The 7-step consultation: what we learned and how to improve it?

Ramos, Victor Manuel Borges; Carrapiço, Eunice Isabel do Nascimento

doi:10.1590/1413-81232025307.21842024

Abstract

In 2008, the book, “A Consulta em 7 passos” (Consultation in 7 steps), was published in Portugal. This work proposes, for training and learning purposes, the structuring of medical consultations into three stages and seven steps: preparation; first minutes; exploration; evaluation; plan; closure; and final reflection. This article aims to briefly assess “what we have learned and what we believe can be improved”. Over the years, the authors have gathered new ideas, criticisms, and suggestions on the application of the method in dozens of meetings and training sessions with interns and residents. The most important points include: the method should be applied with flexibly; the consultation should be considered to be only one piece of the broader and more complex mosaic that is health care for each person; it is important to emphasize the perspective of the meeting of people, agendas, and objectives; the existence of a personal, unified, and integrative clinical record; the optimal use of information and communication technologies; the need to develop a “personal/individual care plan” and the concept of “personal self-management of health”; the inclusion of the person-centered clinical method in a more comprehensive systemic model; and the development of collaborative intelligence and action in multidisciplinary teams dedicated to caring for each person and family.

Key words:
Medical Consultation; Patient-Centered Care; Primary Health Care; Personal Health Management

Resumo

Em 2008 foi editado em Portugal o livro “A Consulta em 7 passos”. Nesta obra, propõe-se para efeitos de treino e aprendizagem, a estruturação das consultas médicas em três fases e sete passos: preparação; primeiros minutos; exploração; avaliação; plano; encerramento; e reflexão final. Este artigo pretende fazer um breve balanço “do que aprendemos e do que consideramos poder melhorar”. Os autores recolheram ao longo dos anos em dezenas de reuniões e sessões de formação com perceptores e residentes novas ideias, críticas e sugestões sobre a aplicação do método. Destacam: o método deve ser aplicado com flexibilidade; a consulta deve ser considerada apenas uma peça do mosaico mais amplo e complexo que é a atenção de saúde a cada pessoa; é importante dar ênfase à perspetiva do encontro de pessoas, agendas e objetivos; a existência de um prontuário clínico pessoal, unificado e integrador; o aproveitamento otimizado das tecnologias de informação e comunicação; necessidade de desenvolver o “plano pessoal/individual de cuidados” e o conceito de “autogestão pessoal de saúde”; incluir o método clínico centrado na pessoa num modelo sistémico mais abrangente; desenvolver inteligência e ação colaborativas nas equipes multiprofissionais dedicadas aos cuidados a cada pessoa e família.

Palavras-chave:
Consulta Médica; Cuidado Centrado no Paciente; Cuidados de Saúde Primários; Autogestão Pessoal de Saúde

Resumen

En 2008 se publicó el libro “A Consulta em 7 passos”. En este trabajo, con fines de formación y aprendizaje, se propone estructurar las consultas médicas en tres fases y siete pasos: preparación; primeros minutos; exploración; evaluación; departamento; cierre; y reflexión final. Este artículo pretende repasar brevemente “lo que aprendimos y lo que consideramos que podemos mejorar”. A lo largo de los años, los autores han recopilado nuevas ideas, críticas y sugerencias sobre la aplicación del método en decenas de reuniones y sesiones de formación con perceptores y residentes. Se destacan los más importantes: el método debe aplicarse con flexibilidad; la consulta debe ser considerada sólo una pieza del mosaico más amplio y complejo que es la atención de salud de cada persona; es importante enfatizar la perspectiva de conocer personas, agendas y objetivos; la existencia de una historia clínica personal, unificada e integradora; el uso optimizado de las tecnologías de la información y las comunicaciones; necesidad de desarrollar un “plan de atención personal/individual” y el concepto de “autogestión personal de la salud”; incluir el método clínico centrado en la persona en un modelo sistémico más integral; Desarrollar la inteligencia y acción colaborativa en equipos multidisciplinarios dedicados al cuidado de cada persona y familia.

Palabras clave:
Consulta Médica; Atención Centrada en el Paciente; Atención Primaria de salud; Gestión Personal de la Salud

Explanatory Note

The “7-step” method proposes structuring medical consultations into three stages (initial, intermediate, and final) and seven steps: preparation; the first few minutes; exploration; evaluation; plan; closure; and final reflection.

