Consultation ModelsRamesh Mehay
Course Organiser, Bradford
Adapted from Neighbour’s “The Inner Consultation”
Aims n ObjectivesAims n Objectives
Aims Aims to introduce GPRs to several types of consultation to introduce GPRs to several types of consultation
models and how to integrate them into practicemodels and how to integrate them into practice
ObjectivesObjectives Why all this talk of modelsWhy all this talk of models What’s the point of making models of the consultationWhat’s the point of making models of the consultation What types of model there are What types of model there are What use is a model when you’ve made itWhat use is a model when you’ve made it
What are consultation skillsWhat are consultation skills
ThinkThink Behaviours that result in desired outcomesBehaviours that result in desired outcomes There are many behaviours that can result in the same There are many behaviours that can result in the same
outcome just like…….outcome just like……. There are many ways to skin a cat!There are many ways to skin a cat!
ModelsModels
Models are all around usModels are all around us Can you think of any? Life or Medical?Can you think of any? Life or Medical?
ChildhoodChildhood LanguageLanguage RecipesRecipes LogicLogic
Medical ModelMedical Model
So Why are Models so Important?So Why are Models so Important?
Patients don’t function simply as machinesPatients don’t function simply as machines They have feelings tooThey have feelings too
Doctors don’t function simply as machinesDoctors don’t function simply as machines They have feelings tooThey have feelings too
Every presenting complaint can be placed in a psycho-Every presenting complaint can be placed in a psycho-social context (RCGP)social context (RCGP)
Purpose of ALL modelsPurpose of ALL models
They make sense of sensationThey make sense of sensation
They help people toThey help people to UnderstandUnderstand Predict andPredict and ControlControl
Essential for mastering consultation skillsEssential for mastering consultation skills
what happens to them
THE MODELSTHE MODELS Tell the group an interesting Dr-patient story.Tell the group an interesting Dr-patient story. Now let’s try and apply a model to itNow let’s try and apply a model to it
Are there bits of the model you coveredAre there bits of the model you covered Are there bits of the model you did not cover but may Are there bits of the model you did not cover but may
have helped the consultation if you did?have helped the consultation if you did?
But let’s look at the old consultation model firstBut let’s look at the old consultation model first
The Old Consulting ModelThe Old Consulting Model
PatientPatient Patient accepts, respects and leaves Patient accepts, respects and leaves
Enters sick roleEnters sick role Dr advises Dr advises
(often in high class English)(often in high class English)
Enters surgeryEnters surgery Patient makes gifts Patient makes gifts
Ticket of admission Ticket of admission Dr rations his skill & Dr rations his skill & attentionattention
Temporarily hands over care to the DoctorTemporarily hands over care to the DoctorCLOTHED DOCTOR, NAKED PATIENTACTIVE DOCTOR, PASSIVE PATIENT
Classification of ModelsClassification of Models
Patient centred
Doctor centred
Behaviour orientated
Task orientated
Physical, Psych, SocialStott & DavisByrne & LongPendleton et al
HelmanHealth Belief Model
Byrne & Long (I)6-Category AnalysisTransactional Analysis
CounsellingBendixBalint
Michael Balint (1957)Michael Balint (1957)
““The Doctor, the patient and their illness” The Doctor, the patient and their illness” Physical, Psychological, Social AspectsPhysical, Psychological, Social Aspects Doctor’s apostolic functionDoctor’s apostolic function Entry ticketEntry ticket Hidden agendaHidden agenda Doctors have feelingsDoctors have feelings Collusion of anonymityCollusion of anonymity The “drug doctor”The “drug doctor”
Focusses on the doctor / patient relationshipFocusses on the doctor / patient relationship
J Spence (1960)J Spence (1960)
The Purpose & Practice of MedicineThe Purpose & Practice of Medicine Places the consultation at the heart of good practicePlaces the consultation at the heart of good practice
The RCGP (1972)The RCGP (1972)
The Future General Practitioner, Learning & TeachingThe Future General Practitioner, Learning & Teaching
Physical, Psychological & SocialPhysical, Psychological & Social Traditional consultation model: Active / PassiveTraditional consultation model: Active / Passive Hypothetico-deductive modelHypothetico-deductive model Holistic Model of the ConsultationHolistic Model of the Consultation
John Heron (1975)John Heron (1975)
Six Category Intervention analysisSix Category Intervention analysisInterventions can be: Interventions can be:
1 Prescriptive1 Prescriptive
2 Informative2 Informative
3 Confronting 3 Confronting
4 Cathartic 4 Cathartic
5 Catalytic 5 Catalytic
6 Supportive 6 Supportive
Authoritative
Facilitative
Eric Berne (1976)Eric Berne (1976)
Games People PlayGames People PlayTransactional analysisTransactional analysisParent, Adult, Child rolesParent, Adult, Child rolesThe Adult / Adult goalThe Adult / Adult goal
Byrne and Long (1976)Byrne and Long (1976)
Doctors Talking to PatientsDoctors Talking to Patients
Sequence of events in a consultation:Sequence of events in a consultation:
1.1. Establishing a relationshipEstablishing a relationship
2.2. Why has the patient comeWhy has the patient come
3.3. Verbal and/or physical examinationVerbal and/or physical examination
