consultation MODELS & Performance criteria Dr. Yousif E. El Gizouli MRCGP (UK), JMHPE (MAASTRICHT)

ROAD MAP What is Consultation What is consultation model Why consultation models Types of consultation models Barriers to effective consultation What are the Performance Criteria Application of Performance criteria & Take home message.

The consultation The central act of medicine which deserves to be understood. The occasion when, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trust. (Wright & Macadam)

WHAT is a Consultation MODEL?

A structure or a framework Similar conclusions, but also reflect great variety; Many shapes, sizes, and styles, Not the real world. There is no one right model.

Why learn consultation models? For anything we do regularly; To make our own model; To understand the patient’s perspective. Help teachers teach on the consultation.

TYPES of the consultation models

Stott and Davis (1979)

Q4 Strength Weakness Simple Doctor –centred Modification of Help Seeking Behavior in a way which does not damage the doctor patient relationship. Opportunistic Health Promotion Difficult to apply to some problems

Schofield, Tate and Havelock (1984) PENDLETON’S MODEL Schofield, Tate and Havelock (1984)

Seven Tasks: 1. To define the reasons for the Patient’s attendance 2. To consider other problems 3. To choose with the Patient. 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. 6. To use time and resources appropriately. 7. To establish a relationship with the Patient.

Strength Weakness Patient’s-centred. Considered Patient’s ICE Although set out in logical sequence, not all consultations will follow this order. Encourages patient responsibility Not appropriate for acute settings like emergencies. Used in the MRCGP Consultation Observation Tool

Roger Neighbor

Pros. Cons. Empowers the patient Is a bit doctor centred at times (safetynetting) & (housekeeping) Difficult to understand Easy to remember

Pros. Cons. Comprehensive The 71 micro-skills puts people off applicable to all medical interviews with patients. Probably best read after having read one of the other more introductory ones first Evidence-based Two separate books are available

Performance Criteria?

  Your name is Ahmad a 35-Ys- old, working as a bus driver in near school, 3 days ago after you hold a heavy tire, you felt a LBP  The pain is down the back and not goes down, it is stabbing in nature, aggravated by leaning forward and stiff in the morning, it is ease by lying in a bed   Your concern today is that, it could be a disc prolapse because you have an elder brother who had a prolapse last Year, you hope your doctor to ask for MRI to be reassured and also to give you a sick leave.

A- DISCOVER THE REASONS FOR THE PATIENT'S ATTENDANCE 1- Encourage 2-Respond to signals (Cues) 3-Psych-social 4- ICE

B- DEFINE THE CLINICAL PROBLEM(S) 5- Red Flags 6- Examination 7- Working Diagnosis

C- EXPLAIN THE PROBLEM(S) TO THE PATIENT 9- Explanation incorporate Pt.’ ICE 10- Confirm Pt.’ understanding

D- ADDRESS THE PATIENT’S PROBLEM(S) 11- Management Plan 12- INVOLVE Pt. in management plan

E- MAKE EFFECTIVE USE OF THE CONSULTATION 13- Enhance Concordance 14- Follow-Up

Barriers to effective consultation

Patient factors Hearing or linguistic difficulties Upset patients Psychiatric illness Loss of faith in the doctor (poor reputation, adverse incident etc) Patients that ‘violate’ the doctors values e.g. drug misusers or alcoholics Problem Patients

Doctor factors: Attitudes – a doctor centred consulter, burnt out depersonalisation, angry. Poor emotional housekeeping. Skills – poor consultation or clinical skills. Knowledge – lack of knowledge . Bored –lack of personal or professional development

Practice factors: Pressure of time – running late. Poor systems (e.g. telephone access, appointments, admin). Poor staffing, inappropriate skill mix etc which unnecessarily increase workload. Unnecessary interruptions – telephone, staff, patients. Physical factors - lay out of the room, lighting, extraneous noise.

Take home message There have been a number of helpful consultation models Models give a framework for learning & teaching the consultation For beginner a model to be kept in mind. The idea is not to produce clones who consult in the same way.

Take home message The consultation remains the main & basic tool for family medicine Consultation skills are learnt behavior. The consultation should be a discussion and sharing of ideas between two experts. Each consultation should be tailored to fit the different needs of each patient.

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