3 ObjectivesTo understand why consultation skills are important in Family PracticeTo discover, why communication skills development is essential in consultationTo learn the essential features of a consultation in Family PracticeTo become familiar with consultation models in Family Practice
4 Consultation SkillsFamily Physicians often need to be bearers of the worst imaginable newsThey have to arrange complex and often uncertain information into something understandableThey have to respond to differing needs of a hugely diverse range of patients and their familiesAnd they have to do much of this when they are busy and under pressure
5 Consultation Skills (Silverman et al. 1998) If a joint management plan, which the patient understands, feels comfortable with, and is prepared to adhere to, is not made:the patient is not likely to follow it andall our efforts in assessment and diagnosis are wasted(Silverman et al. 1998)
6 The Evidence Base Individual Consultation: For the doctor it is one of many routine encounters, somethingto be got through as fast as possible .But for the patient it may be the most important – and stressful– aspect of their week….or the last six months,as they wait anxiously for the appointment and their chanceto see the doctor…… ”(Dr Julie Draper, an unpublished quote, Cambridge University Medical Training Workshop, December 2001)
7 The Evidence Base54% of patient’s problems & concerns not elicited (Stewart et al, 1979)Doctors frequently interrupt their patients soon after their opening statement (mean time 18 seconds) so patients subsequently failed to disclose significant history points (Beckman and Frankel, 1984)Failing to discover the patients ideas, concerns & expectations (ICE) led to dysfunctional consultations (Byrne and Long, 1976)
8 Deficiencies in Communication Doctors may not obtain enough information about patients’ perspectiveProvide information in inflexible wayPay little attention in checking how well patients have understoodLess than half of patients’ psychological morbidity is recognized
9 Blocking Behavior Offering advice and reassurance before the main problems have been identifiedExplaining away distress as normalAttending to physical aspects onlySwitching the topic“Jollying” patients along
10 Reasons for patients not disclosing problem Belief that nothing can be doneReluctance to burden the DoctorDesire not to appear pathetic or ungratefulConcern that it is not legitimate to mention themDoctors’ blocking behaviorWorry that their fears about what is wrong withthem will be confirmedLack of confidentiality and trust
11 What is a failed consultation? No rapportUsing medical jargonNot exploring the patients agendaNot eliciting relevant symptoms and signsNo contingency plan(safety netting )No summarizationFailing to clarify and involving the patientNot exploring in socio-cultural & economic context
12 Problems in Communication: Limitations in our settings Shortage of timeLanguage barrier – low literacyFirm misconceptions and mythsLack of awarenessNot ready to take responsibility for his illnessSocio-cultural, economic barriersFatalistic attitude (It’s God’s will)
13 Barriers to Communication in Clinical Practice Personal BarriersLack of training: undergraduate/postgraduateUndervaluing importance of communicationFocus only on treating diseasesPersonal LimitationsOrganizational BarriersLack of timePressure of workInterruptions
14 Why Consultation Skills? When doctors use consultation skills effectively:Patients’ problems identified more accuratelyPatients more satisfied with their carePatients more likely to comply with treatmentPatients’ distress & vulnerability to anxiety & depression are lessened
15 Why Consultation Skills? When doctors use consultation skills effectivelyDoctors’ well-being is improvedFew clinical errors are madePatients are less likely to complainReduced likelihood of doctors being suedGood communication is good for doctorsgood for patients andgood for the health service
16 Consultation Models The Medical Model: Traditional model. History taking Examination Investigation Diagnosis Treatment Follow-up.Does not recognize the complexity and diversity of the consultation in Family Practice.
