Presentation on theme: "How do you teach the General Practice Consultation?"— Presentation transcript:
1How do you teach the General Practice Consultation? Dr Ian McKelvey
2I underestimated two things when I opted to become a GP… GP ReceptionistsThe Value of the Consultation
3Consultation Models. Calgary Cambridge Pendleton et al– The ConsultationNeighbour – The Inner ConsultationStott and Davies – The exceptional potential of each primary care consultationByrne and Long – 6 phasesHelman’s ‘folk model’McWhinney’s disease Illness ModelCounselling ModelThe RCGP’s COTMcKelvey – The Consultation Hill.
4….they are all interchangeable and pretty much say the same thing! In theory there is no difference between theory and practice; in practice there is.
6Define reason for attendance nature and history of problems Aetiology Roger NeighbourConnectingSummarising...physical, psychological, social.Handing Over …influencing, negotiating, gift-wrapping, ‘my friend John’….Safety-netting....?OKHousekeeping.. Am I in good shape for the next patient?Pendleton et alDefine reason for attendancenature and history of problemsAetiologyIdeas, Concerns, ExpectationsEffects of problemsConsider other problemsContinuing problemsAt risk factorsWith patient, choose appropriate action for each problemAchieve shared understanding of problem/sInvolve patient in management and encourage him to accept appropriate responsibilityUse resources appropriatelyIn the consultationIn the long termEstablish and maintain a relationship with the patient that helps achieve the other tasks
7McWhinney’s disease-illness model Patient presents at a particular time when have reached either their‘limit of symptom tolerance’ or‘limit of anxiety’useful to move focus to patient agenda ( hospital doctor to GP)Draws parallel between traditional medical model of illness and a patient centred perspective.If you can understand which trigger is at work the consultation is more likely to be successful.
8McWhinney Medical Parallel Patient Parallel HF On and on Understanding of patients experience
9Helman’s Folk ModelPatient comes to a doctor seeking answers to 8 questions….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 for further help?What can you (the doctor) do about it?How can I stop it happening again?Anthropological model and helps registrars gain insight into the patients agenda.
10Stott and Davies. The Exceptional Potential in each primary care consultation Management of presenting problemsModification of help-seeking behavioursOpportunistic Health PromotionManagement of continuing problems
11Counselling Model Ultimate patient centred approach ‘Allow patient to explore in their own way and at own pace the origins, implications and solutions to their problem’Doctor must have ability to keep own opinions and suggestions to themselvesUse techniques such as reflecting, interpreting and judicious use of silence in order to bring the patient to an insight which is his own and nobody else’sPERHAPS NOT IDEAL TO EMBRACE PRIOR TO CSAi.e. BOLLOCKS
12Neighbour’s Consultation Model 4. Safetynetting3. Handing Over5. Housekeeping2. Summarising1. Connecting
13The centipede was happy, quite, Until a toad in funSaid, “Pray, which leg goes after which?”This worked his mind to such a pitchHe lay distracted in a ditchConsidering how to run.
141. Connecting Rapport Gambits & Curtain Raisers Minimal cues – verbal and non-verbalWhat is said & not saidRepresentational systems-V,A & KEye movements3 cardinal mental thought processesSpeech censoringInternal SpeechAcceptance SetIn chess, opening moves are ‘gambits’, but when patient enters room sometimes they come out with an unscripted ‘curtain raiser’. Eg “you are a difficult man to see – anyway, I’ve been getting these stomach pains…”
15Rapport The ‘sine qua non’ of effective communication Two people being mutually responsive to each others signalsNot the same as liking someoneDr owes it to the patientA process, not a state. Something you do, like tuning a radioReading the physical signs of someones mental stateCan be practiced by developing greater sensory awareness of the minimal cues by which people signal their thoughts and feelings.Minimal cues….?
16Minimal Cues - the physical signs of mental illness Verbal – what’s said and not saidNon-verbal AuditoryVisualKinaestheticImagine being invisible at a party….
17Pedicates - Visual(V) Auditory (A) Kinaesthetic (K) I see what you mean (V)I hear what you are saying say (A)I grasp what it is you are going through (K)The future looks bleak. My life’s a mess (V)We’re not in tune with each other any more. We just row and clash. (A)I don’t know where to turn. I feel stuck in a rut. (K)
202. Summarising What information do we need? I, C, E. Feelings Effects of symptoms, treatment etcWhen should you elicit that information?What signals can the patient give to suggest thatmore information could be elicited?How should we elicit the information?
213.Handing Over Negotiating Give the patient options Influencing in my opinion…Use questions instead of statementsReframingShepherding –value laden phrases, eg admission or notpresuppositions eg tea or coffeepre-emptingmy friend John…Gift WrappingChunk & CheckHow to give instructions – rule of 3.Rule of 3…say what you are going to say, say it, then say what you’ve said.
