Is there a crisis in clinical consultations?

At medical school and beyond, a great deal of training focuses on the clinical consultation. There is a vast literature devoted to the subject. Thousands of medical educators worldwide spend their time inculcating good consulting skills in students and trainees. Yet we pay surprisingly little attention to the real-life conditions in which consultations actually take place. These are often far from ideal. Many patient encounters happen in circumstances where satisfactory conversations, let alone reflective and sensitive ones, are well nigh impossible. The factors preventing good consultations are well known. Staff may be overworked and harassed, so that their priority is to do everything as quickly as possible. Colleagues may be hard pressed, so that everyone is reluctant seek to advice or call in help. Wards, out-patient rooms and casualty departments can be overcrowded and noisy, at time even chaotic. They may provide little or no opportunity for privacy or confidentiality. Paper and electronic records may be difficult to access – or they may be set out in ways that do not highlight important information. Fragmentation between specialties and departments, and poor systems of communication, may lead to long hold-ups in patient management. The presence of computers may enhance the consultation in some ways, but it is equally likely to introduce distractions, particularly through the requirement for continual data entry. The cumulative effect of these factors is that the consultation style that doctors learned in their training may be may be replaced by an automatic one that is aimed mainly at professional self-defence and clinical fire-fighting.