2Consultation Models"Bad consultations result from having insufficient clinical knowledge, from failing to relate to patients or from failing to understand the patient's behaviour, his perception of his illness or its context“- JGR Howie (1985)
3Consultation Models Descriptive Normative Conceptual Practical A model is a perspective or simplification. It is not right or wrong, just more or less useful.Models of GP consulting are similar in their attempt to broaden the conventional medical approach to include psychosocial issues, the family, and the physician. Some models are descriptive - they say what has been or can be observed in consultations. e.g. (Byrne & Long, Calgary Cambridge). Others are normative - they say what should happen in a good consultation. ( e.g. MRCGP, Stott and Davis, Pendleton, Neighbour, Patient-centred) Some are conceptual frameworks with no description of methods or behaviours for implementation (e.g. Stott and Davis). Others focus on practical behaviours within a less developed framework (e.g. Pendleton).
4The Biomedical ModelTake an accurate and relevant history (OBSERVATION).Perform an accurate and relevant examination (OBSERVATION).Make a provisional diagnosis (HYPOTHESIS).Order and interpret the results of appropriate investigations (HYPOTHESIS TESTING).Make a definitive diagnosis (DEDUCTION).The biomedical approachTake an accurate and relevant history (OBSERVATION).Perform an accurate and relevant examination (OBSERVATION).Make a provisional diagnosis (HYPOTHESIS).Order and interpret the results of appropriate investigations (HYPOTHESIS TESTING).Make a definitive diagnosis (DEDUCTION).This reductionist Model is what most people pick up from Medical School.What are the problems with the model?It is reductionist: patients are seen and treated in terms of signs, symptoms and diagnoses and labelled accordingly.It is doctor-centred: there is no mention of the patient’s feelings, beliefs, and opinions, any sharing of information or agreement of a management plan.It flounders when no objective physical disorder is unearthed.It does not recognise the importance of non-verbal communication.It omits the therapeutic use of the doctor-patient relationship.It fails to recognise that a consultation can be one of a series as is often the case in general practice.It over-emphasises the importance of decisions based on personal clinical experience: these are apt to bias because of the limited number of patients any one doctor can experience.
5M Balint (1957) The Doctor, His Patient and The Illness The Apostolic FunctionThe Drug DoctorThe Sick RoleThe Long ConsultationMichael Balint observed in 1957 that a doctor's personality interacts with medical training to produce a unique way of dealing with patients. Doctors tend to avoid examining their own behaviour and so a fixed style develops.Balint called this the 'Apostolic Function'. This incorporates the doctor's beliefs about how patients ought to behave when ill, how they should behave with doctors and how they should cooperate in their cure.Balint referred to the ‘Drug Doctor' to describe the powerful therapeutic effect of doctors as people, that is the effect of the doctor's personality apart from the treatments they prescribe.Traditionally, the patient adopts the Sick Role and hands over partial or complete responsibility for his well-being to the doctor. This role allows the patient to drop out of other roles, such as that of breadwinner, and be treated in a dependent, cossetted way. The sick role also requires the patient to seek recovery; otherwise social disapproval and withdrawal of privileges may follow.Balint promoted the use of the ‘Long Consultation' at a time when the average consultation took six minutes. He gave the patient an hour after surgery to explore the underlying psychosocial causes behind frequent attendances and repeated failures to resolve a problemA single long session can give insights to the doctor and enough support to the patient to lead to a new rapport and often a resolution of the problem.
6Berne (1964) Games People Play / Transactional Analysis Parent / Adult / ChildAt any given moment we are in one of three states of mind, one based on a rational assessment of our situation, the other two based on memories recorded mostly in early childhood. These states are named (critical or nurturing) Parent, Adult and (dependent or spontaneous) Child. The Adult is the thinking person, while Parent and Child are replayed memories of what happened to us (mostly at the hands of our parents) and of the feelings we had as a small child.The two participants in a transaction are therefore each in one of these three states. Consultations conducted between a paternalistic (Parental) doctor and a submissive (Child-like) patient is seldom in the best interests of either but produces no conflict. Conflict will occur however if the patient doesn't accept this position and adopts either an authoritarian role back (Parent) or an unexpectedly questioning (Adult) stance. Best understanding is achieved by Adult to Adult consultations where the two parties respect each others' autonomy.Games are behaviours used in a bid to feel better by making someone else feel worse. Recognising a game and not playing it prevents the doctor from being manipulated into accepting responsibility for the results of the patient's own behaviour.For instance, in the game 'Poor Me - Yes, But' the patient presents a problem but always has reasons why proffered solutions are not acceptable. Thus the doctor is proved useless, the point of the game. Some games are deadly as some people will even commit suicide to hurt and 'win'.