224. Safety Netting“General Practice is the Art of Managing Uncertainty”If I am right, what do I expect to happen?Worst case scenarioInstructions to patientF/U - What if patient doesn’t come back?How will I know if I am wrong?What will I do then?What to say to the patient
235. House KeepingLong termIn between PatientsDuring Consultations
24CSA and nMRCGP 13 cases Own room 10 minutes each. 2 minutes between each caseA practical assessment of consulting skillsExpensive £1,260 a throw.Examiner sits in the cornerBreak in the middle after 7 patients of 15 minsNo marks will be gained after 10 mins when buzzer soundsNo 1-2 minute warning buzzer“shows poor time management” is a reason they can fail you at any station…..and they will
25CSA Each case is marked on 3 domains data gathering, examination and clinical assessment skillsClinical management skillsInterpersonal skillsAll domains have equal weightingDo not spend 8 minutes on history and examination…you will fail this station
27The Consultation Hill. “seek first to understand, then be understood” Shared SummitPreparationAscentDescentReflection“seek first to understand, then be understood”
28Preparation Personal preparation System preparation patient access, phone, booking systems, reception staff, waiting room, toilets, IT system, forms, equipments, consultation room, PILs, telephone interruption policy.Personal preparationBe rested, mentally and physically. If late, don’t rush. Offload ‘baggage’. Identify personal prejudices and stresses and leave outside the clinical encounter
29Ascent Reason for attendance/ information gathering ICEs Why here, why now?Preferred representational system? (VAK)Acceptance set?RapportHistory and ExaminationLargely patient ledDr – listening, facilitating, encouraging, interpreting, clarifying, empathising (actively)End by ‘summarising’ to reach shared summit. (beware of reaching the wrong summit if Dr and patient don’t share same understanding of patients reasons for attending)Dr should by the end have established a ‘working diagnosis’ and formulated an action plan.
30Shared SummitPause, take in the air, enjoy the view of a shared understanding. ( pause, slow intake of breath, reflective look, shift in body posture, change of tone, rate, volume of speech)Can be identified and acknowledgedMay be most exposed here, so Dr must be preparing for a safe descent down a devised route which is now more Dr led.Route planned so can negotiate and ‘hand over’ using information gained on the ascentNeed to get here in 7-8 minutes for the CSA!
31DescentTailored explanation of the problem and a solution offered, incorporating and using patients already established health beliefs and understanding, which can be sensitively modified if appropriate.Management plan proposed and seek approval from the patient (acceptance set)Confirm patients understanding and define their responsibility and involvement in the process. This will increase complianceWhat if it goes wrong? Acknowledge this and plan another assault on the consultation hill?Foothills include ‘safety netting’Acceptance set…calliibrate what the patient does when they say ‘yes’ and ‘no’ by lobbing in some leading questions early and watching how they respond eg ‘the right shoulder’…’yes’
32Reflection Always something to be learnt from any clinical encounter PUNs and DENs (Eve ; discovering learning needs in GP)It’s a lifetime of learning….!
33My last word, ….honestYou need to reflect upon how your work affects your physical, mental, spiritual and emotional state ….….as healthy doctors are more likely to provide good medical care.Kit fit, let the journey be safe for both you and patient, enjoy the challenge of the consultation hill and strive to make the next trip more successful.‘In general practice the consultation is a journey, not a destination’….Roger Neighbour
34So how do you teach all this….? Joint surgeriesVideo analysisRole PlayHas to be experiential…Trainee has to identify the area to work on and feel it important enough to improve/work on. Can use SET-GO (what I Saw, what Else did you see, what do you Think,,clarify Goal, any Offers how to get there.Do it in bite sized chunks – Work on one task per week
35Ideas‘Tell me about what you think is causing it.’‘What do you think might be happening?’‘Have you any ideas about it yourself?’‘Do you have any clues; any theories?’‘You’ve obviously given this some thought, it would help me to know what you were thinking it might be’.Concerns‘What are you concerned that it might be?’‘Is there anything particular or specific that you were concerned about?’‘What was the worst thing you were thinking it might be?’‘In your darkest moments ...‘Expectations‘What were you hoping we might be able to do for this?’‘What do you think might be the best plan of action?’‘How might I best help you with this?’‘You’ve obviously given this some thought, what were you thinking would be the best way of tackling this?’Effects on Life…..the 50p game.
36Gathering data to understand the patient's problems The Three Function Approach to the Medical Interview (1989) Cohen-Cole and Bird have developed a model of the consultation that has been adopted by The American Academy on Physician and Patient as their model for teaching the Medical Interview.Gathering data to understand the patient's problemsDeveloping rapportEducation and motivationOpen-ended questionOpen to closed coneFacilitationCheckingSurvey of problemsNegotiate prioritiesClarification and directionSummarisingElicit patient's expectationsElicit patient's ideas about aetiologyElicit impact of illness on patient's quality of lifeReflectionLegitimationSupportPartnershipRespectEducation about illnessNegotiation and maintenance of a treatment planMotivation of non-adherent patientsNeighbours 9 rules of thumb of ‘How to give instructions’