SQU Med J, December 2010, Vol. 10, Iss. 3, pp. 318-325, Epub. 14th Nov 10 
Invited Article
Submitted 3rd May 10
Revision ReQ. 1st June 10, Revision recd. 23rd July 10
Accepted 27th July 10

Communication Skills – Why?
Being clinically active in general practice and 
psychiatry in the 1970s and 80s, we noticed, as did 
many colleagues, that conditions were changing for 
physicians. A new wave of patient expectations and 
complaints began, and there were fewer manpower 
hours, but more patients. Physicians began to 
complain about too much work (increasingly many 
doctors lost their motivation and basic curiosity). 
Many were at risk of burning out.

A lot of the patient complaints were due to 
insufficient communication skills in the health care 
system. 

On the positive side, patients defended their 
right to become collaborators with their doctor 
rather than just subordinate customers. Health 
care information had become readily available in 
newspapers and magazines and on the Internet 
leading to doctors being challenged by well 
informed patients.

A growing awareness of compliance and life 
style issues arose. The need for a patient focused 
health care culture and rehabilitation outcomes 
became apparent. This was supported by research 
and development on consultation models.1,2 
We participated in some of this research 

World Federation for Medical Education, Faculty of Health Sciences, The Panum Institute, University of Copenhagen, Copenhagen, 
Denmark
*Corresponding Author email: wfme@sund.ku.dk

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aBstract: Medical curriculum revisions all over the world in the last 20 years have increased the number 
of teaching hours in communication skills. This article describes a concrete communication skills teaching 
programme focused on general practice. Since the spring of 1992, more than 2,000 physicians from Denmark, 
Sweden and Finland have attended courses within this programme in Kalymnos, Greece. The training mainly 
takes place in groups of 8 doctors and 1 supervisor. The skills training is based on video feedback using the 
Window Supervision Method described here. We have identified several classical pitfalls for the doctor which this 
training programme seeks to address. We have also defined the 9 steps in an effective consultation process, which 
are given the acronym PRACTICAL. The major issue is to discriminate between the patient’s, the doctor’s and the 
shared part of the communication process. In our experience, this model shortens the consultation time to c. 15 
minutes as doctors collaborate with their patients and build up an agreed agenda in order to deal effectively with 
the main problems of the patients.

Keywords: General practice; Communication; Skills

SPECIAL CONTRIBUTIONSPECIAL CONTRIBUTION

Developing Communication Skills for the 
General Practice Consultation Process

*Jørgen Nystrup, Jan-Helge Larsen, Ole Risør



Jørgen Nystrup, Jan-Helge Larsen and Ole Risør

Special Contribution | 319

and developed a new model for conducting  
consultation in general practice.3,4,5 With this model, 
we wanted to offer general practitioners a set  
of tools and skills to become more efficient 
communicators and more satisfied doctors. We 
launched the consultation training courses in 
Kalymnos, Greece, in the spring of 1992 with,  
so far, close to 2,000 physicians from Denmark, 
Sweden and Finland having attended them.

Communication in the 
Medical Curriculum
Curriculum revisions all over the world in the  
last 20 years have increased the number of  
teaching hours in communication. The importance 
of communication is emphasised in lectures and 
small group teaching as well as in skills laboratories 
with simulated patients. This all has the purpose 
of improving the doctor-patient collaboration and 
relationship which is not an option, but a necessity.6 
A well-known international programme of teaching 
communication skills in the medical curriculum 
is published by Juliet Draper and co-workers.7,8 
Doctor Ong and partners have written a review of 
the literature on doctor-patient communication.9 

In addition to the factors mentioned above, 
there are some classical reasons for making sure 
that future doctors do have sufficient competence 
as communicators. First, history taking is a crucial 
task for any physician and an essential part of it is 
building up a trusting relationship with the patient 
without which collaboration and compliance with 
the patient is not attainable. Special communication 
skills are required to deliver so-called 'bad 
news' – poor prognosis! – but even sound 
instructions, explanations and reassurance require  
skillful communication. Stressful working loads or 
single exhausting experiences require debriefing 
or supervision implying new communication 
challenges. Medical education must be life-long 
and communication skills should be continuously 
trained and refined.

Specific Challenges in the 
Consultation
Based on our courses we can delineate several 
classical pitfalls for the doctor:

1. Patients with a long list of complaints. Requires 

skills to prioritise and collaborate with the 
patient.

