1. How do our beliefs and attitudes affect how we manage consultations?

2. How are our beliefs and attitudes formed?  Personality/temperament  Socioeconomic status  Parental attitudes/upbringing  Cultural norms  Life events  Training

3. The Apostolic function  Balint 1957 a doctor's personality interacts with medical training to produce a unique way of dealing with patients. Doctors tend to avoid examining their own behaviour and so a fixed style develops the 'Apostolic Function'. This incorporates the doctor's beliefs about how patients ought to behave when ill, how they should behave with doctors and how they should cooperate in their cure.

4. Myers-Briggs personality types  ST-- sensing plus thinking (practical and matter-of-fact)  SF -- sensing plus feeling (sympathetic and friendly)  NF -- intuition plus feeling (enthusiastic and insightful)  NT -- intuition and thinking (logical and ingenious)

5. Consulting styles  In the doctor-centred consulting style, the doctor: dominates the consultation asks direct, closed questions rejects the patient's ideas evades the patient's questions

6. Consulting styles  In the patient-centred consulting style, the doctor: asks open questions actively listens challenges and reflects the patients' words and behaviour to allow them to express themselves in their own way

7. The difficult doctor  Approximately 15% of patient encounters in adult primary care settings are unusually difficult from the physician's perspective  factors independently associated with high frustration included age 55 per week, higher stress, practice in a medicine subspeciality, and greater number of patients with psychosocial problems or substance abuse

8. First impressions/judgements Victim? Responsible for own addiction? Product of abusive upbringing?

9. First impressions/judgements  Victim?  Responsible for own problems?  Vulnerable?

10. First impressions/judgements  Uneducated?  Unfortunate?  Able to understand choices/make decisions about health?

11. Scenario 1  A woman comes to see you with a cervical smear reminder letter; she hasn’t had a smear for about 10 years. She says she is a lesbian and does she really have to have a smear test? How do you respond?

12. Scenario 2  The practice (which has 3 male partners and one woman) has advertised for a new partner – at interview, a shortlisted applicant tells you that she is a practising Catholic and is unwilling to see any patients for contraception. How do you react?

13. Scenario 3  At a practice meeting, you propose that asylum seekers and others with language problems should be offered double appointments. One of your colleagues objects, saying that this is unfair to all the other patients who might like a double appointment. What are the implications?

14. Scenario 4  An Asian mother, with limited English language, attends for the third time in a week with her 3 year old child reporting concerns over an ongoing coryzal illness. The child is well and you are frustrated by the persistent visits. How do your health beliefs/attitudes differ from hers? Why?

15. Scenario 5  A 17 year old girl presents requesting NHS funded referral to an aesthetic surgeon for her “ugly chin”. Her appearance is, in your view, quite acceptable. She is distraught and claims that her life is unbearable because of this problem. How do you respond?

16. Dealing with Prejudice

17. Case Study  Case published in Journal of Medical Ethics in 2001 (though based on an incident in the 1980s)  Author was a medical SHO working in infectious diseases  Patient a man with HIV/AIDS  Also involved a PRHO working on the unit

18.  Uses the method of re-writing the events from the viewpoint of all involved  “climbing inside someone’s skin and walking around in it for a while to see how it feels”  Helps us to identify prejudices and where they come from

19. “I’m not going in there: I’m not taking blood from him and I’m not re-siting his drip” The House Officer

20. The House Officer’s Viewpoint  Group work – what issues are raised?  Where does the prejudice come from?

21. The Patient’s Viewpoint  Group work –  How does he feel about how he is being treated?  Why?

22. The SHO’s Viewpoint  What could have been done differently?  What can be learned?

23. Points for Consideration  Our prejudices can be explicit or subconscious  It can be useful to think about our points of view to identify where these come from  Prejudice can come from either party – doctor or patient  Feeling uncomfortable can be good if it helps us to do something about the situation

24. References  Dealing With Prejudice Alan O’Rourke, Journal of Medical Ethics 2001  To Kill a Mocking Bird. Harper Lee