Every trainer eventually supervises a registrar who is struggling with consultations — sometimes one who has already had an exam attempt that did not go to plan. It is one of the more challenging parts of the role, partly because the problem is often hard to name precisely, and partly because the registrar’s confidence is usually fragile by the time the difficulty is obvious. A structured approach helps both of you.

Diagnose before you treat

The instinct is to offer general encouragement and more practice. But “consultation skills” is not one thing, and vague reassurance rarely helps. The first job is to work out specifically where the consultation is breaking down. Is it data gathering — too narrow, too scattered, missing the patient’s agenda? Is it clinical reasoning that is sound but never quite makes it into a clear management plan? Is it the relationship — a registrar who knows what to do but struggles to bring the patient with them? These need very different interventions, and treating the wrong one wastes everyone’s time.

Watching real consultations, ideally several, is the way to locate the breakdown. One consultation can mislead; a pattern across several tells you where the real gap is.

Make the pattern visible to the registrar

A struggling registrar often cannot see their own pattern. They experience each difficult consultation as a separate misfortune rather than a recurring habit. Part of your job is to hold up a mirror, gently but concretely, so they can see that, for instance, they consistently move to management before they have understood the concern. Once a registrar can see the recurring issue, they can work on it. Until they can, they tend to flail at everything at once and improve at nothing.

Tools that review performance across multiple consultations can help here, because they make the pattern objective rather than dependent on your impression alone. A registrar who hears “your safety-netting was rushed in six of your last eight cases” finds that harder to dismiss than a single piece of in-the-moment feedback.

Build a focused plan

Once the gap is identified, resist the urge to fix everything. Pick the one or two things that, if improved, would lift the most. Give the registrar concrete, repeatable practice on those specific elements rather than generic “do more consultations.” Volume without focus rarely helps a struggling registrar; focused repetition on the identified weakness usually does.

Protect their confidence

Finally, remember that a struggling registrar is often anxious, and anxiety degrades consultation performance independently of skill. Low-stakes practice, where they can attempt, fail, and try again without it feeling like an assessment, rebuilds confidence as well as competence. The registrar who can practise freely, away from the pressure of being observed, often relaxes enough to let the skill you are trying to build actually emerge.