1. Consultation Analysis VTS 3/10/07

2. Analysis of consultations How could consultations be analysed? How could we derive any models? Byrne & Long (1976), “Doctors talking to patients”.

3. 5 models of the consultation z Stott & Davis z Pendleton et al z Roger Neighbour z Cambridge-Calgary z John Heron z RCGP curriculum COT z Consultation models.docConsultation models.doc

4. Stott & Davis - The unique potential of each primary care consultation z Dealing with the acute problem z Dealing with chronic problems z Opportunistic health promotion z Modification of help-seeking behaviour zStott NC, Davis RH, “The Exceptional Potential in each Primary Care Consultation”, Journal of the Royal College of General Practitioners 1979; 29: 201–5

5. Stott & Davis - The unique potential.. zWhat is the meaning of “Modification of help-seeking behaviour”? yNot wasting resources – making better use y Empowering patients – encouraging self- reliance and reducing dependency y Controlling demands on NHS yAn example might be to suggest that someone who repeatedly presents within 24 hours of the onset of a sore throat might consider self medication for future episodes

6. Stott & Davis - The unique potential.. z What is the meaning of “Opportunistic health promotion?” yTimely advice yRelevant to the presentation yDirects attention to aetiological factors yEvidence that it is more effective then

8. Pendleton et al – 7 tasks of the consultation z Why did the patient attend? z Consider other problems z Choose appropriate action(s) z Share understanding z Involve patient – management and responsibility z Effective use of time & resources z Establish/ maintain relationship with patient zPendleton et al, “The Consultation: an approach to learning and teaching”, Oxford Medical GP Series

10. Roger Neighbour - The Inner Consultation z Connecting z Summarizing z Handing Over z Safety-netting z House-keeping zNeighbour, R (1987), “The Inner Consultation”, Kluwer Academic

11. Cambridge-Calgary z Initiating the session z Gathering information z Explanation and planning z Closing the session zKurtz SM, Silverman JD, Draper J (1998) Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press ( Oxford) zSilverman JD, Kurtz SM, Draper J (1998) Skills for Communicating with Patients. Radcliffe Medical Press (Oxford)

12. John Heron - interventions z Six types of intervention: z Authoritative xPrescriptive – directing patient’s behaviour xInformative – imparting information xConfronting – raising patient’s awareness z Facilitative xCathartic – enabling abreaction of painful emotion xCatalytic – eliciting xSupportive – affirming patient’s worth

13. Heron – interventions 2 zPrescriptive - Directs the behaviour of the patient - treatment and follow up zInformative – Imparts knowledge, information and meaning to patient zConfronting - Raises the patient’s consciousness about some limiting factor zCathartic - Enables patient to abreact painful emotion zCatalytic - Seeks to elicit self discovery zSupportive - Affirms worth & value of patient

14. Heron – interventions 3 zDegenerate Intervention yFails in one or more of these aspects yPractitioner lacks personal development, training, experience, awareness or combination of these yUnsolicited xInsensitive blundering into territory - intrusive yManipulative xMotivated by self interest regardless of needs of patient xFrom stress, lack of control, lack of awareness xFacipulation - using facilitation to manipulate a desired outcome yCompulsive yUnskilled zHeron J, “Helping the Client: A Creative Practical Guide”, 2001 (First published 1975)

15. RCGP Curriculum Statement 2: The General Practice Consultation zSix core competencies: zPrimary Care Management zPerson-Centred Care zSpecific Problem-Solving Skills zA Comprehensive Approach zCommunity Orientation zA Holistic Approach zBeing a GP.pdfBeing a GP.pdf

16. Competencies following on from the RCGP curriculum statement: z Communication and consultation skills z Practising holistically z Data gathering and interpretation z Making a diagnosis / decisions z Clinical management

17. What is the aim….. z A doctor who is competent to practise independently as an unsupervised GP

18. Assessed by….. zCOT z CSA

19. Assessing the consultation for the COT z Insufficient evidence z Needs further development z Competent z Excellent

20. Units of Competence and Performance Criteria z Discover the reason for the patient’s attendance z Define the clinical problem(s) z Explain the problem(s) to the patient z Address the patient’s problem(s) z Make effective use of the consultation

21. Performance Criteria zPC1: The doctor is seen to encourage the patient’s contribution at appropriate points in the consultation zPC2: The doctor is seen to respond to signals (cues) that lead to a deeper understanding of the problem zPC3: The doctor uses appropriate psychological and social information to place the complaint(s) in context zPC4: The doctor explores the patient’s health understanding

22. Performance Criteria zPC5: The doctor obtains sufficient information to include or exclude likely relevant significant conditions zPC6: The physical /mental examination chosen is likely to confirm or disprove reasonable hypotheses zPC7: The doctor appears to make a clinically appropriate working diagnosis zPC8: The doctor explains the problem or diagnosis in appropriate language

23. Performance Criteria zPC9: The doctor specifically seeks to confirm the patient’s understanding of the diagnosis zPC10: The management plan (including any prescription) is appropriate for the working diagnosis zPC11: The patient is given the opportunity to be involved in significant management decisions zPC12: The doctor makes effective use of resources zPC13: The doctor specifies the conditions and interval for follow up or review