The consultation

The art of accompanying the patient

By

Ghislaine Young

Sir James Spence

• A consultation is…

• “An occasion when, in the intimacy of the consulting room a person who is ill or believes himself to be ill, seeks the advice of a doctor whom he trusts.

• 2 orientations: the illness and the patient

• A meeting of experts

Hippocrates

• “It is more important to know what sort of person has a disease then to know what sort of disease a patent has”

Alan Alda

Never have your dog stuffed!

• “I began to understand that what I do in the scene is not as important as what happens between me and the other person. And listening is what lets it happen. It’s almost always the other person who causes you to say what you say next. You don’t have to figure out how you’ll say it.”

Listening, or are you pretending?

• “you have to listen so simply, so innocently, that the other person brings about a change in you that makes you say it and informs the way you say it. The difference between listening and pretending to listen.. Is enormous: one is fluid, the other rigid. One is alive, the other stuffed…”

Real Listening is..

• “ a willingness to let the other person change you. When I’m willing to let them change me, something happens between us that is more interesting than a pair of duelling monologues. “

Don’t just do something, sit there!

• The way to do is to be. –Lao Tzu

• “being is a fundamental mode of existence or orientation to the world, one of aliveness and authentic relatedness”- Joseph Jaworski

• Nursing is… about being with the patient- Stephen Wright

The Dialogue

• A “flow of meaning”

• Is used to deepen the therapeutic relationship and develop rapport

• To shine a light on any symptoms the patient presents with, and

• Symptoms are shaped by prior context and perceptions of the patient

HALT!

The examination

• If you don’t look you don’t see!

• Seek your patient’s permission and explain the process

• Be comprehensive and use it to build your hypothesis (don’t skimp!)

• Notice, notice, notice! The clues are there!

The hypothesis

• Is developed to understand the patient’s experience and concerns, fears , expectations

• To reach a diagnosis

• To facilitate a treatment pathway and or care plan

Karl Popper

• “knowledge is advanced by the positing and testing of hypotheses. Countless hypotheses are being tested at once in the unconscious mind; only the winning shortlist is handed to our consciousness”

• Developing a hypothesis is about discerning the truth. There are facts and there are perceptions of the facts!

Ay, there’s the rub!

• Symptoms are only given meaning and so expression by the patient

• The clinician too is influenced by his or her prior context and experience, education and level of training and most of all by their attitude.

Confirmation Bias

• Ron Berghmans and Harry Schouten: • Is “a tendency for people to favour information

that confirms their preconceptions or hypotheses regardless of whether the information is true”

• The danger is that GPs look for diagnosis by confirming their initial thoughts. But if you are only looking for “white swans” that is all you will see.

The art of managing uncertainty

• Most common things happen most commonly, but have you ruled out the rare?

• Be open and prepared to challenge your pre-conceptions

• The patient condition is dynamic so re-evaluate as necessary and don’t over rely on colleagues’ findings or judgements!

Making the diagnosis

• Making a diagnosis

• The word comes from the Greek meaning “through” or “between” and “knowing”.

• Dossey suggests that making a diagnosis involves using the right brain or intuition to infer patterns that are woven through facts and between data.

Diagnosis as tapestry

• “ making a diagnosis is like confronting a tapestry. Our task is to absorb the pattern, to grasp the the design, not to bludgeon our way through with linear reasoning”.

The art of intuition and the science of logic

• Blaise Pascal: (1657, Pensees)

• “There are two excesses: to exclude reason, to admit nothing but reason”

• Or as Einstein puts it:

• “the intuitive mind is a sacred gift, the rational mind is a faithful servant”

“

Communicating back to the patient

• Share your findings and thoughts

• Explain rationale

• Involve the patient at every step

• Be empathic and deal with sensitive issues appropriately

• Be alert to cultural or ethnic issues

• Provide support

Explanation and planning

• The Calgary- Cambridge Model

• “ chunks and checks” give information in manageable chunks, check for understanding, uses patient’s response as a guide to how to proceed

• Tell the patient what you going to say, say it, then repeat what you have said….

Aiding Accurate Recall and Understanding

• Use concise, easily understood language

• Use diagrams or models

• Use patient information leaflets (CKS Patient Co UK)

• Self management plans

• Relate any explanations to the patient’s own frame of reference and context

Shared Understanding and Decision Making

• Encourage patient to contribute own ideas and thoughts (Nothing about Me without Me- Don Berwick)

• Work in mutual partnership• Negotiate plan of action and offer informed

choices where appropriate or possible• ask about support systems, but also aim to

empower the patient to take the lead in their own care

The 15 minute hour- Stuart and Lieberman

• “The sorrow which has no vent in tears may make other organs weep”. (Henry Maudsley)

• People become stressed when they are unable to adapt to external or internal environments and this in turn predisposes to further ill health and accounts for much presentation in primary care

• Goal of therapy: enhance coping mechanism and patient self esteem, restore functioning, prevent further decline.

The BATHE technique

• Background: “what is going on in your life?”

• Affect/feeling: “how are you feeling about that?”

• Trouble: “what troubles you the most?”

• Handling: “how are you handling that?”

• Empathy: “that must be very difficult”

Sharing the story..

• We are constantly telling ourselves and other stories about ourselves

• These stories create our reality and affect our experience

• These stories determine what we are capable of doing

Therapy means..

• 1. Hearing the story

• 2. Reflecting the story back with empathy

• 3. Limits must be challenged

• Introduce the word YET: it infers possibility of change in the future for we are not totally imprisoned by the past

Reframing..

• Focus on strengths

• Aim for small wins

• Encourage to own responsibility for behavioural change

Remember…

• The past is gone

• The future is not yet here

• We can only act/feel in the here and now

Ralph Waldo Emerson

• “Finish everyday and be done with it. You have done what you could, some blunders and absurdities no doubt crept in: forget them as soon as you can. Tomorrow is a new day. You shall begin it serenely and with too high a spirit to be encumbered with your old nonsense”

Beware the steroptypes

The medical consultation

• Is there a difference if managed by a nurse or doctor?

• If there is is it personal, ideological or instinctive?

• Cohn defines the consultation as the “sword and bow” ie a tool to reach a correct diagnosis and plan the right care

• Balint: the drug is the doctor..

The nursing consultation

• Is the bedrock of developing rapport with the patient and sharing their experience of their illness or symptoms- “presencing”

• Can be the means to the end, but also the fundamental process in aiding recovery in itself

• Differences may be imagined or are some a reality…?

Thank you! Any questions??