Consultation Skills and SAFER Consulting

Introduction

We must place the safety of our patients at the heart of our consultations by adopting patient safety attitudes and behaviours and using strategies and interventions to reduce the risks posed by diagnostic uncertainty and incorrect diagnoses, incorrect clinical decisions and incorrect management of a patient.

During your surgical attachments, you will have observed several patient safety-focused measures employed to reduce the risk of the patient being harmed before, during and after the operation. For example, pre-operative marking of the operation site and using checklists to monitor the use of swabs and instruments during the operation.

This approach has reduced the risk of harm to patients undergoing surgery. A similar approach, known as SAFER consulting, can be adopted to reduce the risks present in consultations. This will help bring a patient safety focus to your consultations and improve your diagnoses, clinical decisions and how you manage patients.

This article will cover the SAFER consulting model and how symptom-specific or disease-specific plans and toolboxes can help you structure your consultation during an OSCE or clinical practice. 

Consultation plans

During resuscitation training, we learn that coming to a cardiac arrest with a pre-prepared plan (e.g. a resuscitation algorithm) and following that plan is the most efficient, effective and safest way of managing the situation.

The same principle applies during consultations. If you come to the consultation (or OSCE) with a pre-prepared plan for a specific symptom or medical condition and follow that plan during the consultation, you are less likely to make an incorrect diagnosis or decision and more likely to provide the correct treatment for the patient.

As you progress through your clinical attachments, you can create plans for the different symptoms and conditions you encounter in the patients you see. You can merge these plans to help you consider a wider range of differential diagnoses for each symptom.

For example, in a patient with abdominal pain, you must consider a wide range of causes beyond the gastrointestinal system, such as gynaecological and vascular causes. 

Coming to an OSCE with a plan for assessing and managing a patient with abdominal pain and following that plan during the OSCE will help to make your consultation run more smoothly, and you are less likely to forget to consider a serious cause!

Creating a plan

Symptom-related plans

The plan for each symptom should contain three sections:

• The causes of that symptom and how each cause is diagnosed
• The criteria for determining whether a patient should be admitted to hospital, reviewed, or sent home with safety-netting advice
• How the patient should be managed, including the investigations and treatment required for each cause.

A patient safety focus can be brought to this using the mnemonic SAFER. You should place the “must-not-miss” and “must-always-consider” causes at the top of your list of causes to ensure that you always follow the first rule in medicine, which is to “always exclude the worst, first”.

Approximately 70% of incorrect diagnoses involve just three disease processes:

• Cancer
• Acute vascular events
• Serious infections

It is important to always consider these possibilities amongst the differential diagnoses. Often, it is the early or atypical presentations of a serious illness which are missed, misdiagnosed, or diagnosed late.

Condition-related plans

You can follow the same process when creating a plan for a specific condition. You need to know how to determine the severity of the condition, when to initiate or change treatment, and when to admit or review the patient.

SAFER can also help remind you that there may be an alternative cause for the patient’s symptoms rather than assuming that the symptoms are due to an exacerbation of the patient’s pre-existing condition.

For example, shortness of breath in a patient with pre-existing asthma or COPD may have an alternative cause (e.g. pulmonary embolism) which may be overlooked if that cause is not considered or checked for.

Consultation toolboxes

Whereas a plan tells you what information needs to be gathered, a “toolbox” tells you how to gather that information.

Creating a toolbox involves taking the symptom or condition plan and thinking of the best way to gather that information during the consultation and the action needed.

A wide range of “tools” can help you assess, make decisions and manage your patients, many of which are included in the relevant guidelines. In addition to the generic information-gathering tools, such as the clinical assessment wagon wheel, there are symptom and condition-specific risk assessment, illness severity and decision-making tools that you can add to the toolbox and specific management plans.

For example, in a patient presenting with shortness of breath, you could assess the degree of breathlessness by using the Medical Research Council (MRC) dyspnoea score and assess the risk for them having had a pulmonary embolus with a Wells score.

You can then create a traffic light system of action plans to help you make the correct clinical decisions and management pathways for your patient.

Summary

There are two reasons why a diagnosis, decision, or management plan may be incorrect.

Firstly, you may not know the causes of a symptom and how each cause is diagnosed, or you may not know the criteria upon which decisions are based, or you may not know the management plan. Secondly, you may not recall this information during the consultation (or OSCE scenario).

This emphasises the importance of coming to the consultation with a plan and toolbox that will help you gather the correct information, process the information correctly and act on that information correctly. Creating plans and toolboxes and then practising using these will help you to prepare for your OSCEs and consultations.

Using mnemonics can help you to organise, prioritise and recall information during an OSCE or consultation. During consultations, using checklists and templates can help you recall, gather and process information and help reduce the risk you forget to gather a critical piece of information.

Editor

Dr Chris Jefferies

References

• Hopcroft, K., & Forte, V. (2020). Symptom sorter. CRC Press.
• Silverston, P. (2020). SAFER diagnosis: a teaching system to help reduce diagnostic errors in primary care. British Journal of General Practice, 70(696), 354-355.
• Silverston, P. (2020). SAFER PRACTICES: reducing the risk of diagnostic errors. Practice Nursing, 31(2), 80-86.
• Ely, J. W., Graber, M. L., & Croskerry, P. (2011). Checklists to reduce diagnostic errors. Academic Medicine, 86(3), 307-313.
• Newman-Toker, D. E., Wang, Z., Zhu, Y., Nassery, N., Tehrani, A. S. S., Schaffer, A. C., … & Siegal, D. (2021). Rate of diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate using the “Big Three”. Diagnosis, 8(1), 67-84.