Parallel Consulting
“I’ve learned much more in the GP practices by doing things hands on, seeing patients on my own and after that, consulting with the doctors themselves and then having the debriefing session.”
— Junior doctor
Introduction
Traditionally, medical students have been observers in the general practice environment, sitting quietly in the corner and watching the GP at work. In some environments this style of teaching remains predominant. Recent paradigm shifts in medical education have trumpeted the benefits of active learning. Active learning opportunities facilitate a deeper approach to learning that is understood to be more effective than passive approaches such as rote learning or observation. In contrast to standard learning modes in which the learner passively listens or observes, active learning approaches engage the learner in his or her own learning through talking and listening, writing, reflection and doing. These approaches aim to increase knowledge gain and recall.
While traditional observation of a clinical consultation in a purposive manner can provide an active learning experience, particularly where it is followed by critical reflection, ongoing engagement of a medical student or junior doctor requires a variety of strategies to meet his or her learning needs. Parallel consulting, a commonly used model in VI teaching practices in Australia, is a learning strategy that requires maximum engagement of the student or junior doctor.
What is parallel consulting?
A unique opportunity for autonomy in patient care while at the same time having expert supervision and one-on-one teaching.
Parallel consulting (also known as ‘wave’ consulting) is a common form of supervision being used in VI teaching practices. Parallel consulting consists of a GP supervisor seeing patients in parallel with either a medical student or junior doctor (or at times both).
In a parallel consulting model, the junior learner consults with a patient independently and in their own consulting room. The junior learner can experience taking a patient history and performing appropriate physical examination. The learner is given an opportunity to problem solve, determine the most likely diagnosis and to consider the best treatment options.
After the medical student or junior doctor has completed the initial history taking, clinical examination and discussion of treatment options with the patient, the GP supervisor joins the learner and the patient in the consultation. The junior learner presents the patient to the GP supervisor. The GP supervisor ensures that all the patient’s problems have been addressed. The supervisor and learner make the final decisions about patient management and follow-up requirements, in conjunction with the patient.
In the parallel consulting model, the GP supervisor continues consulting his or her own patients in a separate consulting room. The GP supervisor is scheduled with a lesser patient load (usually two or three patients an hour) to enable time to join the end of the junior learner’s consultation. The junior learner’s patient scheduling is dependent on experience, with patients initially scheduled on an hourly basis, increased to half-hourly as experience and confidence increases.
In a VI teaching practice with more than one level of learner, the GP supervisor may be supervising more than one individual. For example, the supervisor may be available for the GP registrar to discuss any specific concerns arising in their consultations, while signing off on all consultations conducted by the junior doctor and medical student. In some VI practices, all the learners will come together throughout the day or after the practice closes, to debrief and share their most interesting cases.
Benefits of parallel consulting
Parallel consulting models offer numerous benefits to the learner, the GP supervisor and the practice. Some of these benefits are discussed below.
Autonomous consultation
One of the primary benefits of parallel learning is the autonomy a junior learner is given in his or her clinical practice. The experience of consulting a patient alone provides opportunity for:
increasing confidence and competence;
developing history-taking, physical examination, diagnosis and decision-making skills;
gaining autonomy in practice;
feeling like a ‘real’ doctor; and
establishing a relationship with the patient.
The experience of consulting with a patient autonomously prompts and reinforces professional identity.
Time-effectiveness
Literature on teaching in the general practice setting consistently reports the time pressures involved in supervising medical students and other junior learners. One of the benefits of parallel consulting is its time-effectiveness. In a study done in South Australia,8 it was shown that while GP supervisors may perceive there are time pressures associated with parallel consulting, video recordings of over 500 GP consultations indicated that this perception is not based on any discernible difference in the time taken with patients. There was no significant difference in consultation times between a regular GP consultation (with no student present) and a parallel consultation—both take approximately 12 minutes in a rural general practice setting.
Cost-effectiveness
Supervisors have frequently expressed concern about the cost of having learners in their practice. There is emerging evidence that having longer term students in a practice and utilising a parallel consulting model is cost-neutral or of small financial benefit. That benefit improves as GPs teach two same level learners, or as senior GP registrars are also involved in the teaching of medical students.