This method has been used in several locations where internships/postgraduate and specialization residencies in family medicine are carried out, as well as in some postgraduate medical training programs in several Portuguese-speaking medical schools.

Studying, training, and perfecting techniques to conduct and critically analyze consultations are considered to be essential as foundations for clinical professional proficiency, especially in the first years of practice. Making aware, with clarity and sufficient detail, what takes place in each consultation: in terms of content, structure, processes, and results, can have a positive impact on the quality of care provided, the efficiency of the consultation, and the satisfaction of users/patients and doctors themselves.

The “7-step” method is a suggested work and should be applied with critical thinking and flexibility. In parallel, it is proposed that the following be developed in Portugal from a theoretical, methodological, technological, and practical point of view: the “personal medical record”, integrated, unified, supported by appropriate digital technologies, including systemic interoperability; the “personal/individual care plan”, as an essential component of the “personal medical record”; the concept and practices of “personal self-management of health”; and the “integrated clinical model”.

Introduction

Between 2003 and 2007, a reflective and practical exercise was designed within the scope of general and family medicine residency, at the Cascais Health Center in Portugal, on the initiative of and with the participation of residents and preceptors from that health center, specifically dedicated to practical training in carrying out medical consultations. This exercise was based on a practical selection of available literature, with emphasis on the works of Pendleton and other authors¹^-⁷.

However, the bibliography consulted at the time, although essential, was insufficient to respond to and overcome many of the pragmatic challenges faced by young doctors in consultations. The preceptors also became aware that, despite their practical experience in family medicine consultations, they would benefit from a framework of practical guidance that would both help them support residents and critically improve their own reflective and practical skills in consultations.

Therefore, to answer their questions and needs, they began a process of reflection and critical analysis of what they had been doing for years, in an intuitive and repetitive manner. They realized the need to detail and clarify what was taking place in each consultation: in terms of content, structure, processes, and results. They then began a process of interactive co-creation, based on the difficulties and needs perceived by the residents and the preceptors themselves.

The work resulted in six practical guidance sheets, organized as follows: a general framework and summary text, together with five sheets related to the five consultation steps defined at the time. The steps were: 1. The first minutes; 2. Exploration; 3. Evaluation; 4. Plan; 5. Conclusion | Closure.

This exercise became known by residents and preceptors from other health centers who invited the initial group to organize training sessions in various locations to present and discuss what was being done at the Cascais Health Center. Several modifications were made during those sessions, enabling improvements and development in the initial forms. In this sense, and over the course of several sessions with colleagues from other locations, the “7-step” model was created. The steps “Preparation” and “Final Reflection” were added to the five original steps.

This exercise became widely known, to the extent that the Board of the Portuguese Medical Association of General Practitioners (known since 2011 as the Portuguese Association of General and Family Medicine (Associação Portuguesa de Medicina Geral e Familiar - APMGF)) proposed the publication in book format of all the materials that had already been developed and written⁸. It is important to note that the specialty of GFM in Portugal can be considered equivalent to Family and Community Medicine in Brazil.

To create a structure of the book and improve the didactic impact of the already prepared practical forms, explanatory paragraphs and testimonies of brief vignettes and notable clinical situations were gathered, which were illustrative and sometimes quite humorous. More than 30 family doctors from various regions of Portugal participated in this process. Several illustrations were included in the book, and it was edited in 2008. Since then, it has been made available for free in several sites, specifically at: https://apmgf.pt/wp-content/uploads/2020/06/A-Consulta-7-passos.pdf.

The following year, an article summarizing the essential content of the book was published in the Revista Portuguesa de Clínica Geral (currently named Revista Portuguesa de Medicina Geral e Familiar)⁹. This article has been widely accessed in Brazil, Portugal, and other parts of the world.

Nonetheless, the “7-step” method has been used in several locations where specialization residencies in Family and Community Medicine are offered (in Portugal, the specialty is called General and Family Medicine) as well as in some post-graduate medical training programs in several Portuguese-speaking medical schools. Based on the initial proposal, several authors have carried out exploratory empirical studies and even adapted it for remote application during the COVID-19 pandemic¹⁰^,¹¹.