4.4. Considering the conditionConsidering the condition
5.5. Further investigation or treatmentFurther investigation or treatment
6.6. TerminationTermination
Stott & Davies (1979)Stott & Davies (1979)
The potential of each primary care consultationThe potential of each primary care consultation
1.1. The management of the presenting problemThe management of the presenting problem
2.2. Modification of help seeking behaviourModification of help seeking behaviour
3.3. Management of continuing problemsManagement of continuing problems
4.4. Opportunistic health promotionOpportunistic health promotion
Pendleton (1984)Pendleton (1984)
The consultation, an approach to learning and teachingThe consultation, an approach to learning and teaching11 Define the reasons for the patient’s attendanceDefine the reasons for the patient’s attendance22 Consider other problemsConsider other problems33 With the patient, choose an appropriate solution to With the patient, choose an appropriate solution to
each problemeach problem44 Achieve a shared understanding of the problemsAchieve a shared understanding of the problems55 Involve the patient in the management and encourage Involve the patient in the management and encourage
the patient to take responsibilitythe patient to take responsibility66 Use time and resources appropriatelyUse time and resources appropriately77 Establish or maintain the doctor patient relationshipEstablish or maintain the doctor patient relationship
Roger Neighbour (1987)Roger Neighbour (1987)
The Inner ConsultationThe Inner Consultation A journey with five checkpointsA journey with five checkpoints
11 ConnectingConnecting22 SummarisingSummarising33 Handing overHanding over4 Safety Netting4 Safety Netting5 House Keeping5 House Keeping
Housekeeping and safety netting are his original Housekeeping and safety netting are his original contributionscontributions
Lesser & Gask (1991)Lesser & Gask (1991)
Problem Based InterviewingProblem Based InterviewingEmphasises the detection of psycho-social distressEmphasises the detection of psycho-social distressProblem detection skills;Problem detection skills; Beginning the interviewBeginning the interview Picking up verbal cuesPicking up verbal cues Responding to verbal cuesResponding to verbal cues Picking up non-verbal cuesPicking up non-verbal cues Responding to non-verbal cuesResponding to non-verbal cues Demonstrating empathyDemonstrating empathy Exploring health beliefsExploring health beliefs Controlling the pace of the interviewControlling the pace of the interview
Lesser & GaskLesser & Gask
Problem management skills:Problem management skills: Allowing the patient to ventilateAllowing the patient to ventilate Negotiating with the patient to initiate changeNegotiating with the patient to initiate change Problem solving(like directive counselling)Problem solving(like directive counselling) Re-atrributingRe-atrributing Giving informationGiving information Special skills(special therapies)Special skills(special therapies)
Peter Tate (1994)Peter Tate (1994)
The Doctors Communication HandbookThe Doctors Communication Handbook
11 Discovery the reason for the patients attendanceDiscovery the reason for the patients attendance
2 2 Define the clinical problemDefine the clinical problem
33 Explain the problem to the patientExplain the problem to the patient
44 Explain the problems to the patientExplain the problems to the patient
55 Make effective use of the consultationMake effective use of the consultation
Calgary Cambridge - Silverman et Calgary Cambridge - Silverman et al (1988)al (1988)
5 Check Points5 Check Points
Helman’s ‘folk’ model (1981)Helman’s ‘folk’ model (1981)
Disease vs Illness in General PracticeDisease vs Illness in General Practice
A Patient comes to the Dr. seeking answers to 6 questionsA Patient comes to the Dr. seeking answers to 6 questions
1.1. What has happened?What has happened?2.2. Why has it happened?Why has it happened?3.3. Why to me?Why to me?4.4. Why now?Why now?5.5. What would happen if nothing were done about it?What would happen if nothing were done about it?6.6. What should I do about it or whom should I consult for What should I do about it or whom should I consult for
further help?further help?
Health Belief Model – Becker & Health Belief Model – Becker & Maiman (1975)Maiman (1975)
IdeasIdeas Concerns Concerns ExpectationsExpectations
““ICE”ICE”
Bendix (1982)Bendix (1982)
The Anxious PatientThe Anxious PatientNon-directive counsellingNon-directive counselling
SummarySummary Consultation models help us to decide what to do and Consultation models help us to decide what to do and
how to do ithow to do it There are so many models – confusing or adding There are so many models – confusing or adding
richness?richness? Try and read a couple of consultation booksTry and read a couple of consultation books The aim is to develop your own styleThe aim is to develop your own style Keep your model simpleKeep your model simple And…………make sure you can do something with itAnd…………make sure you can do something with it You may wish to use different models for different You may wish to use different models for different
situations eg Kayes Model for Breaking Bad Newssituations eg Kayes Model for Breaking Bad News
Highly RecommendedHighly Recommended
The Inner Consultation – Roger NeighbourThe Inner Consultation – Roger Neighbour The Dr-Pt Communication Handbook – Peter TateThe Dr-Pt Communication Handbook – Peter Tate SilvermanSilverman