Targeted learning opportunities
Parallel consulting provides the learner with a meaningful learning experience. The experience of parallel consulting is directly relevant to his or her learning goals and encourages engagement with the learning process. Junior learners find parallel consulting to be an engaging activity. Parallel consulting and provides an opportunity to practise:
history taking;
clinical skills;
problem solving;
patient teaching; and
presentation skills
Using their comprehensive knowledge of the patient’s clinical history and communication skills, the GP supervisor can select patients for the junior learner to consult. This allows patients who are most appropriate to the learner’s competence level and learning goals to be scheduled for a student consultation. Through careful selection of cases, the GP supervisor can choose to expose the junior learner to areas of learning requiring the learner’s greater focus. The GP supervisor can also choose to allocate the student more interesting cases, or simply to a representative sample of the daily case load of a GP.
The parallel consulting model in which the junior learner independently assesses the patient and contributes to management planning often provides the GP supervisor with his or her own learning opportunity. Junior learners may investigate patient problems from a different perspective, ask detailed questions about the supervisor’s clinical thinking, or alert the GP supervisor to more recent evidence related to management of a health problem. The process of sharing with the learner often prompts the GP supervisor to reflect on practice or update knowledge.
Maintenance of the doctor–patient relationship
The parallel consultation model allows the GP supervisor to maintain close contact with patients in the clinic, despite the junior learner undertaking the history taking and clinical examination. The benefit of the parallel consultation session is the lack of compromise in the doctor–patient relationship, as the patient still consults his or her own GP, and the GP supervisor maintains comprehensive first-hand knowledge of the patient’s ongoing health and treatment plan. Patients continue to feel that they are receiving quality care because they connect with their GP of choice personally.
Patient acceptability
International research in both rural and regional settings indicates that general practice patients embrace the opportunity to participate in the learning of junior doctors and medical students through independent consultations. Overwhelmingly, patients who have experienced a consultation with a junior learner are unconditionally prepared to consult with a student again in the future. Patients indicate that the vast majority of students have strong communication skills, professional behaviour and conduct a thorough investigation into the patient’s health issues. Patients have also experienced student doctors as more empathetic in a parallel consultation compared to a conventional consultation with the student sitting in. This may be an indication that in the autonomous environment of the parallel consultation, the student learner is more likely to take on the professional role of doctor.
Patients have reported numerous benefits to seeing a student in a parallel consultation including:
receiving a second opinion;
feeling less anxious about discussing their health issue;
having more time overall in the consultation; and
receiving a more comprehensive examination.
The patient is present in the second half of the consultation in which the junior learner presents the patient to the GP supervisor. Many patients experience benefit from this process because they hear more about their own medical problem and have a chance to clarify issues themselves. This component of the parallel consultation may have the additional outcome of enhancing patient education.
In certain situations, patients may have specific issues that they prefer to discuss directly with their own GP, particularly relating to mental health issues or more intimate sexual health issues. In these cases, a patient may refuse parallel consulting. It is crucial for patient acceptability that it is very clear a patient can refuse to see a student if it is not the patient’s preference.
Challenges of parallel consulting
Space
Parallel consulting requires a general practice to provide the junior learner with a consulting room. For some general practices, space is a significant barrier to engaging in or expanding their medical teaching. Some practices manage this by organising parallel consulting only during sessions when there is a free room. Some practices use their treatment room as an extra consulting room if it is available.
Organisation
Parallel consulting requires strong time management skills. The GP supervisor is responsible for not only his or her own patient consultations, but also being available to finalise those consultations undertaken by the junior learners. The requirement for streamlined scheduling of the GP supervisor’s time in conjunction with student activities calls for strong administrative systems within the practice. An understanding of the parallel consulting model, and scheduling of the junior learner’s case load with consideration to the supervisor’s case load, is essential. To achieve full efficiency, a total practice teaching system administered by the practice manager or designated teaching co-ordinator is essential.
Waiting time for patients
The parallel consultation is more time-consuming for the patient, who essentially engages in an extended consultation. However, patients don’t necessarily view this as a disadvantage if they are not kept waiting for too long. If the GP supervisor is not readily available to participate in the second half of the consultation, then it can be difficult for the patient and junior learner. This may arise if the GP supervisor’s independent consultations do not run to schedule or if the GP supervisor is in a prolonged consultation. It can be challenging for supervisors to manage and prioritise two patients at once or to leave a patient alone in the consulting room if the learner requires help urgently.