2. The worried patient. Requires skills to phrase 
the worries and to console or inform rationally.

3. New problems on the way out of the 
consultation room. Need to start all over. The 
agenda for the consultation has not been set.

4. The angry patient. Requires acceptance and 
containing functions.

5. The patient with low self esteem. Requires 
praise and respect, focus on resources.

6. The patient seeking prolonged sickness 
certificate. May be promised some prolongation 
before discussion of alternatives and long term 
solutions.

7. The patient asking for superfluous expensive 
investigations (magnetic resonance (MR) or 
positron emission tomography (PET) scans, 
etc.). The motives for the wishes must be 
thoroughly understood before any decision is 
taken.         

8. The patient in need of life style changes. How 
much information is needed at the outset?

9. The doctor feeling hurt by the patient. Analyse 
the counter transference feelings.

10. Patient asking for more drugs. Check 
the consumption well before deciding on 
continued prescription.

11. Gifts – expensive or clearly personalised gifts 
must not be accepted. Gifts from the doctor 
should be exceptional. 

The Kalymnos Courses
The Kalymnos courses have been run spring and 
autumn since 1992. They have been conducted in 
Danish, Swedish, and English. The setting is 3-hour 
scheduled learning in the morning and 3-hour 
scheduled learning in the evening. The afternoon, 
from 12 noon to 5 pm is free for recreation – an 
important dimension of the course. The general 
practitioners participating in the courses have 
been of different types from the very experienced 
needing new inspiration to very young doctors 
needing basic skills. In groups of 8, the learning 
process is built on mutual respect and eagerness to 



Developing Communication Skills for the General Practice Consultation Process

320 | SQU Medical Journal, December 2010, Volume 10, Issue 3

learn from each other.10

The exercises concerning social networks 
and life scripts aim to develop personal resources 
within the individual doctor enabling him or her to 
integrate personal challenges into the professional 
role as a physician.11 The outcome of the course can 
easily be detected in terms of a high degree of self 
confidence and personal enlightenment by the end 
of the week.

t h e l e a r n i n g f r a m e w o r k i s:
•	 Limited	plenary	sessions

•	 Small	 group	 sessions	 with	 videotaped	 role	
plays

•	 Small	 group	 sessions	 with	 videotaped	 real	
consultations (brought from home)

•	 Video	replay	with	supervision

•	 Training	 in	 supervision	 with	 various	
techniques

•	 Exercise	in	uncovering	own	social	network

•	 Life	script	exercise	

The Phases of Effective 
Consultations
The core of the communication skills training is 
based on the 9 steps shown in Table 1.5

t h e pat i e n t’s pa r t
1.  p r i o r
 Patients usually prepare themselves before 

seeking a doctor. Although many patients and 
doctors like to start the consultation with the 
present complaints, it pays off to start more 
openly tracing the events more generally 
prior to the consultation. This also includes 
self treatment, information from the Internet, 
advices from family and friends and it may even 
include consultations with other doctors. In 
any case, the patient will have a history before 
visiting the present doctor. The patient should 
have the opportunity to reveal his history. 
Information from this phase can help the 
doctor to avoid suggesting remedies already 
tried by the patient. The patients’ preparation 
also includes questions to themselves like: 
What is happening? Why this? Why me? Why 

now? What can I do? Who might be able to 
help me?12

2.  r e l at i o n s h i p
 When the doctor asks the patient to tell his 

story, the relationship is beginning to develop. 
This phase includes more than “Hello! How 
do you do?” and it stretches throughout the 
consultation process. A positive relationship 
is fundamental for trust and confidence in 
the doctor, and necessary for constructive 
collaboration and compliance. The most 
important technique for obtaining a positive 
relationship with the patient is reassurance 
and attentive listening by the doctor. Another 
important technique is to give permission to 
the patient for having his or her complaints, 
and to be the person they are. Many patients 
fear that they are not interesting for the doctor. 
They might even feel shame. 

