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The Consultation – Models, Tasks, Skills

Dr Elke Hausmann GP ST1

GP group 28/09/2011

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Interest in the consultation

• There is more to the consultation than a patient presenting with a medical problem for the doctor to solve

• Both Dr and patient are individuals in particular contexts (family, community, society) – problem may or may not be medical

• Psychologists, psychoanalysts, social scientists, philosophers, doctors…

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Interest in the consultation

• What does happen? (empirical research)• What should happen? (the ‘ideal

consultation’, based on particular values – or what gives results, based on empirical work)

• What could happen? (not all consultations are the same – different tasks)

• Skills – allow the Dr to achieve a good consultation

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Balint 1957Trained doctor and psychoanalyst – worked with GP groups

‘The doctor, his patient and the illness’• Nearly all problems presenting to the Dr have a

psychological element to them• Doctors have feelings and feelings have a

function in the consultation• Explore psychological/emotional aspects of

consultation and use insight for benefit of the patient

• The doctor as drug – the doctor has a therapeutic role in all consultations, not only those with a defined disease process

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Berne 1958Psychiatrist – ‘games people play’

• Transactional analysis

• Model of the human psyche: three ‘ego states’ • Critical or Caring Parent – commands, directs,

prohibits, controls, nurtures• Logical Adult – sorts out info and works logically• Spontaneous or Dependent Child – intuition, creativity,

spontaneity, enjoyment• Parent-doctor and child-like patient? TA approach to

increase doctor’s repertoire, break out of repetitious cycles of behaviour (‘games’)

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RCGP triaxial model 1972RCGP working party’s ‘job description’ of the GP

• ‘The Future General Practitioner’

• Consideration of the physical, psychological and social condition of the patient

• Not to think purely in terms of organic illness

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Heron 1975Humanist psychologist – approach now used in business, education, public service etc

Six Category Intervention Analysis (3 doctor- and 3 patient-centred – authoritative and facilitative categories)

1. Prescriptive – giving explicit advice or instructions2. Informative – imparting new knowledge (relevant to

patient? Enough? Not enough?)3. Confronting – challenging a restrictive attitude or

behaviour, may cause upset – needs follow up!4. Cathartic – seeking to release emotion (weeping,

laughter, trembling, anger) to move forward5. Catalytic – encouraging the pat to discover and

explore his own latent thoughts and feelings6. Supportive – offering comfort and approval, affirming

the pat’s intrinsic value – allow patient to cope better

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Becker and Maiman 1975Developed from Rosenstock 1966 for studying and promoting the uptake of health services (TB)

Health Belief Model – decision to consult depends on:

• Health motivation - The individual’s general interest in health matters, acc to personality, soc class, ethnic group etc

• Perceived vulnerability and perceived seriousness - How vulnerable or threatened a pat feels to be by a particular disease

• Perceived cost/benefits of an action - The individual’s estimation of the beliefs of treatment weighed against cost, risks and inconvenience

• Cues to action - Trigger factors, such as alarming symptoms, advice from family or friends, messages from the mass media, disruption of work and play

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Health Belief Model

Patients vary enormously in the way they accept responsibility for their health (locus of control)

• Internal controller – patients who feel they control their own health destiny, have firm idea of own diagnosis and expectations of what Dr should do for them

• External controller – patients feel their likelihood of developing illness or staying healthy is completely out of their control, modifying lifestyle does not make a difference

• Powerful other – patients who feel their health destiny rests with a particular person (could be GP), respond to their advice

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Byrne Founder member RCGP + Long Psychologist 1976Based on 2500 tape-recorded consultations from over 100 Drs in UK and NZ

• ‘Doctors talking to patients’ – doctor-centred• Style of consultation depends on personality of

doctor and patient – doctor-dominated to virtual monologue by patient

• Narrow repertoire of consultations skills – doctors who ask more open questions see their patients less frequently

• 6 stages to consultation (establish relationship, discover reason for attendance, history +/-examination, dr + pat consider condition (illness), discussion of Rx or further Ix, closing consultation)

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Stott and Davies 1979Academic GPs

4 tasks that can take place in each consultation:

1. Managing the presenting complaint (eg sore throat)2. Modifying health-seeking behaviour (eg self-

medication for future episode in pat presenting repeatedly in 24 hrs for sore throat)

3. Managing ongoing problems (eg DM, depression)4. Opportunistic health promotion (eg smoking,

weight, cervical smear, immunisation…)

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Helman 1981GP and medical anthropologist – ‘Suburban Shaman’ 2006

Folk Model of Illness – illness vs disease

• what has happened?

