1. Consultation Models

2. Introduction Models enable the Dr to think where in the consultation the problems are, Models enable the Dr to think where in the consultation the problems are, There are lots of models. There are lots of models. Task orientated, Skills based, Task orientated, Skills based, Some are based on the doctor patient relationship, or the patients perspective of illness. Some are based on the doctor patient relationship, or the patients perspective of illness.

3. What models do you know?

4. Consultation models 1957 M Balint - The Doctor, His Patient and The Illness 1957 M Balint - The Doctor, His Patient and The Illness 1964 E Berne - Games People Play 1964 E Berne - Games People Play 1975 Becker & Maiman - Sociobehavioural Determinants of Compliance... 1975 Becker & Maiman - Sociobehavioural Determinants of Compliance... 1975 J Heron - Six Category Intervention Analysis 1975 J Heron - Six Category Intervention Analysis 1976 Byrne & Long - Doctors Talking to Patients 1976 Byrne & Long - Doctors Talking to Patients 1977 RCGP definition - Physical, psychological & social... 1977 RCGP definition - Physical, psychological & social... 1979 Stott & Davis - The Exceptional Potential in Each Primary Care Consultation 1979 Stott & Davis - The Exceptional Potential in Each Primary Care Consultation 1981 C Helman - Disease vs Illness in Gen Practice 1981 C Helman - Disease vs Illness in Gen Practice 1984 Pendleton et al - The Consultation 1984 Pendleton et al - The Consultation 1987 R Neighbour - The Inner Consultation 1987 R Neighbour - The Inner Consultation 1987 R C Fraser - Clinical Method: A Gen Pract Approach 1987 R C Fraser - Clinical Method: A Gen Pract Approach 1996 Kurtz & Silverman The Calgary-Cambridge Observation Guide to The Consultation 1996 Kurtz & Silverman The Calgary-Cambridge Observation Guide to The Consultation

5. Traditional medical model The classic medical diagnostic process involves the following steps: observation - history and examination observation - history and examination hypothesis -provisional diagnosis hypothesis -provisional diagnosis hypothesis testing - investigations hypothesis testing - investigations deduction - definitive diagnosis. deduction - definitive diagnosis.

6. Balint -1957 Hungarian doctor and psychoanalyst Hungarian doctor and psychoanalyst Founded with his wife Enid in the 1950 Founded with his wife Enid in the 1950 This experince led to his book “The Doctor, his Patient and the Illness“ This experince led to his book “The Doctor, his Patient and the Illness“ Balint groups Balint groups

7. Balints consultation approach Psycological problems are often manifested physically and physical disease has psychological consequences Psycological problems are often manifested physically and physical disease has psychological consequences Passing responsibility of dealing with a problem on to someone else was defined by Balint as“collusion of anonymity“ Passing responsibility of dealing with a problem on to someone else was defined by Balint as“collusion of anonymity“

8. Balints consultation approach Doctors have a therapeutic role in the consultation : drug doctor Doctors have a therapeutic role in the consultation : drug doctor Doctors feelings have a function in the consultation Doctors feelings have a function in the consultation Balint describes the „Flash technique“: the doctor becomes aware of his feelings and interprets this back to the patient Balint describes the „Flash technique“: the doctor becomes aware of his feelings and interprets this back to the patient

9. Transactional Analysis Eric Berne 1964

10. T-A model This model discusses the 3 “ego-states” Parent - critical/caring. Parent - critical/caring. Adult – logical. Adult – logical. Child – dependent. Child – dependent. Believes human psyche is influenced by mother and infant intimacy and that infant style intimacy can develop in certain relationships including dr-pt.

11. T-A model Useful to recognise when a dr-pt relationship develops into a parent-child dynamic. Consultations may develop into games where the pts interests are not served. Need to try to recognise the new dynamic and try to have both dr and pt take on the adult role.

12. DVD case 5

13. Helman 1) What has happened? This includes organising the symptoms and signs into a recognisable pattern, and giving it a name or identity. 1) What has happened? This includes organising the symptoms and signs into a recognisable pattern, and giving it a name or identity. 2) Why has it happened? This explains the aetiology or cause of the condition. 2) Why has it happened? This explains the aetiology or cause of the condition. 3) Why has it happened to me? This tries to relate the illness to aspects of the patient, such as behaviour, diet, body-build, personality or heredity. 3) Why has it happened to me? This tries to relate the illness to aspects of the patient, such as behaviour, diet, body-build, personality or heredity. 4) Why now? This concern the timing of the illness and its mode of onset (sudden or slow) 4) Why now? This concern the timing of the illness and its mode of onset (sudden or slow) 5) What would happen to me if nothing were done about it? This considers its likely course, outcome, prognosis and dangers. 5) What would happen to me if nothing were done about it? This considers its likely course, outcome, prognosis and dangers. 6) What are its likely effects on other people (family, friends, employers, workmates) if nothing were done about it? This includes loss of income or of employment, or a strain on family relationships. 6) What are its likely effects on other people (family, friends, employers, workmates) if nothing were done about it? This includes loss of income or of employment, or a strain on family relationships. 7)What should I do about it or to whom should I turn for further help? Strategies for treating the condition, including self-medication, consultation with friends or family, or going to see a doctor. 7)What should I do about it or to whom should I turn for further help? Strategies for treating the condition, including self-medication, consultation with friends or family, or going to see a doctor.

14. Roger Neighbour – The Hand 5 checkpoints 5 checkpoints –Connecting –Summarising –Handing-over –Safety-netting –Housekeeping Inner consultation Inner consultation –“2 heads” – the Organiser and the Responder

15. Role play in 2 groups, one group looking at Helmans model, the other looking at Neighbours model Helmans Helmans What has happened? What has happened? Why has it happened? Why has it happened? Why has it happened to me? Why has it happened to me? Why now? Why now? What would happen to me if nothing were done? What would happen to me if nothing were done? What are its likely effects on other people (family, friends) if nothing were done What are its likely effects on other people (family, friends) if nothing were done 7)What should I do about it or to whom should I turn for further help? 7)What should I do about it or to whom should I turn for further help? Neighbour Neighbour –Connecting –Summarising –Handing-over –Safety-netting –Housekeeping

16. –Pendleton, Schofield, Tate and Havelock (1984) –(1)To define the reason for the patient’s attendance, including: –i)the nature and history of the problems –ii)their aetiology –iii)the patient’s ideas, concerns and expectations –iv)the effects of the problems –(2)To consider other problems: –i)continuing problems –ii)at-risk factors –(3)With the patient, to choose 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 and encourage him to accept appropriate responsibility – – (6)To use time and resources appropriately: –i)in the consultation –ii)in the long term –(7)To establish or maintain a relationship with the patient which helps to achieve the – other tasks.

17. consulting styles In the doctor-centred consulting style, the doctor: dominates the consultation dominates the consultation asks direct, closed questions asks direct, closed questions rejects the patient's ideas rejects the patient's ideas evades the patient's questions evades the patient's questions In the patient-centred consulting style, the doctor: asks open questions asks open questions actively listens actively listens challenges and reflects the patients' words and behaviour to allow them to express themselves in their own way challenges and reflects the patients' words and behaviour to allow them to express themselves in their own way

18. The Calgary-Cambridge approach to communication skills teaching (1996) Suzanne Kurtz & Jonathan Silverman Suzanne Kurtz & Jonathan Silverman 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. 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.