3.  a n x i e t i e s  (c o n c e r n s  a n d 
e x p e c tat i o n s)

 Through our courses we have learned that the 
key to managing the consultation is embedded 
in the phase we call anxieties: clarifying 
ideas, concerns and expectations on behalf 
of the patient, and revealing the reflections 
of the patient.1 If this part of the consultation 
is not fully completed, it is not possible to 
work out a valid and prioritised agenda for 
the consultation. This might result in the 
classical remark from the patient with his 
hand on the door handle on his way out: “Oh, 
what I really came to see you for was…!”  The 
patient, like the doctor, has his or her model 
of the world which includes a model of the 
illness. Examples of such models are: destiny, 
biological, environmental, and psychological. 
It is very useful for the doctor to know which 
model the patient is employing most in the 
present situation. 13 Asking for the patient’s 
concerns reinforces the respectful relationship 
and may give the patient a deep sense of relief 
that the doctor is interested in such feelings. 
The patients often have their very concrete 
expectations about the consultation varying 
from reassurance, explanation of symptoms to 
expensive laboratory investigations, extended 
sick leave or prescription of addictive drugs. 
Instead of waiting for or maybe fearing these 



Jørgen Nystrup, Jan-Helge Larsen and Ole Risør

Special Contribution | 321

demands, the doctor should encourage these 
expectations to be put into words early in the 
consultation in order to plan and make the 
right decision later on in the consultation. To 
summarise this phase, a Norwegian doctor has 
suggested five key questions.14

  1. Why do you want to see me today?

  2. What are your own thoughts on the   
    situation?

  3. What are your own thoughts on the   
    reason for the problem?

  4. What are you particularly worried   
    about?

  5. What do you want me to help you with?

 So far, the consultation has focused on the 
premises of the patient. We call this phase 
the patient’s part of the consultation. This 
distinction between the patient’s and the 
doctor’s part is crucial to learn and practice 
because if the doctor interrupts the patient, he 
or she will eventually distract the patient. This 
can make the patient forget what s/he needs to 
tell the doctor, leading to confusion and waste 
of time for both of them. 

t h e d o c t o r’s pa r t
4.  c o m m o n  u n d e r s ta n d i n g
 First the agenda of the consultation should be 

settled. This should be initiated by the doctor 
through testing their common understanding. 
The doctor summarises what he or she has 
heard, and how different complaints and 
wishes should be prioritised in the present 

consultation. The summary should be phrased 
as the doctor’s temporary understanding and 
preferably contain both emotional (affective) 
and factual (cognitive) statements. The doctor 
is seeking the informed consent of the patient. 

5.  t r a n s l at i o n
 The doctor now continues with traditional 

physician communication. He asks questions 
to circumscribe the symptoms. When did it 
all start? Where is the pain most severe? Is 
there any fever? Etc. In this phase, the doctor 
will conduct a physical examination and he 
may order some laboratory investigations. In 
this way, the doctor translates the verbal and 
physical findings, giving an explanation to the 
patient and maybe a diagnosis, prescription, 
referral, treatment etc.

t h e c o m m o n pa r t
6.  i n t e r ac t i o n
 The doctor’s suggestions might be 

challenged by the patient, requiring further 
interaction with negotiations in respect of  
aetiology, treatment modalities, and further 
investigations. The doctor may try to change 
the terms of reference of the patient or 
present a choice of possibilities. The more the  
patient agrees to the plan, the more  
compliance is likely.

7.  c o n v e rt i n g  i n s i g h t
 In order to strengthen compliance further 

the doctor might invite a discussion on 
the obstacles and facilitators to solving the 

Table 1: PRACTICAL model for doctor-patient communication (9 steps)

P rior to the consultation  (feelings, thoughts and actions)

R elationship (permission) The patient’s part

A nxieties (ideas, concerns, and expectations - both affective and cognitive)

C ommon understanding (summarise, check of health beliefs)

T ranslating (verbal, physical examination into a diagnosis) The doctor’s part

I nteraction (common understanding, change of frame of reference, doctor’s or patient’s choice)

C onverting insight into action (impede, promote)

A greement check (safety netting, prolonging) The common part

L et’s try it (OK feelings on both sides, housekeeping)



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322 | SQU Medical Journal, December 2010, Volume 10, Issue 3

problem. This also can be named converting 
insight into action.

8.  ag r e e m e n t  c h e c k
 In order to finish the consultation an agreement 

check is advisable. Can we conclude, that we 
agree so and so? Do we need a safety net in 
terms of a follow-up consultation? This can 
be necessary also for the doctor to verify his 
judgment or simply to quality assure his or her 
work.

9 .   l e t ’s  t ry  i t
  Bye, bye… Before starting the next consultation, 

housekeeping is necessary for the doctor. It 
might be some fresh air, a cup of tea or coffee 
– or a brief interaction with another staff 
member in the workplace. The doctor’s screen 
should be erased before the next patient comes 
in.

