CONSULTATION MODELS

An overview

Dr Andrew Ashford

The Limes Medical Centre

Classification

Phys, psych, socialStott and DavisByrne and LongPendleton et al

Helman ‘folk model’Health Belief ModelNeighbourCalgary-Cambridge

Byrne and Long (ii)6-Category AnalysisTransactional Analysis

CounsellingBendixBalint

DOCTOR CENTRED

PATIENT CENTRED

TASK ORIENTED

BEHAVIOUR ORIENTED

(after Neighbour: The Inner Consultation)

(1) Royal College of GPs

• The Future General Practitioner - Learning and Teaching - RCGP working party 1972

• “… His diagnoses will be composed in physical, psychological and social terms.” (from the job definition of a GP)

(2) Stott and Davis

A

Management of presenting problems

C

Management of continuing problems

B

Modification of help-seeking behaviours

D

Opportunistic health

promotion

The potential in each primary care consultation (Stott and Davis 1979)

(3) Byrne and Long (i)

Phase I The doctor establishes a relationship with the patient

Phase II The doctor either attempts to discover or actually discovers the reason for the patient’s

attendance.

Phase III The doctor conducts a verbal or physical examination or both.

Phase IV The doctor, or the doctor and the patient, or the patient (in that order of probability) consider the condition.

Phase V The doctor, and occasionally the patient, detail further treatment or further investigation.

Phase VI The consultation is usually terminated by the doctor.(Doctors Talking to Patients - a study of the verbal behaviour of general practitioners consulting in their surgeries)

(4) - Pendleton et al

(1) To define the reason for the patient’s attendance, including:(i) the nature and history of the problems:

(ii) their aetiology:

(iii)the patient’s ideas, concerns and expectations;

(iv)the effects of the problems.

(2) To consider other problems:(i) continuing problems;

(ii) at-risk factors

(3) With the patient, to choose an appropriate action for each problem.

(4) To achieve a shared understanding of the problems with the patient.

(5) To involve the patient in the management and encourage him to accept appropriate responsibility.

(6) To use time and resources appropriately:(i) in the consultation

(ii) in the long term

(7) To establish or maintain a relationship with the patient which helps to achieve the other tasks.

(5) - Helman’s ‘folk model’

• What has happened?

• Why has it happened?

• Why to me?

• Why now?

• What would happen if nothing were done about it?

• What should I do about it or whom should I consult further about it?

(6) Health Belief Model

• General interest in health matters

• Level of vulnerability, level of threat

• Benefits of treatment v. costs, risks, inconvenience

• Factors prompting action - symptoms, advice, media

IDEAS…CONCERNS…EXPECTATIONS

(Becker and Maiman 1975: Socio-behavioural determinants of compliance

with medical care recommendations)

(6) Health Belief Model (ii)

The basic constructs:-

• Perceived susceptibility

• Perceived severity

• Perceived benefits

• Perceived barriers

plus

• Cues to Action

(7) Byrne and Long (ii)

Patient centred

Doctor centred

Use of patient’s knowledge and experience

Use of doctor’s special skill and knowledge

“Absent doctor”

“Absent patient”

Silence Listening Reflecting

Clarifying and Interpreting

Analysing and Probing

Gathering information

Boredom Indifference Not listening Being “miles away” Confused noise

Using silence Seeking/using patient ideas Encouraging Indicating understanding Clarifying Reflecting Offering observation

Offering observation Summarising to open up Repeating for confirmation Seeking pt’s ideas Placing events in sequence Challenging Open-ended question Concealed question

Direct question Correlational question Placing events in sequence Suggesting Offering feelings Exploring Open-ended question Repeating for confirmation

Direct question Closed question Correlational question Self-answering question Suggesting Placing events in sequence Repeating for confirmation Reassuring Justifying self Chastising Summarizing to close off

Rejecting pt’s offers Rejecting pt’s ideas Evading pt’s question Drowning pt’s words Justifying self Confused noise

(8) Six Category Intervention

• Prescriptive - giving advice or instructions, being critical or directive

• Informative - imparting new knowledge, instructing or interpreting

• Confronting - challenging a restrictive attitude or behaviour, giving direct feedback within a caring context

• Cathartic - seeking to release emotion in the form of weeping, laughter trembling or anger

• Catalytic - encouraging the patient to discover and explore his own latent thoughts and feelings

• Supportive - offering comfort and approval, affirming the patient’s intrinsic value

(John Heron 1975)

(9) - Miscellaneous

• Transactional Analysis (TA)

• Counselling

• Bendix - The Anxious Patient

• Balint - The Doctor, His Patient and

the Illness

(10) Neighbour - The Inner Consultation

5 CHECK POINTS:• Connect

Am I on this patient’s wavelength?• Summarize

Have I sufficiently understood the problem to be able to summarize it back to them correctly?

• HandoverIs the patient clear about who is doing what

next?• Saftynet

What should the patient do if events do not turn out as expected?

• Housekeeping Am I in a fit state for the next patient ?

Calgary-Cambridge (i)

THE TASKS

• Initiating the session

• Gathering Information

• Building the relationship

• Explanation and planning

• Closing the session

Initiating the Session

Gathering Information

Explanation and Planning

Closing the Session

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Expanded Framework

Calgary-Cambridge (ii)

THE EXPANDED FRAMEWORK

1. Initiating the session

– establishing initial rapport (1-3)

– identifying the reason(s) for the consultation

(4-7)

2. Gathering information– exploration of problems (8-14)– understanding the patient’s perspective (15-19)– providing structure to the consultation (20-23)

3. Building the relationship– developing rapport (24-28)– involving the patient (29-31)

Calgary-Cambridge (iii)

4. Explanation and planning– providing the correct amount and type of

information (33-35)– aiding accurate recall and understanding (36-

41)– achieving a shared understanding:

incorporating the patient’s perspective (42-45)– planning: shared decision making (46-51)

5. Closing the session (52-55)

Calgary-Cambridge (iv)

Options in explanation and planning

– if discussing opinion & significance of problems (56-59)

– if negotiating mutual plan of action (60-67)– if discussing investigations and procedures

(68-70)

Calgary-Cambridge (v)

Calgary-Cambridge (vi)

70 Skills !! - are you ‘avin’ a laugh?

…Well, NO

1. Each one validated by research for a specific purpose

2. Not all skills needed all the time

THE TOOLBOX ANALOGY

How to learn (and teach) communication skills

• Experiental learning methods

• Problem-based learning methods

• Didactic methods

How to learn (and teach) communication skills (ii)

Experiential• systematic delineation / definition of essential skills• observation• well-intentioned, detailed & descriptive feedback• video / audio recording & review• practice & rehearsal of skills• active small-group or one-to-one learning

How to learn (and teach) communication skills (ii)

Problem-based learning• start with learner’s perceived needs - relevance• balance between self-directed & facilitator-directed• planned with negotiated / emergent objectives• practical problems from “real life”• learners direct pace

Conventional rules of feedback

• Positive first for safety

• Self-assessment first

• Recommendations not criticisms!

Agenda-led, outcome-based analysis