Preparing
This phase concerns what the practitioner does before direct patient contact. It includes getting in the best frame of mind (see “Five Cs” above), preparing the physical space, finding out more about the case from the medical record and colleagues and, for students, checking a given patient is suitable to see.

The phase is summarised in the phrase “Self, Space, Story, Glory!”

Self – connect to sense of compassion and curiosity. Hydrate, visit the bathroom. Clear any emotional debris from previous encounters.
Space – attend to chair positions, lighting, heating. In a ward environment consider privacy issues and issues with visitors.
Story – read up on latest consults, problem list, current meds, investigations and recent correspondence. Speak to nursing and medical staff.
Glory – prepare to give this encounter your best shot and perhaps make a difference for your patient whilst learning.

Opening
This phase concerns the opening minutes of the consultation and includes general observation, introductory statements (e.g. my name is...), rapport building and understanding the patient’s (and practitioner’s) agenda.

We have co-created opening statements specifically for clerking consultations, considering purpose, timings and consent to note-take. See here for ideas to help medical students get off to a good start. We also encourage “care statement” such as “is there anything I can get for you just now before we get started?”.

Gathering
We train students to “gather” in three interwoven areas. Firstly to “understand the biomedical presentation” through a focused medical history and examination. Then to understand the patient’s perspective on the current situation under the lengthened acronym ICE-IE:

I – ideas about the problem including on causes and diagnoses
C – concerns about how the problem will effect life
E – expectation on how this consultation might progress things
I – impact of the problem on daily life
E - emotional reaction to the problem

We encourage students to move beyond a social history of drugs and alcohol and invite students to explore the patient’s “Lifeworld”, which includes explorations of diet, physical activity and home life. We are working actively on the concept of “Lifestyle History”.

Formulating
This phase foregrounds the clinical reasoning that will have begun in “preparing”. Set between gathering and explaining, formulating is an invitation to stop the cognitive train and consider how our thinking is developing. We draw on clinical decision-making models and teach under the rubric STOP4What?:

STOP! Self-consciously pause in the consultation, allowing yourself a moment to consider.
What? Mental summary of history, observations and examination findings.
So What? Consider aetiologies: predisposing, precipitating and perpetuating causes. Differential diagnoses and/or salient problems.
What Else? Actively thinking of alternate diagnoses and more nuanced problems (based on an understanding of common biases)
What Next? Judicious consideration of possible tests, treatments, referrals and human factors.

ILOs here follow a familiar focus on the communication of information on diagnosis, prognosis and treatment. With an awareness that over half of the population has a limited health literacy we teach using the rubric “Check, Chunk, Check” and discuss the importance of appropriate communication for the patients’ level of understanding.

Check: patient’s current understanding, patient’s desire to know more and likely cognitive capacity, calibrating for age, linguistic skills etc. Practitioner checks own understanding.
Chunk: deliver information in appropriately sized packages, with pause for micro-checks, avoiding technical language, and using visual aids and metaphors as appropriate.
Check: put emphasis on explainer – e.g. “please mention anything I could have explained more clearly.” Consider requesting “playback” from patient. Seek out specific concerns in relation to ICE-IE.

COGConnect assumes that at every encounter there exists opportunity for aiding the patient to play an active part in their health and healthcare. This can range from encouraging self-observation, providing suggestions for groups or apps, through to formal motivational interviewing in areas like drugs and alcohol, eating well, exercising and prioritising sleep. Attitudinal objectives are key to this phase including belief in patients as capable and autonomous persons, at various stages in the cycle of change.

Planning
By signposting planning we wanted to bookmark the need for shared decision-making and emphasise the active role that patients have in supporting their own health. It is the phase where clinicians and patients decide what could and should happen next.

Doing
In various contexts the consultation involves a procedure. Prescribing medication could be located in this phase. Learning outcomes centre on consent, patient safety and clinical competence.

This phase includes skills in creating a concise summary, offering the patient the chance to ask for clarifications and potentially checking understanding through questioning or playback. Here sits the key skills of “safety-netting”, arranging follow-up and ending on an encouraging note.

This relates to actions outside the face to face encounter. Making an accurate clinical record, recording and actioning practitioner educational needs arising from the consultation, making referrals and marking the consultation for discussion later with colleagues. It emphasises the consultation as a continual learning process and respects patients’ views that doctors need to reflect on their attitudes, internal bias and learning from all interactions.