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Does a background in general practice add to a doctor’s ability to communicate in palliative care? Derek Willis It’s interesting teaching you – you have a helicopter view of what is going on. Most trainees need to be taught to think laterally about consultations; you need to be taught to stop.

First of all let me declare my ‘medical upbringing’. ‘I am a hybrid; trained as physician and general practitioner (GP)’, the comment came from my supervisor when I started doing work-based assessments on my long haul, gathering evidence to specialise as a consultant in palliative medicine. To be fair, he had noticed that I often used this helicopter view to hide when I didn’t know the answer to a specific therapeutic question. My supervisor’s response made me think what my dual life as a former physician and then GP had mutated me into. What each had taught me and what skills each had given me. I was grateful for the way that Royal College of Physicians membership exam had taught me to diagnose conditions and the way it helped me as a medical problem solver. I was doubly grateful for the grounding in communication skills that GP training and practicing as a GP had given me. It also made me look at the communication skills training that other palliative medicine trainees get, and wonder if it really was as robust as the experience I had as a GP trainee. Maybe general practice discussions about snotty noses and sick Correspondence to Dr Derek Willis, Severn Hospice, Apley castle, Telford TF1 6RH, UK; [email protected]

notes may not have been that useful. However, given the number of ‘difficult conversations’ and collaborative discussions to find the right treatment or non-treatment in palliative care; the depth and width of experience of communication that GP training and experience provided can be nothing but good. This article is my argument about what palliative care specialists have to learn from general practice training and what we may want to steal for our training.

CULTURE Each medical specialty seems to have a skill or type of procedure that it has built itself round. That skill then, I would argue, comes to symbolise that specialty. For example, gastroenterologists pride themselves concerning their ability with endoscopes and respiratory physicians with bronchoscopes. Primary care has made consulting its own skill and made ‘the consultation’ the tool with which the specialty works.1 This is not to say that communication is not important in other specialties, but GPs have deconstructed the consultation, produced models to explain what goes on during their 10 min interaction and at a basic level take pride in the fact that this is what they are good at. I still have my icon to Roger Neighbour and in his ‘The Inner Consultation’, he says, No matter how much general practice changes, nothing will ever change the central role of the consultation2

Willis D. BMJ Supportive & Palliative Care 2013;3:221–222. doi:10.1136/bmjspcare-2012-000363

At heart, GPs think that the way you understand what is going on physically, emotionally and socially for a patient, arrives at a diagnosis and also arrives at a collaborative way forward. Through clinical examination or tests and through what goes on in a good consultation. Put more simply GPs should be good at communication, because the culture of the specialty states that good GPs are good communicators. EXAM Consultation skills are thought to be so important to general practice that they are more formally assessed than other specialties. A doctor has to reach a particular competency in consultation skills over and above those demonstrated in work-based assessments. In the dark ages, when I was training, this was through submitting videoed consultations that were graded by external examiners. Perhaps due to the level of dyspepsia that getting the video camera to work has caused, this has now been replaced by a ‘mock surgery’ using role players to construct an assessed virtual surgery. The fact that a simulated surgery is part of the exit exam shows the priority that the specialty gives communication. I would also argue that different assessment methods, viewed by different examiners are likely to guarantee that an embryonic GP has had their skills tested more rigorously than trainees in palliative medicine. APPRENTICESHIP One of the best ways of learning how to communicate is to watch and be watched doing it.3 The GP registrar year, now split and sometimes in two different group practices, gives more opportunity for a doctor to be watched doing the job of consulting. My experience was of having a morning each week for a full year of alternating patients where I watched a principal consult then they watched me. My learning from this experience was immense, and I never learnt so much about my strengths and weaknesses as a consulter as during that time.

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Column PRACTICE To my simple mind, it seems fairly clear that the more times one does something the better one gets at it. A GP generally has 10 min to see a patient. A morning surgery will last 3 h so that they will have seen 18 people by the end of the surgery. If you calculate how many consultations that is a year it adds up to a lot of practice at communicating, diagnosing and collaborating with patients. Again one has to admit that the consults may not all be ‘significant’ conversations. A lady may not have deep psychological problems that need exploring when she attends for her pill check. However, it is difficult to argue that the sheer volume of patients, problems and discussions that a GP has during their professional life does not impact positively on their communication skills. LONGITUDINAL CONSULTATIONS There is a perceived pressure in palliative medicine to cover all the bases in the first meeting. This often means that you take the patient everywhere from introducing the service to the preferred place of care via symptom control issues without drawing breath. One of the useful phrases I learnt from my GP days was the ‘longitudinal consultation’. In other words view the consultation as lots of little consultations that add up to one large consultation. Or put really simply you don’t have to cover everything in the first meeting because you will be seeing them again triage their problems. This has proved a really useful skill when I

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have been seeing patients in a palliative medicine context where the first consultation often involves me addressing people’s fear about seeing me in the first place. Often when I have tried to cover everything or seen others do so during the initial visit, we have succeeded in scaring a patient with so much information that they haven’t come back. Less is more! COLLECTED THOUGHTS So what is the thrust of my argument? I am not being as simplistic as to say GP training good, physician training bad. Both have strengths and holes when they are applied to palliative medicine training. My argument leaves me with a few questions, Entry into palliative medicine via general practice training and the Membership of the Royal College of General Practitioners (MRCGP) is now more difficult and lengthy than via general or internal medicine training and the MRCP. Will we put off colleagues with a primary care background and if we do so will we lose something? Would palliative medicine registrars benefit from 6 months in primary care and would it develop their communication skills further? Does the palliative medicine curriculum need more of a longitudinal emphasis to development of communication skills? When I did my training, a two-day training course in communication skills was the extent that was required within 4 years of palliative medicine training. Do we feel this is enough?

The exit exam for palliative medicine is a multiple choice question paper. Does this send out the correct signal about the importance we place on communication skills? By not formally examining our future consultants’ communication skills are we being effective in assessing their ability to communicate? Now if I was following Roger Neighbour’s consultation model correctly, I would now be doing ‘housekeeping’, in other words reflecting on how the consultation has made me feel. Maybe I’ll have to wait until the journal publishes its letter page before I can truly reflect on this. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. To cite Willis D. BMJ Supportive & Palliative Care 2013;3:221–222.

REFERENCES 1 RCGP Curriculum 2010, Statement 2.01 The GP Consultation in Practice, revised 30 May 2012. http://www. rcgp-curriculum (accessed 17 Sep 2012). 2 Neighbour R. Inner Consultation: How to Develop an Effective and Inituitive Consulting Style. 2nd edn. Radcliffe Publishing The Inner Consultation, 2005. 3 Aspergen K. Best Evidence Medical and Health Professional Education Guide No. 2: teaching and learning communication skills in medicine-a review with quality grading of articles. 1999;21:563–70. doi:10.1080/ 01421599978979

Willis D. BMJ Supportive & Palliative Care 2013;3:221–222. doi:10.1136/bmjspcare-2012-000363

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Does a background in general practice add to a doctor's ability to communicate in palliative care? Derek Willis BMJ Support Palliat Care 2013 3: 221-222

doi: 10.1136/bmjspcare-2012-000363 Updated information and services can be found at: http://spcare.bmj.com/content/3/2/221

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