The reality pyramid reflects several key principles. First, tasks requiring increasing amounts of consultation time (depicted as a series of higher levels of the pyramid) are likely to be provided by a diminishing number of GPs. For example, many GPs are prepared to provide brief advice; few routinely offer a comprehensive range of behavioural strategies that may take as little as 5-10 minutes. Disposable time (the time available to address the GP's own agenda) varies from minus 60 minutes to up to 5 minutes, with a typical average of 30 - 60 seconds per routine consultation.
On average, GPs spend less than a minute in a routine consultation on smoking cessation. The bottom level of the pyramid DOES NOT involve any GP time within the consultation. The activities are directed towards the practice. This should be attractive to busy GPs who do not even have 30 seconds of disposable time. The second aspect of the reality pyramid is that 'less can be more'. This is a variant of the population health paradox.
Second, if most GPs set-up their practice to flag/note the smoking status of patients, refer to Quitline telephone support service, and hand out QUIT books, the impact of these activities will be greater than the effect of a few GPs who offer a more intensive intervention.
Finally, the pyramid symbolises a series of sequential steps that the GP can take. As the pyramid is ascended, the intensity or level of the GP's offerings increases. The segmentation into time intervals assists the GPs in choosing what to offer if they had more time in a consultation. Effective interventions are reframed in terms of the amount of time required to provide them to patients. The ascending layers of the pyramid provide some guidance as to which activities are more worthwhile in a given amount of time. The base of the pyramid represents that none of the GP's consultation time is required. For very busy practitioners, this represents an option that will not increase the pressure on the precious time available within the consultation.