Fifteen years later, after collecting new ideas, criticism, and suggestions on the application of the method in several meetings and training sessions, we will now make a brief review of what was learned and what we believe we can improve in relation to the method itself, as well as the ways in which it can be used in everyday practice.

Starting Point

We believe that it is worthwhile to briefly recap the stages and steps of a General and Family Medicine consultation, especially for those who have not read the book and article mentioned above⁸^,⁹.

Stages and steps of the consultation

The method proposed in 2008 included three stages and seven steps for the execution and critical analysis of a consultation (Figure 1 and Chart 1).

Thumbnail

Chart 1
Steps of the consultation.

Figure 1
Diagram of the stages and steps of a medical consultation proposed in “The consultation in 7 steps”.

Initial Stage - preparation and first minutes

This stage aims to prepare the stage for what is to follow. It requires concentration, focus, attention, and critical selectivity, and is comprised of two steps:

Step 1 - Preparation - when the following points are reviewed: the situation and conditions of the doctor, the context (doctor’s office, home, or other), and the individual who requested the consultation, before being present and interviewed;
Step 2 - The first minutes - when the person is called, met, greeted, and welcomed, and physical and emotional signs are identified, as well as reasons for the consultation. Additionally, schedules will be arranged between the doctor and the patient.

Intermediate Stage - exploration, evaluation and plan (EEP)

This stage corresponds to the course of the consultation, when subjective and objective data and information are collected. It is also during this stage that the core interactions of the consultation take place; mutual understandings are validated; and the evidence, data, information, and knowledge gathered are intellectually processed. The essential objective is to arrive, always with the patient’s participation and involvement, at an assessment and a mutually agreed action plan. Although the steps should be sequential, in practice there is always some form of multidirectionality between these three steps. It may be the case, for example, that certain data is only obtained when discussing the plan, which may then result in a “front to back” movement, and vice-versa. It is, therefore, necessary to maintain some structure and flexible discipline when conducting the process, thus allowing for the indispensable openness. This stage consists of three steps:

Step 3 - Exploration - when data and information (subjective, objective, and contextual) are collected, analyzed, and contextualized;
Step 4 - Assessment - when interpretation, diagnoses, explanations, and predictions (prognoses) are conducted, and impacts on quality of life are assessed and anticipated;
Step 5 - Plan - when decisions related to the current consultation are prepared and integrated into the ongoing individual care plan, if there is one. This is the stage of proposals, negotiations, agreements, and compromises for action, including prevention.

Final stage - closing and final reflection

This is the time to review and summarize what took place. First, with the person who consulted the doctor, then as a recorded self-reflection. The purpose is to evaluate how the consultation went, to reflect if the desired outcome was reached and that nothing important was left behind, and to think about the following steps.

Two steps were considered in this stage:

Step 6 - Closing - when the doctor verifies if any doubts remain, the agreed plan is reviewed, and the farewell happens;
Step 7 - Reflection and final notes - a brief critical reflection about what happened.

This organization in three stages and seven steps, which may seem fragmentary, can and should, with training, be carried out smoothly and quickly. It has training and learning objectives, and can be adapted and applied in multiple ways. It may be used, for example, to improve clinical attitudes and behaviors in only one or in several of the proposed steps and stages.

Many of the tropics discussed here seem to be obvious issues, which in practical terms, happen in a matter of fractions of a second, automatically, in an intuitive and agile manner by experienced doctors. However, automation, intuition, and agility require a long process of learning and training. The purpose of this exercise is to help to accelerate the achievement of high levels of quality in clinical performance. Unfortunately, many of the details covered here are often ignored or poorly executed, with loss for both the patients and for the doctors, as well as for the doctor-patient relationship.

It is in the early years of clinical practice that “the way of conducting a consultation” is constructed. Such practice is often repeated hundreds or thousands of times uncritically in the following years, based on a combination of influences, be that through the examples of more experienced colleagues that the young doctors might imitate, especially those who left a more lasting impression, or through the characteristics of the doctor’s own personality. Therefore, it is important, especially during the years of specialty residency, to train and perfect specific attitudes and behaviors in order to construct and consolidate proper practices of structuring consultations and of reaching better results: technical efficiency, patient satisfaction, and professional satisfaction.