• why?

• why me?

• why now?

• what would happen if nothing were done?

• what should be done about it?

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Pendleton 1984Social psychologist – PhD on analysis of the consultation

The doctor’s tasks - seven tasks model1. Define reason for attendance (ICE, effects of

illness = patient’s agenda)2. Consider other problems3. Doctor and patient choose appropriate action4. Share understanding with patient5. Involve patient in management decisions6. Use time (new) and resources well7. Establish and maintain dr-pat relationship

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Tuckett et al 1985Medical sociology – study of doctor-patient communication in GP

‘Meeting between experts’• Consultation as meeting between two experts• Doctor expert in medicine (underlying pathology,

differential diagnosis)• Patient expert in own illnesses (unique illness

experience)• Shared understanding is the aim• Doctors should seek to understand the patient’s beliefs• Doctors should address explanations in terms of the

patient’s belief systemExample: patient repeatedly comes in with chest pain, re-

assured it’s not cardiac – turns out his uncle recently died of cancer of the oesophagus

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Neighbour 1987Former RCGP president

‘The Inner Consultation’ – the doctor’s two heads: organiser and responder (while being active organiser it’s difficult being responsive and vice versa)

5 checkpoints:1. Connecting – develop rapport/empathy2. Summarising – reasons for attending, feelings,

concerns, expectations3. Handing over – sharing agreed mx plan, hands

control back to pat4. Safety-netting - making contingency plans 5. Housekeeping – getting ready for next pat(new: safe doctoring and healthy doctor!)

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Fraser 1992Professor of GP in Leicester – ‘Clinical method – a General Practice approach’

Areas of competence:• Interviewing and history taking• Physical examination• Diagnosis and problem-solving – current probability

about cause of illness rather than certainty • Patient management (RAPRIOP –

reassurance/explanation, advice/counselling, prescribing, referral, investigations, observation + follow-up, prevention)

• Relating to patients – friendly but professional• Anticipatory care – health promotion/disease prevention• Record-keeping

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Tate 1994Developed from Pendleton – retired GP and former Convenor of MRCGP examinations

‘The Doctor’s Communication Handbook’

• Importance of ideas, concerns, expectations

• Updates strategies and skills in internet-era

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Stewart and Roter 1997American academics (John Hopkins University) – research using audiotapes

Gathering of info about patient’s problems along two parallel pathways

• Patient’s agenda – exploring ideas, concerns, expectations, feelings, thoughts and effects culminating in an understanding of the patient’s unique experience of the illness

• Doctor’s agenda – exploring symptoms, signs, investigations and consideration of the underlying pathology and diff diagnosis

• Need to be brought together for shared understanding – allows for explanations, planning and decision-making

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Calgary-Cambridge 1996Derives from Pendleton – evidence-based approach to integration of the ‘tasks’ of the consultation

and improving skills for effective communication

1. Initiating the session (rapport, reasons for consulting, establishing shared agenda)

2. Gathering information (patient’s story, open and closed questions, identifying verbal and non-verbal cues)

3. Building the relationship (developing rapport, recording notes, accepting patients’ views/feelings and demonstrating empathy and support)

4. Explanation and planning (giving digestible info and explanations)

5. Closing the session (summarising and clarifying the agreed plan)

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Launer 2002London GP

‘Narrative-based’ model of the consultation – techniques to help understanding the patient’s story:

• Circular questioning or picking up patients’ words to form open questions and help patients to focus on meaning

• A focus on listening (avoid note-taking during consultation)

• Exploring the context of the problem (family, work, community)

• Conversations circularity co-creation curiosity contexts caution

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To do in the next consultationbased on e-GP learning module on the consultation

• check patient's understanding• try to see from patient's perspective • modify help-seeking • ideas, concerns, expectations• cues to hidden agenda? • summarise• safety-netting• negotiate agenda

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References

• www.patient.co.uk/doctor/Consultation-Analysis.htm

• http://www.gp-training.net/training/communication_skills/consultation/index.htm

• http://www.yorksandhumberdeanery.nhs.uk/general_practice/documents/consultationmodelsindetail-BillBevington.doc

• The Condensed Curriculum Guide RCGP 2007• e-GP learning module ‘Models of the

Consultation’