7RCGP Model (1972) Physical, Psychological and Social ‘The Triaxial Model’ Extend thinking beyond organicConsider Emotional, Family, Social and Environmental factors'Physical, Psychological and Social’ (1972)The RCGP model encourages the doctor to extend his thinking practice beyond the purely organic approach to patients, i.e. to include the patient's emotional, family, social and environmental circumstances.
8Becker & Maiman (1975) Health Belief Model IdeasConcernsExpectationsBecker and Maiman combined a number of patient beliefs and attitudes into a 'health belief model' which included:the patient's interest in health matters, which may correlate with personality, class and social grouphow vulnerable the patient feels to a particular disease and how severe he feels the threat to bethe patient's estimate of the benefits of treatment versus the costs, risks or inconveniencethe factors that prompt the patient to take action - such as developing alarming symptoms, advice from family or friends or reports in the media
9Heron (1975) Types of Intervention PrescriptiveInformativeConfrontingCatharticCatalyticSupportiveJohn Heron, a humanist psychologist, developed a simple but comprehensive model of the six types of intervention a doctor, counsellor or therapist could use with a patient or client:(1) Prescriptive - giving advice or instructions, being critical or directive (2) Informative - imparting new knowledge, instructing or interpreting (3) Confronting - challenging a restrictive attitude or behaviour, giving direct feedback within a caring context (4) Cathartic - seeking to release emotion in the form of weeping, laughter, trembling or anger (5) Catalytic - encouraging the patient to discover and explore his own latent thoughts and feelings (6) Supportive - offering comfort and approval, affirming the patient’s intrinsic value.Each type of intervention can be looked at separately during training sessions as options throughout the consultation.
10Byrne & Long (1976) 6 Phases of the Consultation 1. The doctor establishes a relationship with the patient2. The doctor discovers or attempts to discover the reason for the attendance3. The doctor conducts a verbal and/or physical examination4. The doctor, the doctor and patient, or the patient (in that order of probability) consider the condition5. The doctor and occasionally the patient detail further treatment or investigation6. The consultation is terminated, usually by the doctorByrne and Long studied over 2000 audio recordings and in 1976 described six phases in the consultation which give it a logical structure.The model is useful for analysing 'dysfunctional' consultations where the patient may be misunderstood and dissatisfied while the doctor may be frustrated.Byrne and Long also described a spectrum of consulting styles, one extreme being doctor-centred and the other, patient-centred.
11Byrne & Long (1976) Consultation Styles doctor-centreddominates the consultationasks direct, closed questionsrejects the patient's ideasevades the patient's questionspatient-centredasks open questionsactively listenschallenges and reflects the patients' words and behaviour to allow them to express themselves in their own wayIn the doctor-centred consulting style, the doctor:dominates the consultationasks direct, closed questionsrejects the patient's ideasevades the patient's questionsIn the patient-centred consulting style, the doctor:asks open questionsactively listenschallenges and reflects the patients' words and behaviour to allow them to express themselves in their own wayThe style can vary within a single consultation, for example open in seeking information but dogmatic over treatment.
12Stott & Davis (1979) Areas to Explore The identification & management of the presenting problemModification of the patient's help-seeking behaviourThe management of continuing problemsOpportunistic health promotionStott and Davis talked of “The exceptional potential in each primary care consultation” . They outlined four areas which can be explored each time a patient consults:The identification & management of the presenting problemThe main task of every consultation is to find and treat the reason for the attendance: the nature of the problem, the effect on the patient, the patient's ideas concerns and expectations and an answer to the question, Why now?2. Modification of the patient's help-seeking behaviour'Doctor' means teacher. Teaching the natural history of minor illness and about self-medication is an important part of a long-term strategy for making best use of practice resources. Patients may need to be reminded how to make appropriate use of the practice's appointment system or out-of-hours cover. Every doctor-patient encounter plants the seeds of future patterns of illness behaviour which will affect the over-use (and under-use) of medical services.3. The management of continuing problemsThe GP, as the coordinator of the patients' health care, should consider reviewing any coexisting conditions at each consultation. The doctor's continuing interest in the patient's hypertension, diabetes, epilepsy or asthma is likely to produce better adherence to any management plans.4. Opportunistic health promotionHealth promotion can be improved by taking action when the patient attends for other reasons. Vaccination, cervical screening, blood pressure checks and enquiring and advising about smoking or drinking habits can often be done or at least suggested. The doctor should not, however, become overzealous and insensitive to the patient's needs and wants but it is usually possible at least to ask the patient back to see the nurse 'for a checkup' if a gap is spotted.
