Why the consultation?• Pivotal to everything we do as GPs• Gives insight into doctor-patient
relationship• Likely to feature in every module of the
exam• Leads to better patient understanding,
better concordance, fewer complaints
“Poor communication about illness causes more suffering than any other problem except unrelieved pain”.
Avril Stedeford - Facing Death 1984
Consulting in UK General Practice
• Average length of 7.5 minutes• Fastest in Europe• We will each do 200,000 during
out careers
Why model the consultation?
• We subconsciously make models for anything we do regularly
• By studying other peoples models we can develop our own
• Helps us understand patient’s perspective
• Make us safer and more thorough
What if we cannot make a diagnosis?What if a patient doesn’t like the
management plan?What if the patient has hidden agenda?What if the patient’s concerns are not
addressed?
Summarising• Explaining back to the
patient what they have told you.
• Allows for correction, development of ideas/understanding
• Useful tool if things are not going well
Handing over• Agreeing on a
management plan• Giving ownership and
responsibility of that management plan to the patient
Safety-netting• Considering “what if?”• Can take form of follow-
up, what to do if problem continues, referral.
• For benefit of patient and the Dr.
Housekeeping• The Dr recognising
the importance of looking after oneself.
• Coffee, going for a walk, check score in the cricket.
Neighbour’s model Pros:• Good for acute
problems• Recognises
importance of Dr looking after himself
• Empowers patient
Cons:
•Dr centred
Helman’s “Folk Model”• 1981• Medical Anthropologist• Patients form a theory based on their
– Experience– Imagination– Peer group views
Helman’s “Folk Model”• WHAT has happened?• WHY has it happened?• Why to ME?• Why NOW?• What would happen if NOTHING DONE
about it?• What should I DO ABOUT IT or whom
should I consult?
Helman’s “Folk Model”Pros:• Very patient
centred• Patient
satisfaction
Cons:• Time• Hard to apply to
certain situations e.g. severe mental health, elderly, emergencies.
Transactional Analysis• 1964 Eric Berne• Parent
– Critical or caring
• Adult– Logical
• Child– dependent
Transactional AnalysisPros:• Important to be
aware of role• Attempt to break
patterns of behaviour
Cons:• Not always
relevant
Stott & Davis• Management of the PRESENTING
PROBLEM• Modification of HEALTH SEEKING
BEHAVIOURS• Management of CONTINUING
PROBLEMS• Opportunistic HEALTH PROMOTION
Stott & DavisPros:• QOF• Long term
benefits of modifying behaviour
Cons:• May miss
psychological problems
• No account of patient’s health beliefs
Pendleton et al• DEFINE the reason for attendance
• Consider OTHER PROBLEMS
• With the patient chose an APPROPRIATE ACTION for each problem
Pendleton et al• Achieve a SHARED UNDERSTANDING of the
problems with the pt
• INVOLVE the pt in management decisions & encourage to TAKE RESPONSIBILITY
• Use TIME & RESOURCES appropriately
• ESTABLISH or maintain a RELATIONSHIP with the pt
PENDLETON1. Define the reason for the patient’s attendance,
including:• Nature and history of problem• Their aetiology• Ideas concerns and expectations• Effects of the problem
2. Consider other problems:• Continuing problems• At risk problems
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:• In the consultation• In the long term
7. To establish or maintain a relationship with the patient which helps to achieve the other tasks
Pendleton et alPros:• Pt centred• Ideas, concerns,
expectations• Encourages pt
responsibility• Basis for
summative assessment videos
Cons:• Emergencies