Implementing parallel consulting
For many general practices, especially those in rural locations, a lack of consulting room space precludes the opportunity to implement the parallel consulting supervision model. The model requires individual consulting rooms for both the GP supervisor and the junior learner. An ideal practice set-up would situate the junior learner’s consulting room adjacent to the GP supervisor’s consulting room.
Scheduling
A practice scheduling system that integrates the junior learner’s case load with that of the GP supervisor is essential. The practice manager and administrative staff will require strong organisational skills and a full understanding of the parallel consulting model to maximise patient throughput in an efficient manner. Some timetabling examples are provided below.
Timetable 1: Supervising a junior learner with less experience
| GP supervisor | Junior learner | ||
|---|---|---|---|
| 0900 | Patient X | 0900 | Patient A |
| 0915 | Patient y | 0915 | Patient A |
| 0930 | Join junior learner with patient A | 0930 | Present patient A to supervisor |
| 0945 | Patient Z | 0945 | Arrange management and document patient A |
Timetable 2: Supervising a junior learner with more experience
| GP supervisor | Junior learner | ||
|---|---|---|---|
| 0900 | Patient X | 0900 | Patient A |
| 0915 | Join junior learner with patient A | 0915 | Present patient A to supervisor |
| 0930 | Patient Y | 0930 | Document patient A |
| 0945 | Repeat cycle | 0945 |
Timetable 3: Supervising two junior learners of varying experience
| GP supervisor | Junior learner 1 (more experience) | Junior learner 2 (less experience) | |||
|---|---|---|---|---|---|
| 0900 | Patient X | 0900 | Patient A | 0900 | Patient D |
| 0915 | Join junior learner 1 with patient A | 0915 | Present patient A to supervisor | 0915 | Patient D |
| 0930 | Join junior learner 2 with patient D | 0930 | Document patient A | 0930 | Present patient D to supervisor |
| 0945 | Patient Y | 0945 | Patient B | 0945 | Document patient D |
| 1000 | Join junior learner 1 with patient B | 1000 | Present patient B to supervisor | 1000 | Patient E |
| 1015 | Patient Z | 1015 | Document patient B | 1015 | Patient E |
| 1030 | Join junior learner 2 with patient E | 1030 | Patient C | 1030 | Present patient E to supervisor |
| 1045 | Join junior learner 1 with patient C | 1045 | Present patient C to supervisor | 1045 | Document patient E |
| 1100 | 1100 | Document patient C | 1100 | ||
| 11.30 | Repeat cycle | ||||
Sharing supervisor load
There are various advantages and disadvantages to various alternatives for timetabling supervision for parallel consulting. If the learner has too many supervisors there may be poor continuity. A longitudinal relationship with the supervisor builds confidence and autonomy for the learner, and this may be compromised when too many supervisors become involved. However, a shared model of supervisors is essential to reduce the teaching load. The model chosen will depend on the number of supervisors and their willingness to supervise learners. The table below gives options for sharing supervision.
| Timetabling | Advantages | Disadventages |
|---|---|---|
| New supervisor every week | Continuity of supervision and expectations for the learner. Easy for staff and patients to understand. Ability to see improvement in the learner over the week | Potentially exhausting for supervisor. |
| New supervisor every day | Roster is easy to share and clear for staff and learners. If a regular day then complex patients who don’t like learners within their consultations can be scheduled on other days. | Learner has to adapt to new teacher every day. One whole day teaching can be tiring for the supervisor |
| New supervisor every session | Fresh supervisor in the afternoon, starting on time. Part-time supervisors can contribute to teaching proportionate to their workload. Allows many more supervisors to contribute to teaching and sharing the load. | Poor continuity of teaching—learner has to adapt to new supervisor every session. Supervisors less likely to get an appreciation of learning needs and abilities and may have less confidence in the learner. Supervisors less likely to observe the learner. |
| New supervisor every hour | Supervisors free to see their own patients most of the day and much less exhausted. Supervision requirements are spread across each day and become a normal part of a working day. Works best when supervisors are there most days. Learners are more likely to run on time as supervisors more available. Continuity over time with a large number of supervisors. Establish a culture in which teaching is part of the practice’s regular activities. | Complex to organise and can be confusing for learner. Staff need to be very aware and organised. Good co-ordination of patient communication required. Learners need to think for themselves rather than second-guessing supervisor—this can lead to more uncertainty but may also help establish learner autonomy. Learners may not receive targeted patients to consult (e.g. may be scheduled with supervisor’s ‘book on the day patients’), which may skew their experience. Less time for positive feedback and unpacking of difficult cases. |
Booking patients for parallel consulting
Flexibility
Scheduling times for patient appointments need to be changed, depending on the learner and their needs. Medical students will probably need one patient per hour, while registrars can usually commence with two patients per hour. In regard to medical students, some supervisors will look at their bookings for the day and identify patients who are appropriate for student consultations.