17 Balint, 1957: The Doctor. His patient and The Illness----a philosophy rather than a consultation model.Psychological problems are often manifested physically.Doctors have feelings. Those feelings have a role in the consultation.Doctors need to be trained to be more sensitive to what is going on in the patient’s mind during a consultation.Reference: Churchill Livingstone (2000) ISBN:
18 Berne, 1964: Games People Play---describes how to recognize behaviours (‘games’) patients might use and rolespatient and doctor might adopt—’Patient, Adultand Child’.Reference: Penguin Books (2004) ISBN:
19 Byrne and Long, 1976 Doctors Talking to Patients---6 aspects: Doctor establishes a relationship with the patient.Doctor attempts to/actually discover the reason for attendance.Doctor conducts verbal + physical examination.Doctor or doctor + patient or the patient consider the condition.Doctor (occasionally the patient) detail treatment and investigation.Consultation is terminated—usually by the doctor.Reference: RCGP (1984) ISBN:
20 RCGP, 1976: The consultation can be divided into ‘physical, psychological, and social’ aspects i.e. in generalpractice doctors should address emotional, family,social, and environmental factors in addition to thetraditional ‘organic’ medical approach.Reference: JRCGP (1977) 27:117
21 Stott and Davis Model, 1979: Management of presenting problems. ‘Exceptional potential of the consultation’. 4 tasks:Management of presenting problems.Management of continuing problems.Modification of help-seeking behavior.Opportunistic health promotion.Reference: JRCGP (1979) 29:201-5
22 Pendleton et al, 1984: The doctor’s tasks: Define the reason for patient’s attendance – Presenting problem.Consider other problems (continuing problems and at-risk factors).Choose an appropriate action for each problem (involves negotiation between doctor and patient).Achieve a shared understanding of the problem (doctor and patient).
23 Pendleton et al, 1984: Cont’d Involve the patient in the management and encourage the patient to accept appropriate responsibility.Use time and resources appropriately.Establish and maintain a relationship between doctor and patient.Reference: The New Consultation. Oxford University Press (2003) ISBN:
24 Neighbour, 1987: The Inner Consultation Checkpoints: Connecting (doctor establishes rapport with the patient).Summarizing (doctor clarifies the patient’s reasons for consulting)Handing over (doctor and patient negotiate and agree a management plan).Safety netting (doctor and patient plan for the unexpected---managing uncertainty).Housekeeping (doctor is aware of his/her own emotions).Reference: Petroc Press (1999) ISBN:
25 Fraser, 1992: Areas of competence: Interviewing and history taking. Physical examination.Diagnosis and problem solvingPatient management.Relating to patients.Anticipatory careRecord keeping.Reference: Clinical Method: A general practice approach. Butterworth Heinemann (1999) ISBN:
26 Moving from open to closed questioning The Open-to-Closed ConeOpen ended questions to explore the fieldMid-way questions – directional statementsClosed questions – used following informationgathering to focus in
27 OutcomeExplanationPlanningIllness FrameworkDisease FrameworkDoctors agendaPatients agendaFoundationMeeting + greetingDeveloping rapportAn architectural model of consultation
28 Interventional Styles John Heron AuthoritarianinformativeprescriptiveconfrontingFacilitativesupportivecatharticcatalytic
29 Breaking Bad News The ABCDE Mnemonic for Breaking Bad News Arrange for adequate time, privacy and no interruptions(turn off Pager/phone or to silent mode)Review relevant clinical informationMentally rehearse, identify words or phrases to use and avoidPrepare yourself emotionallyHave family or support persons presentAdvance preparationBuild a therapeutic relationshipCommunicate wellDeal with patient & family reactionsEncourage and validate emotionsIntroduce yourself to everyoneBuild rapportUse touch when appropriateSchedule follow-up appointmentsAsk what the patient or family already knows.Determine what & how much the patient wants to know.Warn the patient that bad news is coming.Proceed at the patient’s pace.Avoid medical jargon.Allow time to answer questionsConclude each visit with a summary and follow-up planAssess and respond to the patient and the family’s emotional reactionBe empathetic.Do not argue with or criticize colleagues.Explore what the news means to the patient.Offer realistic hope according to the patient’s goals.Use interdisciplinary resources.Take care of your own needs; be attuned to the needs of involved house staff and office or hospital personnel.
30 Dealing with Anger It is the patient who is angry, not you! Do not leave the anger unexploredBe supportive to your staff
31 Dealing with Anger Handling patient confrontations: Explore the anger towards the end of the consultation.Recognize your weaknessesVerbal Communication Techniques:Wish I couldAgree in principleBroken recordNonverbal communications
32 Consultation Duration Longer consultations result in lesser prescription of drugs and more patient satisfaction.
33 Essentials of Consultation Meeting & greetingHistory with good eye contactStarting with open ended questionsPatient- centered approach –let the patient talkSummarizing & ICERelevant exam & investigations (if needed)Patient involvement in managementSafety- netting & follow up
34 CONCULSIONThe traditional medical model does not recognize the complexity and diversity of the consultation in family practice.The models proposed for consultation in family practice are many. Each views the process from a slightly different perspective.The consultation model should match the individual needs of the patients and doctors.