1. Consultation skills
ST1 2016

2. New slide Bob Newhart video – just stop it.

3. Timetable 3.15 – tea/ coffee
2.10 – presentation of models by registrars
Introduce Calgary-Cambridge model and consider the ideal structure of a consultation.
3.15 – tea/ coffee
Group to develop and discuss ideas about ICE and psychosocial enquiry, consider how to explain diagnoses and check understanding.
4.00 – role play
4.30 – prep for PBL – metabolic.

4. Consultation – it’s a skill.

5. Why the consultation ? Pivotal to everything we do as GPs
Gives insight into the doctor-patient relationship
Likely to feature in every module of the exam
Leads to better understanding, better concordance and fewer complaints.
“poor communication about illness causes more suffering than any other problem except unrelieved pain”.
Avril Stedeford – Facing death 1984

6. Consultation facts. Consultation rates per year in GP attenders.
per person/ year. 9% had home visits.
Average appt length = 6 mins.
per person/ year. 4% had home visits.
Average appt length = mins.
The CQC (2014) say that there are approx 300 million consultations per year. 90% of all NHS contacts.
GP receives less than 9% of the NHS budget.
From October 2014, the CQC will start to rate GP services to help people choose – 4 grades.
88% of the population’s experience of general practice was ‘very good’.
From 2002 to 2011 – 54% increase in consultants – 23% increase in GPs.
Over 90% of all contacts within NHS occur in primary care

7. Consultation skills
The dictionary definition of a consultation is “a meeting for deliberation, discussion, or decision”.
In medicine, the consultation is of huge importance.
It is the framework within which the doctor and patient interact, and thus forms the platform upon which everything else we do for our patients is built
It is the cornerstone of general practice.
Hand out of calgary-cambridge model.

8. ENHANCED CALGARY-CAMBRIDGE GUIDE TO THE MEDICAL INTERVIEW
Kurtz SM, Silverman JD, Benson J and Draper J (2003) Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides
Academic Medicine 78(8):
THE BASIC FRAMEWORK

9. EXPANDED FRAMEWORK

10. Calgary- Cambridge 1. Initiating the Session
Establish initial rapport.
Greeting and introduction.
Identify the reasons for the consultation.
Listen to the opening statement without. interruption- remember the golden minute!
Confirm list and screen for further problems.
Negotiate the agenda.
“We may not have time to deal with everything today, which problem(s) would you like us to concentrate on?”

11. Calgary –Cambridge 2. Gathering information
Explore patient’s problems.
Listen attentively.
Open to closed cone of questioning.
Pick up on cues- verbal and non verbal.
Periodically summarise.
Understand the patient’s perspective.
Ideas
Concerns
Expectations
Effects on life

12. Calgary- Cambridge 2. Gathering information
Psycho social occupational information
Think lifestyle
Relevant medical questions
Red flag questions

13. Calgary- Cambridge 3 Examination
ALWAYS ASK PERMISSION TO EXAMINE!
Remember to offer chaperones for intimate examinations.
Brief, focussed, relevant. And slick !

14. Calgary- Cambridge 4 Explanation and planning.
Providing the correct amount and type of formation
Chunks and checks
Discover how much information the patient wants to know.
Avoid jargon and medical terminology
Aiding accurate recall and understanding
Diagrams/written information
Check patients understanding
Achieving a shared understanding
Which incorporates the patient’s perspective
Planning: shared decision making
No decision about me, without me……. (NHS white paper – liberating the NHS 2012)

15. Calgary- Cambridge 5 Closing the session
Summarise
Contract for the next step for both patient and Dr+ safety net

16. Calgary- Cambridge Provide structure to the consultation
Make organisation overt:
Summarise
Signpost
Chunking and checking
Try to maintain a logical sequence

17. Calgary- Cambridge Building the relationship
Use appropriate verbal and non-verbal behaviour
Develop rapport
Involve the patient

18. Consultation scripts
Generally, I wouldn’t recommend memorising scripts and phrases because a conversation between two people naturally flows when they respond each other.  
Scripts and phrases can make the consultation look artificial.  
However, it’s useful to have an ‘idea’ of the kinds of things to say.  Please develop your own phrases and remember to contextualise them according to the specific situation you are in.