For example, an attitude and behavior assessment chart can be used in the course of each consultation. Some examples are provided in the end of the book and in the previously cited article⁸^,⁹.

The study, training, and improvement of techniques to conduct and critically analyze consultations are absolutely essential foundational elements of clinical professional proficiency. As examples, we can mention the ability to maintain a consultation structure, as well as the development of competence in becoming aware of one’s own behaviors, attitudes, and technical and relational abilities, specifically referent to interpersonal communication and the construction of mutual trust within the professional context. However, we must not forget that underlying all possible methods, techniques, and competences, there must be a genuine interest in helping the patient. The opposite is also true, that is, despite being driven by an intense desire to help others, we may not achieve the desired results due to insufficient attention to the acquisition and continuous improvement of the necessary technical and professional skills¹²^,¹³.

What have we learned?

Over the last fifteen years, we have been assessing and determining the usefulness and limitations perceived by residents in General and Family Medicine (GFM) and by their preceptors, who are family doctors. Meetings and training sessions were held annually. In addition to oral assessments, written assessments were usually requested through a short questionnaire with open questions for critical assessment and suggestions for improvements.

In parallel with the formative and practical usefulness, unanimously recognized as being obvious to everyone, reservations and warnings were made regarding the risks of an uncritical use of the “7-step” method, as well as suggestions to avoid and overcome those risks and suggestions offered to improve the method.

Among the most often mentioned mistakes, setbacks, and inconvenient situations, we should mention:

Application of the method in any doctor-patient action or interaction: The method was designed especially for situations in which it is the user/patient who actively seeks medical help. In other situations, for example, when the consultation interview or interaction occurs at the initiative of the professional or team, the method may be of little use. It is specifically applicable in cases when a person consults the doctor for one or more specific reasons (symptoms, signs, concerns, doubts, worries, asking for help, among others). This leads us to discuss who consults who?, taking into consideration that in medical jargon all professional-user encounters are considered to be “consultations”. Follow-up actions of previous consultations, surveillance programs with standardized procedures, among others, are inadequate and may be counter-effective in the application of this method.
Linear rigidity in the execution of the “steps” and loss of focus on the individual: Rigid application of the “steps”, with excessive focus on the technique, reduces the professional’s attention to the points of view, concerns, worries, and expectations of the person who seeks help and guidance.
Risk of disconnecting the consultation episode from the required continuity of care: It has been mentioned that there may be a tendency of isolating and disconnecting the consultation episode from the continuity of the line of care that the person receives. An analogy that began to be used was that each consultation episode can be “seen” as a film photogramme, as in the days of celluloid. One isolated photogramme does not allow one to understand the plot, or the narrative in question. Therefore, such questioning must always be present in the mind of the doctor during the consultation. Additionally, the adequate execution of “step 1” may reduce this risk.
The importance of exploring, since the beginning, the “agenda” of the individual being consulted: Some residents and preceptors have mentioned that one of the most important lessons to be learned is to be able to exhaust the patient’s agenda at the beginning of the consultation”, in a systematic and sensitive manner, asking about and listing the reasons for the consultation, concerns, fears, and expectations, from the onset. Failure to do this or ignoring the practice, by the doctor, may result in a loss of focus and time throughout the remaining stages of the consultation, and untimely, may result in its failure. Poor execution of this practice recommended in “step 2” can often lead to “oscillating back and forth” in the other stages and steps.
Avoid confusing support schemes with reality and its complexities: One of the risks that should be avoided, especially by doctors with limited experience, is adopting and using models, methods, and techniques that may distance them from reality and singular human circumstances. They may tend to follow simplistic and limiting representations and paths, losing openness, broad perception, and insight into clues, details, and the depth of knowledge regarding people who seek the help of the doctor. That includes expressed, hidden, or less conscious reasons that doctors may have.
Practical difficulties of the residents and community and family doctors, which sometimes overcome the essential elements of the method: The “7-step” method was created as a support tool to overcome practical difficulties in the process of consultation and make this process more efficient. However, these same difficulties, if not previously considered, compromise the application of the method. Application can be affected by major base-constraints like:
- - Time - Scarcity of time available for consultations, resulting in difficulties with “time management”, or better said, the difficult choice of what to do and what not to do in the limited amount of time of each consultation;
- - Unfriendly computer technology - which, at times, makes the work of the doctors very difficult, instead of facilitating and supporting. The equipment might get in the way between doctor and patient, leading the doctor to pay more attention to the screen and the computer, instead of listening, understanding, and responding to the needs of the person;
- - Bureaucracy - Being administrative (actions and procedures that are irrational and even useless), or technical (applications which are unintelligent, without automation, without adequate alarming, with codified actions and slow diagnoses, for instance);
- - Unfavorable social context - which sometimes leads to hostile situations and conflict between users and professionals of the public services, who are seen as agents of the power system, associated with the users’ social and economic problems;
- - Increasing diversity of human singularities, including those of an ethno-cultural nature - which include language difficulties and difficulties in mutual understanding that come from different views of the world, different beliefs, values and expectations, among others;
- - Complex entanglements of social and health problems and needs - which require the existence of highly sophisticated skills and of multidisciplinary teams in order to handle and deal with these situations;
- - Among others...
To involve and connect the multidisciplinary team in looking at the actual person, with or without disease(s), as the main protagonist of his health process: There is always a tendency to adopt a reductive approach centered on the doctor and the time and space of each consultation. However, the universe of each individual includes and goes far beyond this small world. It requires constant attention to the entire “orchestra” of health and well-being resources, starting with the patient’s themselves and their circumstances, and involving the multidisciplinary team that is closest to them. These attitudes must always be present in the course of medical consultations.