Flagging patients
It is important to have a system that flags patients who have expressed discontent about seeing new doctors or students. By flagging patients who have not given consent, the administrative staff can avoid repeatedly asking patients who have already objected.
‘Fit-in’ appointments
Fill the learners with ‘book on the day’ or ‘fit-in’ appointments. Patients wanting to be fitted in on the day are more likely to have acute presentations of a new illness. These are very suitable cases for medical students.
Patients as teachers
Have a list of patients who enjoy consulting medical students and telling their medical history. Many older adults have more time available and are happy to contribute regularly by educating the learners. Recruit these patients as part of your teaching team.
Training reception and medical staff
Reception staff need to maintain a positive and respectful approach to all learners. When the administrative staff have a respectful approach, a standard is established with patients which indicates that learners add value to the practice and patient consultations. The language used by reception staff and supervisors can be crucial in gaining agreement from patients to see learners.
Always introduce the learner by name to the patient so that they are identified as a professional in the practice. Try:
- You will be with John Smith, who is a senior medical student learning to be a doctor, and Dr X will see you as soon as he is finished with his next patient.
- You are booked in with Dr Jones, who is a qualified doctor training under Dr X to be a GP specialist. Dr Jones will consult with Dr X if necessary.
- Mrs M, we have a senior medical student (John Smith) assisting Dr X today in the practice. Dr X wondered if you would be willing to see John first while you are waiting? John will take a thorough history and give Dr X a second opinion.
- We are a teaching practice of the University of Z, and so we are honoured to have students here learning about how to be a doctor from Dr X. Would you mind if Jill Smith, a senior student, talked to you in another consulting room while you are waiting for Dr X? Dr X will join you as soon as he is finished with the patient before you.
As a supervisor, the way you refer to the learner in the consulting room with the patient present will have a huge impact on the patient’s acceptance of the learner. If you acknowledge their opinions, ask their advice and include the learner in the patient’s follow-up management, then the patient is more likely to view the learner as adding value to the team.
Doctors also need to be aware of how they encourage patients to come back and see junior staff. Use the word “we” to show that you are a team:
- John, what is the latest they have been teaching you at medical school about this? Could you check the latest evidence for me, so we can be sure we have explored all treatment options for Mrs Jones.
- Our current medical student, John, is a fabulous student who is very up to date. I would
appreciate you seeing him next week before our consultation, as he would really benefit from
hearing about your condition and understanding more about it.
- Mrs Jones, I would like you to come back early next week to Dr Helen, so she can follow up to see if things are getting better. If they are, then we will review you together the following week. If you have any issues or you think things are getting worse then contact Dr Helen or me.
- Mrs Jones, I would like John, our student, to do a blood test in a few days and if you could please come back to see both of us next week on Wednesday, then we should have the results.
Preparing learners
It is important to give some tips to the learner to enable them to manage the parallel consulting system effectively. If the supervisor is running late it can be awkward for learners to sit with patients without any direction. Preparing the learner to manage this situation is essential.
- Prevention: Teach the learner how to take a preventive health history, check on screening and immunisations. Show the learner how your database can assist in preventive health screening. Help the learner to feel comfortable talking about lifestyle issues (for example, diet, exercise and sleep).
- History review: Encourage the learner to check patient data and update the file. The learner could
review previous consultations and establish if previous problems have resolved for the patient.
- Identification: Discuss with the learner how to identify a patient who is unhappy with waiting. Brainstorm strategies to escalate and deal with this issue. The learner needs to know how to signal to the supervisor if a patient is in a hurry or unhappy seeing a learner.
