Does the structure of the medical consultation align with an educational model of clinical communication? A study of physicians' consultations from a postgraduate examination.

OBJECTIVE: This study examined whether the structure of consultations in which physicians were tasked with sharing information corresponded to the chronological stages proposed by an established educational model of clinical communication. METHOD: Seventy six simulated consultations from a postgraduate examination for general medical hospital physicians were transcribed verbatim and converted into diagrams showing consultation structure. All doctor-patient/relative talk was allocated into six phases: Initiating, Gathering information, Summary, Explanation, Planning and Closing, using the 'communication process skills' from the Calgary-Cambridge Guide to the Medical Interview. RESULTS: The majority of consultations included four or five of the expected phases, with most talk (41-92%) in Explanation and Planning. There was no discernible consistency of structure across the consultations or in consultations from the same scenario. Consultations varied in the presence, sequential order, size, location and reappearance of phases. CONCLUSIONS: The structure of consultations in this standardised setting bore little resemblance to the chronological order of phases predicted by an educational model. PRACTICE IMPLICATIONS: Educational guidance and interventions to support patients in preparing for consultations need to take account of doctors' behaviour in practice. Assumptions about the organisation of medical consultations should be queried in the absence of an evidence base.