How to improve?

As previously mentioned, authors have regularly collected ideas, criticism, and suggestions from residents and preceptors regarding the “7-step” method. Despite the identified limitations and the need to maintain critical attitudes when applying the method, its usefulness has been confirmed in terms of training execution and critical analysis in medical consultations. This applies both to medical students during practical clinical internships, and in particular, to post-graduate residents in general medical specialties, as in the case of the MGF/MFC, but also for other medical specialties.

We believe that possible improvements to the method are, first and foremost, within the reach of any health professional. They depend , essentially, on the freedom, flexibility, and creativity of anyone who wishes to take advantage of the method as a starting point and an element of support for didactic purposes, or more simply, as a practical structuring guide to conduct a consultation. We believe that it can contribute to a more reflective, more critical and continually adaptable medical practice, suited to the ever changing circumstances of people, society, and technological improvements.

Still, some areas for improvement have been identified, as we exemplify here below.

The “7-step” method is a suggestion, to be applied with flexibility: The “7 step” method is merely a suggestion. It must be used with flexibility in order to respond to the need to structure the complex universe of elements, interactions, and challenges that are present in a consultation.
The medical consultation should be considered as only one piece of a much bigger and complex mosaic, which represents health care to each particular individual: It seems useful to us to consider any consultation as just one piece of a broader and more complex mosaic in the personal narrative and the clinical and health pathway of each individual¹³^-¹⁵. Likewise, the act of “consultation”, which may be a central activity in general medical specialties, is an auxiliary instrument of a more cross-sectional and continuous process, in time and space, which transcends each consultation and the sequence of several consultations. Regarding this approach, see the notes below which refer to the “personal/individual care plan” and to the capacitating process known as “personal health management”.
Emphasis on meeting people and considering their roles, views, agendas, and motives: Although this approach has been present since the beginning of the construction and application of the “Consultation in 7 steps” method, the truth is that, as it is often distant from the culture and practices still dominant in most health services, it should be the object of specially focused attention (Figure 2).
Importance of a unified clinical record, integrating a person’s clinical information, and supported by appropriate digital technology: The “7-step” method will benefit from the existence of a personal, unified clinical and health record that integrates each person’s clinical information and is supported by appropriate digital technology, namely secure, with digital interoperability that guarantees the confidentiality of information. This can be considered the core axis of a health information system at the service of the users,¹⁶ a record that can be easily used, in which each person can exercise a level of self-determination in line with their rights and knowledge. Access to personal health information may be authorized by the owner to the professionals that provide care according to specific access and user profiles, adjusted to the professional’s skills and the objectives of the care. An adequate digital transition is essential in order to make the most of the possibilities that the so-called “artificial intelligence” can offer, as well as to facilitate and optimize various components and processes that are part of a medical consultation. Examples include: automatic writing in natural language; automatic coding of acts and diagnoses; warning and alarm systems when in the imminence of risks; contraindications and interactions related to diagnostic and treatment interventions; 3d analyses of the constellations of protective factors; problem clusters and considerations present at any given moment and situations referring to each unique person; handling of syntheses and concise summaries that can be validated by a professional; support in the process of differential diagnosis; among many others.
Optimized use of communication and information technologies: Health information, knowledge management, and information systems, along with associated digital technologies, are powerful tools for facilitating personal and collective health processes. These encompass the so-called “telehealth” universe, which includes teleconferences and teleconsultations. At the personal level, they serve to support clinical assessment and decision-making, as well as to promote integration, continuity, and coordination of care. These functions are particularly critical for people who live with long-term, often multiple diseases, regardless of the services and institutions that provide healthcare to the patients.