The important lesson is to remember the three 
main phases: the Patient’s part, the Doctor’s part, 
and the Common part. All nine phases might seem 
for some doctors to be too structured. Some will 
even think that they will not have sufficient time in 
a normal consultation. Our experience, which has 
been shared with numerous colleagues, is that on 
the contrary this model shortens the consultation 
time through collaboration with the patient and 
building up an agreed agenda (avoiding superfluous 
questions on the doctor’s part and a list of patient 
complaints that the doctor should deal with 
successively). It is our goal to be able to conduct 
most consultations within 15 minutes and in that 
time to be able to deal effectively with the main 
problems of the patient. 

The Window Supervision 
Method
Lectures and texts are not enough to master the 
9 phases of the consultation. It requires various 
skills to manage the different phases. So the main 
focus in the course is learning these skills through 
role play, video feedback of role play and video 
recordings of real life situations brought from the 
doctor’s home consultations. The video feedback 
must be supervised. We prefer a supervision 
method invented by Coles and modified by Larsen, 
Risør, and Nystrup.15,16,17 This supervision has a 
rigid, structured schedule, which must be followed 

sequentially. For this reason, we call the method the 
Window Supervision Method, since one window 
(schedule) must be dealt with before the next one 
should be opened [Table 2]. 

The method thus defines a set of rules which  
make the participants secure, and it conveys a 
supervision culture that prevents self-criticism 
which is a common defense. Supervision amongst 
peers easily creates competition and arguments, 
both scientific and attitudinal. Such arguments 
will very often hurt someone in the group, and 
such arguments will most often create a barrier 
for learning. For this reason no free discussion is 
allowed. By building up trust and confidence, the 
supervision reaches a stage where brainstorming 
is allowed. The objective of the supervision is to 
enhance the doctor’s skills in communicating and 
dealing with their patients. The supervision takes 
place in groups with 8 doctors and 1 supervisor. The 
next section describes how the model works.

t h e c o n t r a c t
In order to emphasise ownership of the process 
on the part of the supervisee, we first of all ask 
the supervisee to state what s/he wants from the 
colleagues. This is called a contract. Sometimes it 
is difficult for the supervisee doctor to formulate 
this in advance. It can facilitate the process to view 
the videotape first. In this way, the doctor might 
present his case and provide more information than 
contained on the videotape.

f e e l i n g s o n t h e pa r t o f t h e 
s u p e r v i s e e

Many different – and often contradictory – feelings 
arise in the doctor during a consultation. In this 
window, the supervisor is particularly interested 
in the feelings towards the patient. Such counter 
transference feelings are often the reason why the 
doctor may feel poisoned after the consultation. A 
successful supervision should be able to detoxify the 
supervisee. Typical negative counter transference 
feelings are: helplessness, meaninglessness, pain, 
loneliness, anger, grief and fear of illness or death. 
Positive counter transference feelings can be 
sympathy, pity, compassion, engagement to help. 
Some of the feelings are real feelings created by the 
situation (the personality and the illness); however, 
surprisingly, many are countertransference feelings 
originating from something that happened in the 



Jørgen Nystrup, Jan-Helge Larsen and Ole Risør

Special Contribution | 323

doctor’s past. It is not constructive in the supervision 
process to spend time on the real origination. This 
might be relevant in psychotherapy. What interests 
us is how different kinds of feelings will influence 
the consultation and how the feelings of the patient 
are transmitted and reflected in the doctor. In 
this way, the feelings of the doctor can become a 
diagnostic tool for how the patient feels.

In many instances, when starting to learn this 
new method, the supervisee will begin by being 
self-critical. The supervisor might clarify the nature 
of these feelings as originating from the doctor him 
or herself, and in this way guide the detection of 
feelings towards the patient. Also the supervisor 
might need to emphasise that supervision is not a 
type of competition. The aim is not to find the right 
solution to the problem, but rather to find different 
and alternative solutions. First of all the aim is to be 
open for learning.

f e e l i n g s o n t h e pa r t o f 
c o l l e a g u e s

Now the colleagues are invited to open their window. 
What are their feelings if they have identified with 
the supervisee? This often runs quite smoothly. 
Additional feelings arise – often unexpected ones. 
This illustrates for the group and for the supervisee 
that no single feeling is sought for, and different 
– even negative – feelings toward the patient can 
be a reality in a consultation. This often creates an 
atmosphere of permission and a group dynamic of 
understanding, sharing and respecting differences 
in attitudes and personalities. The supervisor might 

join the process by sharing his or her own feelings 
towards the patient.