13Helman (1981) ‘Folk Model’ - Questions to be Answered What has happened?Why has it happened?Why me?Why now?What would happen if nothing were done about it?What should I do about it and who should I consult for further help?Cecil Helman, a Medical Anthropologist, suggested that a patient with a problem comes to the doctor seeking answers to six questions:What has happened?2. Why has it happened?3. Why me?4. Why now?5. What would happen if nothing were done about it?6. What should I do about it and who should I consult for further help?
14Pendleton (1984) the Doctor's Tasks Define the reason for the patient's attendanceConsider other problemsTogether choose an appropriate action for each problemAchieve a shared understanding of problemsInvolve the patient in the management of problems and encourage acceptance of appropriate responsibilityUse time and resources appropriatelyEstablish and maintain a relationship with the patient which helps to achieve the other tasksPendleton defined seven tasks forming the aims of each consultation. These identify what the doctor needs to achieve and deal with the use of time and resources:1. Define the reason for the patient's attendance including:the nature and history of the problemstheir aetiologythe patient's ideas, concerns and expectationsthe effects of the problem2. Consider other problems including:continuing problemsat-risk factors3. Together choose an appropriate action for each problem4. Achieve a shared understanding of problems5. Involve the patient in the management of problems and encourage acceptance of appropriate responsibility6. Use time and resources appropriatelyin the consultationin the long term7. Establish and maintain a relationship with the patient which helps to achieve the other tasksRef: D Pendleton et al, The Consultation: an Approach to Learning and Teaching, 1984
15Levenstein (1984) Patient-Centred Model 1. Exploring both the disease and the illness experience2. Understanding the whole person3. Finding common round regarding management4. Incorporating prevention and health promotion5. Enhancing the Doctor-Patient relationship6. Being realisticThe Patient-Centered Clinical MethodThe six interactive components of the patient-centered process:1. Exploring both the disease and the illness experienceA. Differential diagnosisB. Dimensionsof illness (ideas, feelings, expectations, and effects on function)2. Understanding the whole personA. The "person" (life history and personal and developmental issues)B. The context (the family and anyone else involved in or affected by the patient's illness; the physical environment)3. Finding common ground regarding managementA. Problems and prioritiesB. Goals of treatmentC. Roles of doctor and patient in management4. Incorporating prevention and health promotionA. Health enhancementB. Risk reductionC. Early detection of diseaseD. Ameliorating effects of disease5. Enhancing the patient-doctor relationshipA. Characteristics of the therapeutic relationshipB. Sharing powerC. Caring and healing relationshipD. Self-awarenessE. Transference and countertransference6. Being realisticA. TimeB. ResourcesC. Team building
17Disease-Illness Model (1984) This was later developed by MacWhinnney et al . into the ‘Disease-Illness Model’ popular in the US.McWhinney and his colleagues at the University of Western Ontario have proposed a ""reformed clinical method". Their approach has also been called "patient-centred clinical interviewing" to differentiate it from the more traditional "doctor-centred" method that attempts to interpret the patient's illness only from the doctor's perspective of disease and pathology.The disease-illness model below attempts to provide a practical way of using these ideas in our everyday clinical practice.Patient presents problemGathering informationParallel search of two frameworksIllness framework Disease frameworkPatient's agenda Doctor's agendaIdeas SymptomsConcerns SignsExpectations InvestigationsFeelings Underlying pathologyThoughtsEffectsUnderstanding the Differential diagnosispatient's uniqueexperience of illnessIntegrationExplanation and planningin terms the patient can understand and accept
18Neighbour (1987) Checkpoints Connecting: have we got rapport?Summarising: could I demonstrate to the patient that I've sufficiently understood why he's come?Handing over: has the patient accepted the management plan we have agreed?Safety-netting: What if...?HousekeepingConnecting: have we got rapport?2. Summarising: could I demonstrate to the patient that I've sufficiently understood why he's come:the patient's reason for attendingthe patient's ideas and feelings, concerns and expectations are explored and acknowledged adequatelylistening and elicitingthe clinical process - assess, diagnose, explain, negotiate and agree3. Handing over: has the patient accepted the management plan we have agreed?4. Safetynetting: What if...? General practice is the art of managing uncertainty:predict what could happen if things go wellallow for an unexpected turn of eventsplans and contingency plans5. Housekeeping: Am I in good condition for the next patient? - stress, concentration and equanimity
