The duration of consults in medicine has been a bone of contention for years. Nowhere has the issue received more attention than in the UK where the issue of access to general practice has been the subject of debate and discussion since at least since the late nineties. The following graph depicts the duration of consults in one data set:
The accompanying commentary summaries the position well:
The shape of the curve highlights the extent of variation, though the mean is just under 12 minutes … In the GP contract 2014 the requirement for a 10 minute consultation has sensibly been dropped. Some clamour for 15 minutes – and they are right, but for only a small minority of patients. Many more need under 10 minutes, also right. What is inefficient is allocating the wrong time – too short, and rework results. Too long, throughput falls and waits rise.
Therefore the issue is not merely the ‘duration’ of consults but what actually transpires in those meetings. Decades of research have identified the tasks for both parties in the consult (the paper below may not have been written by someone whose first language was English but they make their point):
For example: patients face the issues of how to put their concerns on the floor (Robinson and Heritage 2005); how to show themselves to be properly oriented to their bodies (Halkowski 2006, Heritage and Robinson 2006, Heath 2002); how to direct the doctor’s attention toward and away from certain diagnostic possibilities (Gill and Maynard 2006, Gill et al. forthcoming, Stivers 2002b); and how to deal with diagnoses and treatment recommendations that may or may not correspond to their own views and preferences (Heath 1992, Stivers 2002a, 2006, Peräkylä 2002).
From the point of view of doctors, issues include eliciting all of a patient’s concerns (Heritage et al. 2007, Robinson 2001) and designing solicitations that are fitted to the concerns that patients are likely to have (Heath 1981, Robinson 2006); preparing patients for no-problem diagnoses (Heritage and Stivers 1999) as well as difficult diagnostic news (Maynard 2003, Maynard and Frankel 2006); and securing patient agreement in regard to diagnoses (Peräkylä 2006) and treatment recommendations (Stivers 2006, Roberts 1999). Pilnick et al
We know that the doctor will be taking notes or referring to the patients records during the consultation.
Conversation analytic studies have shown that participants of a conversation constantly monitor each other
and the unfolding speech in order to be able to perform the relevant next action when the present speaker has ﬁnished his turn of talk (Sacks, Schegloﬀ & Jeﬀerson, 1974). The direction of gaze is of utmost importance here, as gazing at the speaker constitutes a display of attention by the recipient (Goodwin, 1980, 1981; Heath, 1986; Robinson, 1998).
In addition to direction of gaze, the engagement framework may be created and maintained by shifting one’s posture (Kendon, 1990; Schegloﬀ, 1991; Robinson, 1998), or gesturing in the visible ﬁeld of the intended recipient (Goodwin, 1986; Heath, 1986). Shifts in posture that may be treated as displays of attention or disattention can be analyzed as shifts of ‘home position’ of the body (Schegloﬀ, 1991)
As in everyday conversation, in doctor– patient interaction the participants constantly monitor each other’s movements and direction of gaze (Heath, 1986; Robinson, 1998)
Johanna Ruusuvuor’s research, quoted above also suggests that there are four circumstances in which the consultation becomes dysfunctional insofar as the patient’s narrative is inhibited.
- Disengagement with home position away from the patient:
The doctor is seated facing the a desk away from the patient and does not make eye contact with the patient as they start to disclose the reason for the consultation.
2. Disengagement with manifest shift in orientation:
The home position of the doctor is towards the desk with his head in torque towards the patient. He releases his torque simultaneously as he withdraws his gaze from the patient.
3. Disengagement at critical point of description:
Turning away at a moment when maintaining mutual involvement in a common focus of interest has been made speciﬁcally relevant, and when the utterance is still incomplete with only the very core of the complaint pending, seems to be interpreted by the speaker as a disengagement from the role of the recipient.
In the last two examples the postural orientation of the doctors, and the way in which the doctors turned away from the patient to the records within the patients’ turns were enough to convey a disengagement from interaction with the patient
4. Disengagement at critical point of story-telling:
The doctor’s home position is towards the patient. From time to time he turns his upper body to torque towards the desk, making notes. The doctor disengages when the patient is about to reach the completion of her/his turn.
There are speciﬁc moments in which disengaging from interaction with the patients hampers a good outcome because it interrupts the narrative and the conversation becomes disjointed. Therefore it may pay great dividends to note where you are looking and how you are positioned during the consultation.