. 2015 Sep 4;19(5):1121–1137. doi: 10.1111/hex.12404

Table 3.

Consultation extracts – missed and used opportunities

Missed opportunities
Extract	Interpretation (linked to core issues from consultation analysis)
Extract 1 (Consultation 80)
GP3: So it works out at 42 units a week…
Patient: I'm just a normal bloke who goes to the pub on a Friday night that's all!	Patient reports drinking above recommended weekly units of alcohol, uses humour to deflect discussion^a
GP3: Yeah, yeah so it's all right, it's just that you know the rec… we just need to advise you what the current guidance is okay?	Practitioner sidesteps discussion, falls back on standard recommendations rather than addressing individual need ^a ^, ^c
Patient: [Laughs]…[pause]	No verbal response from patient^a
GP3: Right now, let's have a look at your medications.	GP changes topic to focus on recording medication use^a ^, ^b
Extract 2 (Consultation 16)
Patient: I'm desperately trying to lose weight…	While being weighed, patient gives clear cue about needing weight management support
PN1: That's 78.2 kilos ok [typing]…which comes to 12st 4Ibs	Nurse focused on recording patient's weight ^b
Patient: [Gasps]	Patient gives clear non‐verbal cue indicating emotional impact
PN1: See what you were before [typing]…more or less 5 kilos – a stone…	Nurse does not respond to emotional cue and points out patient's weight gain^a
Patient: Yeah…I put on a lot when I was first pregnant…	Patient gives reason for weight gain
PN1: Yeah, 68 kilos there weren't you? Have you ever smoked?	Nurse misses/blocks patient cue for discussion of weight and moves on to record smoking status, shuts down discussion ^a ^, ^b ^, ^c
Extract 3 (Consultation 102)
PN8: We've got you down as 10 units per week [alcohol] last time.
Patient: Yeah I've cut it down last – er – I've been cutting down.	Patient offers cue for possible discussion of own successful behaviour change
PN8: Right	Nurse does not respond to patient cue, closes down discussion^a ^, ^c
Patient: I don't really drink…I'm trying to lose weight you see. Now if you'd have said psoriasis impacting weight, I'd have said that's what's caused all my weight problems since I was 7 [laughs] – I would honestly!	Patient cues for discussion a second time, links own alcohol behaviour change with goal of weight loss and raises further link between psoriasis and weight
PN8: Right, um are you on any statins?	Nurse fails to respond to specific concerns of patient, misses opportunity to discuss alcohol, weight and lifestyle–psoriasis links, closes down discussion, focuses on recording medication use^a ^, ^b ^, ^c

Used opportunities
Extract	Interpretation (linked to core issues from consultation analysis – examples of skilled practice)
Extract 1 (Consultation 30)
PN2: You are 13st 6lbs and it's saying at the most you should be 9st 11lbs you see on the computer, so…	Nurse uses ‘guiding’ style and graphical representation of BMI categories to support patient's understanding of appropriate weight^e
Patient: So I'm in the obese scale?	Patient verbalizes concern about weight information provided
PN2: Yeah. So what we gonna do? What do you think you can do exercise wise? They say if you pick something that you like you will maintain it and keep doing it, you know what I mean? Rather than me saying to you ‘Right you need to go for a walk 5 times a week for half an hour’. You need to find something that you like doing really to maintain it and keep it going	Nurse responds directly to patient's concern, signals that she will support patient, explores patient's confidence to make a change^d ^, ^e Gives rational for increasing/maintaining physical activity, encourages individualized choice^d ^, ^e Moves towards planning for change^e
Extract 2 (Consultation 61)
PN9: But first of all just as a first thought…is doing a food diary	Nurse suggests a food diary as part of individual action planning with patient^d ^, ^e
Patient: Right yeah!	Patient expresses interest in food diary activity
PN9: And actually writing down for a week what you have during the day and when you have it and absolutely writing everything down even if it's just a few crisps	Nurse focuses on detail of food diary with patient^d ^, ^e
Patient: Even if it's just a few crisps or whatever, yeah, yeah course yeah	Patient expresses interest in plan
PN9: Yeah, and then I can see you again with that and we have the option of referring you to the health trainer … we do have other referral procedures where we can actually send you to the Active Living Team… It's which fits into your lifestyle and which you would prefer to do?… If we could initially ask you to do a food diary then see me in a week to 10 days with that?	Nurse offers review/follow‐up to discuss food diary, offers possibility of further options for more individualized support^d ^, ^e Encourages individualized choice^e Makes a plan with timeline for follow‐up^d ^, ^e
Patient: Food diary, of course, yep no problem	Patient expresses interest in plan

Core issue 1: lack of detailed CVD risk discussion.

Core issue 2: practitioner focus on recording information.

Core issue 3: lack of patient‐centred practice.

Core issue 1: example of skilled CVD risk discussion.

Core issue 3: example of skilled patient‐centred practice.