic review, Drug History, PMH, PSH, Family History, Social History, ICE, Global cardiovascular risk and Opportunistic Health Promotion. It is also very important to explore how the illness affects the patients daily activities in the history such as Sleep, Work, School, Study, Appetite/ Oral intake, Prayers, Sexual activity and Family dynamics. 

Always bear in mind that the patients are not your PRIMER as in the OSCE exams. They are all human beings who have feelings the same as you. So always be EMPATHETIC throughout your consultation. For example, if the patient started to cry - give her a tissue, or if she tells you that her son recently was admitted to hospital for tonsilitis - ask her how is her son now. At the end of the day, the ultimate goal is to obtain a diagnosis after ruling out all the differential diagnoses in order to formulate a management plan for the patient. Always bear in mind that most diseases have a psychological and a drug cause on top of other aetiology (metabolic, endocrine and etc).  



Question 1: What are the 4P's and 4C's in the Basic Principles of Primary Care?

Question 2: What are the 8 Consultation models and 2 Counselling models?

Question 3: What are the 6 elements of Wagner model (chronic care model)?

Question 4: What is the hypothetical reductive reasoning which is used for history taking in acute cases? Give an example of the best way of asking about history of presenting illness (HOPI)?

Question 5: What are the important elements that need to be covered when taking history in chronic cases such as diabetes and hypertension (4C)? Give an example of the best way of asking about history of presenting illness (HOPI).

Question 6: What are the important points that need to be covered in the Social History? Give an example of the best way of asking about the Social History.

Question 7: What are the important points that need to be covered  in the Drug History? Give an example of the best way of asking about Drug History.

Question 8: What are the important points that need to be covered in the Family History? Give an example of the best way of asking about Family History.

Question 9: What are the ICE elements in the history taking? Give an example of how to ask questions to patients in order to elicit the patients' I.C.E.

Question 10: What are the 5 principles of management (P-LIMA) in primary care?

Question 11: What are the purposes of identifying RED FLAGS in the history taking?

Question 12: Taking a complete Sexual History is one of the weakness of medical students.  Give an example of the best way of taking a Sexual History.