CONSULTATION Dr.Hashim Rida Fida

CONSULTATION Definition Consultation Skill Initiating the consultation Models of consultation Difficult consultations Dr.Hashim.Rida.FIDA

Definition Most text books describe interviewing as a diagnostic procedure which is a systematic process of data-gathering designed to identify problems and to arrive at a conclusion,leading ultimately to a treatment plan. This is only partly true. To achieve its maximum value, the consultation should be therapeutics. Dr.Hashim.Rida.FIDA

The most important skill of family physician is ability to interview patient effectively as follow ; 1.To provide health care to all patients, regardless of their age, sex, socio-economic standing and disease status. 2.To treat disease and promote healthy lifestyles in individuals and communities. 3.To provide comprehensive, continuous care, bearing in mind the cultural, social, psychological and economic factors that influence health and disease. 4.To provide care either directly or through other members of the team, depending on the needs of the patient and the resources of the community. Dr.Hashim.Rida.FIDA

INITIATING THE CONSULTATION OBJECTIVES Establishing a supportive environment Developing an awareness of the patient’s emotional state Identifying as far as possible all the problems or issues that the patient has come to discuss Establishing an agreed agenda or plan for the consultation Enabling the patient to become part of a collaborative process

SKILLS Preparation • Puts aside last task, attends to self comfort • Focuses attention and prepares for this consultation Establishing initial rapport • Greets patient and obtains patient’s name • Introduces self and clarifies role • Attends to patient’s physical comfort, demonstrates interest and respect

Identifying the reason(s) for the patient’s attendance • Opening ended question: identifies the problems or issues that the patient wishes to address (e.g. “What would you like to discuss today?”) • Listening to the patient attentively without interrupting or directing patient’s response

Identifying the reason(s) for the patient’s attendance Checking list of problems or issues that the patient wishes to cover (e.g. “so that’s headaches and tiredness, is there anything else you’d like to discuss today as well?”) • Agenda setting: negotiates agenda and format of interview taking both patient’s and physician’s needs into account

INFORMATION GIVING, EXPLANATION AND PLANNING Gauging the correct amount and type of information to give to each individual patient Providing explanations that the patient can remember and understand Providing explanations that relate to the patient’s illness framework

INFORMATION GIVING, EXPLANATION AND PLANNING Using an interactive approach to ensure a shared understanding of the problem with the patient Involving the patient and planning collaboratively to increase the patient’s commitment and adherence to plans made Continuing to build a relationship and provide a supportive environment

Models of consultation 1.Bio-medical model (hospital model). 2.Bio-psychosocial model. 3.Byrne and long model doctors styles. 4.Balint model. 5.Pendelton model 6.Stott an Davis. 7.Neighbour model. Dr.Hashim.Rida.FIDA

Byrne and long model doctors styles. Patient-centered Use of patient’s knowledge And experience Doctor-centered Use of doctor’s knowledge And skills Dr.Hashim.Rida.FIDA

Balint model The doctor as a drug Elimination by physical examination The child as a presenting complaint Inappropriate referral Dr.Hashim.Rida.FIDA

Stott and Davis model 1.Management of Presenting Problem 2.Management of Continuous problem 3.Modifiation of help Seeking behavior 4.Opportunistic health promotion Dr.Hashim.Rida.FIDA

Neighbour model 1.Connecting (establish a relationship) 2.Summarizing( physical. psycho ad social diagnosis) 3.Handling-over(management of presenting problem) 4.Safety-netting(anticipating care) 5.House-keeping(taking care of yourself) Dr.Hashim.Rida.FIDA

Pendleton 7 Tasks To define the real reasons for pt attendance To consider other problems To choose with the pt. appropriate action for each problem To achieve a share understanding To involve pt. in the management To use time & resources effectively To establish & maintain Dr.-pt. relationship

Pendleton 7 Tasks To Explore the Real Reasons for Pt. Attendance History Nature of the problem Etiology Effect of the problem Ideas Concern Expectation Fears

Pendleton 7 Tasks Skills Needed To Explore the Real Reasons for Pt. Attendance Open ended questions Indirect questions Use of silence Recognition of patient’s cues Immediate response to patient’s cues Confrontation Reflection Probing Summarization

Pendleton 7 Tasks Practicing Consultation Skills Establishing & maintaining Dr- Pt Relationship Prior to consultation Welcoming the patient Initiating the interview Showing interest Balance between intimate relationship & professional relationship Maintaining the relationship Showing empathy Legitimation Showing support

Practicing Consultation Skills Ethical Considerations Respecting patient autonomy Confidentiality Non judgmental attitude

Diagnosis in PHC Hypothetical Deductive Reasoning Method Present Complain + Context of the consultation + Previous knowledge about the patient. + Verbal & non verbal cues 3-5 Hypotheses (Dr. clinical + epidemiological knowledge + Dr. experience) Inclusion or exclusion of hypotheses (Dr. conducting verbal examination or physical examination or selective investigations

Management Skills Negotiation skills Reassurance skills Health Education Counseling Prescribing Investigations Referral Follow up Modification of help seeking behavior Use of medical records House keeping

Difficult consultation 10-20% of daily consultation are difficult. This difficulties are either due to; 1.Difficult patient 2.Difficult Doctor 3 .Difficult communication between the doctor and patient Dr.Hashim.Rida.FIDA

Difficult Consultation Different Patients Need Different Consultation Skills Patient Reluctant to Talk Freely Angry Patient Demanding Patient Talkative Patient Poor Compliance

Difficult Consultation Patient Reluctant to Talk Freely Causes : Patient Factors Dr. Factors Circumstances Examples : The topic Cultural barrier Social class barrier Dr. authority Time constrains Presence of 3rd party

Difficult Consultation Approach to Patient Reluctant to Talk Freely Verbal Communication Giving reason for the question. Comments on the patient attitude Generalization of the problem Asking at the right time Reflection Mirroring Confrontation

Difficult Consultation Approach to Patient Reluctant to Talk Freely Non - verbal Communication. Showing sympathy & empathy Showing real interest Unhurried manner Touch for reassurance Use of physical examination

Difficult Consultation Angry Patient Communication Skills Empathy Legitimation Non-judgmental attitude Respect patient autonomy Support Flexibility

Difficult Consultation Demanding Patient communication Skills Discuss the effect of the problem in the patient life Focus on immediate concern Deal with feelings

Difficult Consultation Demanding Patient communication Skills Comment on the process of the interview Negotiate agenda & goals : 1. Set limit 2. Reinforcement 3. Compromise & Be flexible Focus on patient as well as his demands & complaints

Difficult Consultation Talkative Patient Summarization Prioritization Use of touch Sympathy & empathy

Behaviors which brake the relationship Interruption Close ended question

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