Personal/individual health care and self-management plan: The development of the person-centered clinical method¹⁷^,¹⁸ benefits from two cross-sectional, continuous and personal development processes: a) Theoretical, methodological, and technical development of the “personal/individual care plan”; b) “personal health self-management”. The first must be seen as a personal instrument, associated with the process of integrated and cross-sectioned care of each individual. To be effective, it must be permanently updated. That means, it must be reviewed and adjusted each time that there is a health event or professional intervention in a health service or institution. It is important to distinguish this “base-plan” from the specific plan that results from a specific consultation, regarding a specific situation. The first exists before, during, and after each consultation, and must be always present and accessible for the proper handling of the consultation. It must be an essential component of the personal clinical record mentioned above. Regarding the process of personal health self-management, this can be seen as the corollary of an ongoing process of literacy and capacitation of each person, so that, progressively, these individuals become more capable of taking charge and control of their own health care. These two elements can improve and enrich the “7-step” method and improve the process and the results of each consultation. Above all, it can improve the results of the ongoing process of health care for each person throughout their life journey.
To include the person-centered clinical method in a more comprehensive model that encompasses the healthcare ecosystem of each individual: One of the challenges of medical practice is to maintain its essential core of humanistic attitudes and values, and keep pace with the constant changes in its context. Changes have always been present, but they now seem to be of a different nature, and faster, with both global and local changes. Changes in health systems and geodemographics, social and economic changes, as well as climate changes, especially environmental and epidemiological changes, increase in migratory movements, promoting higher ethnocultural diversity and technological innovation in several essential domains of medical practice. Hence, family health doctors and medical teams must be able to expand the scope of their vision, without losing sight of the centrality of the person in their care. We have called this approach the “integrated clinical model” - a human, professional, and technical challenge that requires constant adaptability of the art, science, and ancient technique of medicine (Figure 3).
“Time management”, methodical action, collaborative processes, and teamwork: The biggest constraint usually mentioned by doctors in training is the difficulty to “manage time”. Since it is impossible to manipulate each unit of time, and no one can “save time for the next day”, or give or lend time to another person, “time management” is not actually possible. However, it is possible to choose what not to do, what to do, and how to do it, within the time available, even though the duration might be somewhat flexible. The most detailed, meticulous, selective, and rigorous stage of each of the steps of a consultation is one of the key challenges for improvements in consultation results. Associated with this basic issue, the following are aspects of how to develop collaborative intelligence and action with an adequate distribution of responsibilities and tasks among all of the members of the multidisciplinary team dedicated to the care of each person and family, who should be included as active and central members of the team.

Figure 2
The medical consultation - meeting of people, social roles, ways of seeing, agendas and objectives.

Figure 3
Integrated clinical model.

Note of conclusion

The “7-step consultation” method has been used in a wide range of places that offer post-graduate programs and specialization residency in family medicine and in some post-graduate medical training programs in several Portuguese-speaking medical schools. After reviewing the “7-step” method the authors reiterate that it must be seen as a working suggestion and applied in a critical manner, with flexibility.

Critical assessments by numerous residents and preceptors in the field of family medicine have been helping the authors to consider additional recommendations when they present and discuss the method in meetings and training sessions. They have been using more comprehensive approaches to medical consultations, namely: the importance of the “personal clinical record”, integrated, unified, supported by appropriate digital technologies, including interoperability; the “personal/individual care plan” as an essential component of that record; the concept and practices of “personal health management”; and the meaning and ways of practical application of the “integrated clinical model”. These are challenges that contribute to broadening and enriching the education and training of future family and community doctors.