p r a i s e t o m y s e l f
Many colleagues wonder about the relevance  
of all the positive comments. They are ready 
for constructive criticism, they often say. Our 
experience tells us, that this is not so. The supervisee 
first needs to be assured of his or her competence. 
Something must be put in the bank account before 
it is meaningful to draw from it. So this window 
encourages the supervisee to describe what he 
or she managed well in the consultation giving as 
many concrete instances as possible. The group is 
not allowed to argue or dispute the descriptions. 

p r a i s e f r o m m y c o l l e a g u e s
Now the colleagues are asked to point out what they 
detected (through the videotape) as working well in 
the consultation. The supervisor might join in this 
session. And the supervisor might summarise the 
content of these two windows making sure that the 
supervisee accepts the positive points.

c o n s t r u c t i v e c r i t i c i s m
In this window, the supervisee is asked (after 
viewing the videotape) what he or she thinks 
could have been done differently, and maybe what  
s/he would want to do differently another time. No 
discussion or arguments is allowed from the group.

b r a i n s t o r m

In order to avoid the tendency for the supervisee 

Table 2: Window Supervision process

What do I want the colleagues help with? ......................................................................................................................................

Physician Colleagues

1. Feelings of the supervisee 2. Feelings of the colleagues

Which feelings does the patient evoke in me? If I place myself in the physician’s situation which feelings does 
the patient evoke in me?

3. Praise to myself 4. Praise from my colleagues

I think … worked well It worked well when you ….

5. Constructive criticism 6. Brainstorm

I wish I had done … in that way If it had been me, I might have done ….

7. Take home messages for the supervisee 8. Take home messages for the colleagues

What I take home is …. As for me, I take home …..

9. Feelings of supervisee 10. Feelings of the colleagues

Now I am feeling ….. Now I am feeling …..



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324 | SQU Medical Journal, December 2010, Volume 10, Issue 3

to defend him or herself, the supervisor might 
instruct the supervisee to turn his back to the group 
– and just listen and reflect on what ideas from the 
brainstorming process could be useful for the kind 
of doctor the supervisee is. Now the group starts 
brainstorming:

“If I had been in the same situation, may be - 
I would have tried this or that. And maybe I also 
would have been able to…. If I had had a real lucky 
day, then…….”

The supervisor does not need to summarise this. 
He might join the session. And he might encourage 
creativity. Also he might permit discussion amongst 
the colleagues at this point. It is, however, important 
to underline that one right solution, in terms of a 
group consensus, is not what is being sought. On 
the contrary, a variety of different constructive 
approaches are welcomed.

ta k e h o m e m e s s a g e s f o r t h e 
s u p e r v i s e e

This window serves the purpose that the supervisee 
might reflect on alternative ways of conducting the 
consultation. What of the many suggestions would 
be relevant for him or her – and what should be 
given priority? The supervisor gives permission to 
neglect or discard what has been said by the group. 
But it is all right to ask if something was interesting 
for the supervisee and draw attention to the helpful 
resources.

ta k e h o m e m e s s a g e s f o r t h e 
c o l l e a g u e s

Now it is time to elucidate the learning in the group 
in a wider context. This is done, by asking each 
individual member, what he or she has learned and 
would like to implement at home.

f e e l i n g s o f t h e s u p e r v i s e e
In order to check the process, the supervisor asks 
about the feelings of the supervisee at this point. 
This is both about the feelings of having gone 
through the supervision process, and if the feelings 
towards the patient, as stated in the first window, 
have changed - particularly whether the negative 
countertransference feelings have diminished or 
vanished. If not, it might be necessary to start the 
supervision all over again.

f e e l i n g s o f t h e c o l l e a g u e s

Exactly the same two questions are put to each of 
the colleagues. It is important to check whether 
somebody has been hurt by the group process. This 
very rarely occurs if the rigid structured schedule is 
adhered to. Another safety measure is time. Don’t 
rush through this exercise. It normally requires 1–1 
½ hours.  

Conclusion 
Some patients are experienced as a burden by 
their doctor who experiences heartbeat, sweat and 
anxiety before consultations. This is often the case 
with psychosomatic patients waiting to tell their 
doctor that their symptoms have worsened since the 
last consultation. With empathy and consultation 
skill tools, the doctors are encouraged to meet the 
patients on a deeper emotional and psychosocial 
level. Our experience from these supervision 
courses is that, after the course, doctors no longer 
feel burdened by their patients. The patients have 
been taken seriously and therefore have received 
the help they sought. 

c o n f l i c t o f i n t e r e s t
The authors reported no conflict of interest.

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