19Fraser (1987) Areas of Competence 1. Interviewing and history-taking2. Physical examination3. Diagnosis and problem-solving4. Patient management5. Relating to patients6. Anticipatory care7. Record-keepingInterviewing and history-takingTo interview and take a history successfully, a GP needs to:introduce self to the patientput the patient at easelisten attentivelyseek clarification of words used by the patientphrase questions simply and clearlyuse silence appropriatelyrecognise verbal and non-verbal cuesidentify the patient's reasons for consultingelicit relevant and specific information from the patient and/or records to help choose from possible diagnosesconsider physical, psychological and social factors as appropriateshow a well-organised approach to information-gathering (see 'interviewing skills' esp Calgary-Cambridge guide)2. Physical examinationThe competent GP must be able to:examine the patient and elicit relevant and discriminating physical signs correctly and sensitivelyuse instruments in a selective, competent and sensitive manneruse information obtained to confirm or refute working diagnoses3. Diagnosis and problem-solvingThe most important task of the consultation is to make the diagnosis, as this is crucial for prognosis and treatment. In general practice an understanding of the psychological and social aspects of a problem are as vital for making a successful diagnosis as a grasp of the purely physical features of illness.For up to 50% of patients who present in general practice, a firm diagnosis based on pathology may not be possible. Where diagnosis at this level cannot be achieved, working diagnoses are often expressed at a lower level in terms of the patient's symptoms, signs or problems.A diagnosis is the current statement of probability about the cause of an illness rather than of absolute certainty. As such it must be regarded as provisional unless more evidence is available or until there is no longer a need for a diagnosis at all.Management decisions often have to be taken on an assessment of symptoms, signs or problems without a definite diagnosis being made.4. Patient managementPatient management can be considered under the following broad headings:Reassurance & explanationAdvice and counsellingPrescribingReferralInvestigationObservation & follow-upPrevention(RAPRIOP)5. Relating to patientsAny experienced GP would give the following advice about the doctor's relationship with patients and their families:be friendly but show professional and ethical behaviourbe sensitive to the patients' needsbe aware how attititudes affect co-operation and compliance"Bad consultations result from having insufficient clinical knowledge, from failing to relate to patients or from failing to understand the patient's behaviour, his perception of his illness or its context"6. Anticipatory careWhere appropriate, time should be taken during consultations to:take any opportunity for health promotion and disease preventionprovide adequate explanation about aims and methods of preventionwin co-operation in a sensitive manner to promote change to a healthier lifestyle7. Record-keepingAn accurate, legible and appropriate record of every doctor-patient encounter and referral should be kept.The information recorded should include at least:the date of the consultationrelevant history and examination findingsany measurements carried out (blood pressure, peak flow, weight etc)the diagnosis or probleman outline of the management planinvestigations orderedfollow-up arrangementsIf a prescription is issued, a record should be made of the:drug namedosequantityspecial precautions given to to patient
20Kurtz and Silverman (1996) Calgary-Cambridge Observation Guide A. Initiating the sessionB. Gathering informationC. Building the relationshipD. Giving information - explaining and planningE. Closing the sessionThis simple five-point plan follows the sequence of events that take place in everyday clinical practice. Within the plan, each task is expanded into a framework for identifying the individual skills of the consultation.Doctors and patients tend to carry out the four tasks of initiating the session, gathering information, giving information and closing the session roughly in sequence while relationship-building is performed continuously during the other tasks.The tasks make intuitive sense, are easy to keep in mind and provide a basis for studying doctor-patient interactions and communication skills.A. Initiating the sessioni) Establishing initial rapportii) Identifying reasons for attendanceB. Gathering informationiii) Exploring the problemsiv) Understanding the patient's perspectivev) Providing structure to the consultationC. Building the relationshipvi) Developing the rapportvii) Involving the patientD. Giving information - explaining and planningviii) Providing the right amount and type of informationix) Aiding accurate recall and understandingx) Achieving a shared understanding: incorporating the patient's perspectivexi) Planning: shared decision-makingE. Closing the session
21MRCGP Video Criteria Doctor encourages patient’s contribution. Dr. responds to cuesDr. elicits appropriate details to place complaint in social & psycho-logical contextDr. explores patient’s health understanding MeritDr. obtains sufficient information for no serious condition to be missed.Dr. chooses an appropriate examination.Dr. makes clinically appropriate working diagnosis.Dr. explains diagnosis.Dr. uses appropriate language.Dr. takes account of patient’s belief Merit.Dr. confirms patient’s understanding Merit.Dr. uses appropriate management plan.Dr. shares management options.Dr. uses appropriate prescribing behaviour.Dr. and patient appear to have established a rapport.