Who doesn’t love a great mnemonic? Medics, with our memories continually being tested as the only determinant of our IQ, have traditionally relied on these helpful acronyms and rhymes to bolster our recall. Into the pantheon of legendary mnemonics strolls FRAYED as a structure for difficult consultations in general practice.
Mirza writes in a conversational, funny, and honest voice, engaging the reader in his FRAYED model. The book is concise and easy to read, with no pretensions of being anything other than a realistic guide from someone who clearly understands the unique challenges of GP consultations. He feels that there needs to be more current consultation models as the last books were written by Roger Neighbour and his contemporaries in the eighties. General practice has evolved significantly since then and the author would like to see new consultation models reflecting this change.
The book goes through each stage of the FRAYED consultation, with case studies to illustrate the point. Mirza’s first step is to identify the consultation as FRAYED (Fact Finding, Refuse Request, Acceptable Alternative, Yield or don’t Yield, End Encounter, and Document Diligently), and he stresses that this shouldn’t be a blanket approach to all consultations in primary care, as most do not consist of demanding patients. His pragmatism and experience show particularly in building in the need for negotiation (‘A’ = Acceptable Alternative) and for occasionally having to accept the patient’s demands (‘Y’ = Yield or don’t Yield). Also included is making a strategic decision to Yield to a request considered to be unreasonable, and feeling ‘OK’ about it afterwards, referred to as ‘loop-holing’.
Mirza maintains a neutral, ‘observational’ tone and doesn’t ‘blame’ the patient’s personality, nor does he point to any GP-specific issues (other than time-pressures) that may lead to a negative spiral in the consultation. He does distance his model from the old label of ‘heartsink’ patients, which he feels is more applicable to repeat-attenders with undiagnosed symptoms and a low mood because of these. I felt that this distinction was not so clear-cut because ‘heartsink’ patients are often those with intractable symptoms. However, in addition to having depression, they are often belligerent and demanding — thus very much worthy of a FRAYED consultation!
Mirza does not offer any analysis or insight into why these consultations can be so difficult. He states honestly that his intention is not to write an academic tome, but that if:
‘… you find yourself in a situation that you haven’t been able to empathise your way out of, you have this tool at your arsenal.’
We’ve all experienced such consultations. Some reflection on (and examples of) the causes of these energy- and positivity-depleting consultations may have made for a more interesting book.
Time will tell if FRAYED will hold as unforgettable a place in the Medical Mnemonic Hall of Fame as ‘DANISH’ for cerebellar signs, or an unrepeatable rhyme for the 12 cranial nerves. As with all good mnemonics, FRAYED certainly is easy to remember and implement. Mirza hopes:
‘… that this book will trigger a new wave of writing about the consultation to suit the current GP landscape …’
and that is definitely a timely aim, but as a GP trainee I do hope that the zeitgeist does not require more than one model for a difficult consultation!