19. A little group work Divide into 4 groups Plenary
Group 1- consider and list some questions to bring out ICE.
Group 2- develop a list of questions for psychosocial occupational history.
Group 3- consider key points on how to explain a diagnosis.
Group 4- consider key points on how to share a management plan.
Plenary
ICE- Remember to ask questions in a different way if answers aren’t forthcoming. Patients may not feel happy to disclose their own ideas for fear of ridicule but may be more than happy to let somebody else seem silly! “Has anyone suggested that you should come to the Dr or suggested that you might have condition X?” If that fails then make suggestions that have occurred to you.
You can use the same tack with concerns and expectations.
PSO- Remember that the idea is to place the condition in context, i.e. how it affects the patient’s life.
Explanation- how much do they know already and fill the gaps, how much do they want to know, chunking, signposting, incorporation of existing health beliefs- include their ICE. “ You mentioned that you thought you had condition x, what would you think if I said that I thought you had condition Y?” Consider ideas about diagrams, PILs, internet.
Shared management- How to share when there are several options? How do we make it less Dr centred when there is only 1option? How can we put the information into understandable form?
Checking understanding- consider useful phrases. Remember that we are checking understanding for both diagnosis and treatment.

20. Some examples
These ideas are taken from the Bradford VTS website and are written by Ramesh Mehay.
There are some scripts for all of the sections we’ve discussed and they are definitely worth taking the time to read!!
I’ve had a look through Bradford VTS website and found some very useful “scripts” for the consultation. Which fit nicely with the 5 groups on slide 14.
Hopefully whizzing through the following 6 slides won’t take too long as we should have covered a lot of this in the group discussion.

21. Ideas

22. Concerns

23. Expectations

24. Psychological…S.O

25. P… Social…O

26. P.S….Occupational

27. How not to do it……………

28. CSA courses suggest.....

29. Psychosocial information
John’s three balls!!!
Shared Management
Check Understanding
Safety Net
Clinical
Information/
Red flags etc.
Ideas, Concerns,
Expectations
Psychosocial information

30. CSA marking

31. Marking schedule
Each case in the CSA is marked in three domains and each domain contributes to an overall score. You must aim to score as many points as possible in each domain in each case.
The pass mark varies with each exam and is peer referenced.
Possible scores:
Clear fail, Marginal fail, Marginal pass, Clear pass

32. Domain 1- data gathering and assessment skills
This means history, examination and the use of medical equipment;
Interivew should be focused and relevant to the complaint
History should be sufficient to reach a diagnosis and exclude likely serious possibilities
Physical examination should be done with courtesy and efficiency
Information from the records is obtained and made use of

33. Domain 2 – Clinical management skills
Explaining the problem/diagnosis
Offering effective and safe treatment
Using investigation, prescription and referral appropriately
Recognition of and response to urgency
Managing risk and co-morbidity
Encouraging health promotion
Arranging appropriate follow up

34. Domain 3 –Interpersonal skills
Attitude, empathy and good communication skills are all being considered
Establishing rapport
Showing sensitivity and empathy
Exploring the patient’s concerns
Listening and understanding
Using appropriate language
Negotiating options for treatment
Respecting patient autonomy

35. Look at a video Use the CSA marking sheet to assess the video
Think about Calgary Cambridge structure and it’s position within the CSA marking schedule.

36. Role play - scenarios
In groups of three - take a case scenario and rotate between doctor/ patient/ observer role.
These are 4-6 minute role plays.
Concentrate on first part of the consultation:
Initiation
Data gathering
Remember empathy and developing rapport.
If time – explanation and SDM.

37. Role play 1. JG man - aged 55. plumber (self-employed)
Lives with wife and 2 sons
Ex-smoker – drinks 10 pints of real ale per week
PMH – HT and IGT
DH – ramipril
Presents with sore throat and hoarse voice for 2w. Wonders if it is laryngitis – thinks an antibiotic will sort it out (I).
Difficult to answer phone due to voice – afraid will lose business (C).
Got antibiotics 5 years ago for something similar and it worked (E).

38. Role play 2. MS. Electrician. Divorced with 2 children at university.
Works a lot due to financial outgoings
Elbow pain for 3 months – worse when using a screwdriver and getting worse, making work difficult.
Ibuprofen helps but causes indigestion +++
Strapping and paracetamol no use. Sick note not an option as needs to work. attending physio would be hard due to long hours.
Must be muscular as worse when using arm (I)
Stopping him from working so needs a quick fix for financial reasons(C).
Needs it sorting now (E).

39. Role play 3. JG, 32 and Female. Primary school teacher.
Been in relationship for 2 years and stopped COC 6 months ago due to weight gain. Now getting irritable and angry as well as feeling bloated – worse prior to periods.
Otherwise well. Feels better when ‘comes on’. Now on POP for contraception. Non-smoker and 10 units of alcohol per week. enjoys job and no stressors. Does not feel depressed – enjoys climbing.
Feels she might be run down (I)
A friend thinks she has PMS (C).
Would like a tablet to “sort it out (E).