- Clear expectations: When the learner rings, be clear about how long you will take to join the
learner’s consultation. Having clear expectations empowers the learner to plan appropriately. Try:
- I will still be about 10 minutes, so could you do a preventive health check-up while you are waiting
- Ask for clarification: Ask the learner to phone you before you join a consultation. The learner can let you know what information will be required when you join the patient and student. For example:
- Mrs Jones is well and is just here for a script.
- Mr Wood has complex issues that he would prefer to discuss in detail with you, rather than go through them twice.
- Mrs Winter is worried about her baby, and the baby is very distressed, so I need your urgent help.
- Debrief: If the learner felt uncomfortable and stressed, debrief about the consultation. Identify what the learner could have done to improve the issues or their communication. Students may need to be reassured that a patient’s frustration is not personal, but is more likely to be about the system, particularly if their appointment is very late
A couple of supervisors in a rural practice found out via an anonymous practice survey that some patients were weary of having learners always present when they consulted. They hadn’t realised it was such a strong feeling amongst patients. One of the supervisors also felt exhausted and was finding teaching not as empowering as it had been. Together, they both looked at how they managed learners in the practice and decided to change the way parallel consulting was organised to improve patient acceptability. Dr X and Dr Y reorganised their appointments, but slightly differently from each other.
When patients rang up for an appointment with Dr X they were offered either a teaching clinic appointment in the morning or private clinic appointment in the afternoon with Dr X. They were clearly told that the teaching clinic appointment would involve assessment initially by a student or junior doctor who would then call in Dr X and the consultation would then be finalised under Dr X’s supervision. They would be bulk-billed for this style of consultation appointment. If they booked into Dr X’s private clinic then they would be charged a private fee but see Dr X only. Patients who were normally bulk-billed would still be bulk-billed at the discretion of Dr X. As Dr X could be booked out for weeks, this model also gave patients access to see Dr X a bit more quickly if they chose to book via the teaching clinic. Dr X found afternoons easier as she was able to see patients more efficiently and get home on time.
Dr Y decided to do something similar; however, he preferred to have one style of clinic with patients either booked into the student/junior doctor or directly with him. Those who were booked into the student or junior doctor were told they would be bulk-billed and explained the process, as described above. Those who were booked with him directly were charged according to usual billing practices.
The benefits of this model allowed patients to see their doctors more quickly if they were willing to be seen first by a student or junior doctor, which was a great benefit to them. For those patients who wanted to be bulk-billed, it gave them an option for this that still involved seeing their GP. Patients were then also guaranteed that they could see their doctor without a learner present if they chose. Patients were happy that at the time of booking they could decide whether they were happy to have a learner involved in their care.
Medical records and note taking
Writing medical notes enables the learner to order their thinking. Often registrars or students will think more clearly and order their thinking when it comes to writing up the consultation. If learners are able to complete the medical notes before they call their supervisor, they may have been able to problem solve, establish a plan and identify gaps in history or examination before the supervisor joins the consultation.
Most supervisors will be able to read the story in the patient’s medical notes much quicker than the learner relaying all the information. However, different practices have different computer systems. If you are able to access the medical notes at the same time, this allows the supervisor to remain in their own consultation while responding briefly with further instructions before joining the learner’s consultation. Of course, this depends on the level of urgency. If your computer system does not allow duplicate access to medical notes, using internal email is an alternative. The learner can paste their thoughts on the case into an email, and you can respond briefly via email.
The learner should still be given the opportunity to present the key information succinctly in front of the patient when the supervisor joins the consultation. This presentation allows the patient an opportunity to give input into the discussion. Any misinformation or problems with the notes can be changed after you have seen the patient, before the notes are saved in the system.
Suggested further reading
De Witt DE. Incorporating medical students into your practice. Aust Fam Physician 2006; 35:24–6.
This is a useful article that provides tips on how to make teaching of medical students more fun and more rewarding for all parties.
Tran PD, Laurence JM, Weston KM & McLellan PL. The effect of parallel consulting on the quality of consultations in regional general practice. Educ Prim Care 2012; 23(3):153–7.
This article provides good justifications for using a parallel teaching method, including its safety and efficacy.
8Walters L, Worley P, Prideaux D & Lange K. Do consultations in rural general practice take more time when practitioners are precepting medical students? Med Educ 2008; 42:69–73.
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