References

¹ Balint M. O médico o seu doente e a doença. Lisboa: Climepsi Editores; 1998.
² Balint E, Norell JS. Seis minutos para o paciente: estudos sobre as interacções na consulta de clínica geral. Lisboa: Climepsi Editores; 1995.
³ Pendleton D, Schofield T, Tate P, Havelock P. The consultation: an approach to learning and teaching. Oxford: Oxford University Press; 1984.
⁴ Pendleton D, Schofield T, Tate P, Havelock P. The new consultation: developing doctor-patient communication. Oxford: Oxford University Press; 2003.
⁵ Livesey PG. Partners in care. The consultation in general practice. London: William Heinemann Medical Books; 1986.
⁶ Borrell I, Carrió F. Entrevista clínica. Manual de estratégias práticas. Barcelona: SemFyc Ediciones; 2004.
⁷ Marvel MK, Doherty WJ, Weiner E. Medical interviewing by exemplary family physicians. J Fam Pract 1998; 47:343-348.
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Chief editors:
Maria Cecília de Souza Minayo, Romeu Gomes, Antônio Augusto Moura da Silva

Publication Dates

Publication in this collection
11 Aug 2025
Date of issue
July 2025

History

Received
11 Dec 2024
Accepted
18 Feb 2025
Accepted
20 Feb 2025

Este é um artigo publicado em acesso aberto sob uma licença Creative Commons

[1] ¹ Balint M. O médico o seu doente e a doença. Lisboa: Climepsi Editores; 1998.

[2] ² Balint E, Norell JS. Seis minutos para o paciente: estudos sobre as interacções na consulta de clínica geral. Lisboa: Climepsi Editores; 1995.

[3] ³ Pendleton D, Schofield T, Tate P, Havelock P. The consultation: an approach to learning and teaching. Oxford: Oxford University Press; 1984.

[4] ⁴ Pendleton D, Schofield T, Tate P, Havelock P. The new consultation: developing doctor-patient communication. Oxford: Oxford University Press; 2003.

[5] ⁵ Livesey PG. Partners in care. The consultation in general practice. London: William Heinemann Medical Books; 1986.

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Steps	Objectives
1. Preparation	a) Brief self-assessment of the doctor’s conditions - strengths and weaknesses for the upcoming interaction; any physiological needs to be met? Are there emotions that could carry over to the next consultation and contaminate it? b) Review who the next user is - brief consultation of the medical record: summary, list of problems, usual therapy, SOAP notes from the last consultation(s), previous notes and other pertinent information. c) Briefly assess the conditions of the office environment: ventilation, lighting, cleanliness, tidiness, etc.
2. First minutes	Welcome, greeting, first words. Careful observation and listening to the user and their reasons and motivations (here and now) The quality of the opening of the consultation is vital to its success. First impressions are very important. It is at this stage that the preparation of the empathetic attitude, the helping relationship, and the therapeutic climate begins.
3. Exploration, analysis and contextualization	Anamnesis, objective examination, and contextualization of the problems addressed. It is important to try to understand, without modifying, the “object” (the person’s history). The physical examination and, in particular, the anamnesis, can have therapeutic effects, in addition to their natural diagnostic purpose.
4. Evaluation	Interrelate and interpret the data and information collected and integrate them into a coherent and meaningful explanatory framework for both parties (physician and patient). Includes defining problems, formulating diagnoses, forecasting (prognosis), and assessing impacts on functionality and quality of life.
5. Plan	Propose, negotiate, and aim to reach an agreement on actions and objectives, including prevention (“opportunistic” or not), in a way adapted to the context, conditions, circumstances, and functioning of the person consulting the doctor.
6. Closure	Confirm what was learned and understood, and that there are no doubts. Ask about whether the patient's expectations were met, accept any feedback from the user, and formally end the consultation (farewell greeting). Explain ways to communicate with the doctor or another member of the team (family nurse, for example). Show availability for questions that may arise later.
7. Final reflection	This phase is dedicated to personal self-reflection on the consultation, as well as to mental and cognitive cleansing and possible emotional decontamination, in order to move on to the next consultation or interaction with another person. This phase can be useful for completing or correcting clinical notes related to that consultation and that individual. Remember that there is always room for improvement!