Consultation Models

1. Consultation Models Aimee Lettis & Karla Grebe

2. The plan… • Why look at consultation models? • Bit about the consultation • Different approaches to the consultation • The traditional medical model • Examples of specific consultation models • Analyse two video consultations using different models

3. Why look at consultation models? Neighbour Berne Balint Helman Stott & Davis Pendelton Fraser Heron Stewart etc.

4. Why look at consultation models? • Pivotal to everything we do as GP’s • Framework within which doctor & patient interact • By studying other’s models, we can develop our own style • Gives us an insight into doctor-patient relationship & patient’s perspective • If done well, leads to better patient understanding & concordance and fewer complaints

5. Consultation models & styles • No correct way to perform a consultation • Approach varies according to situation & participants • Different consultation styles will be effective in different circumstances/ for different doctors

6. Aims of the consultation • Establish constructive relationship with patient • Enable effective communication • Determine whether patient has any health problems/health promotion needs • Find out (if possible) what caused them • Assess patient & family’s emotions & attitudes towards the problem • Establish how problems might be managed • Good communication essential in achieving these aims

7. Potential barriers to effective communication • Lack of time • Language problems • Differing gender/age/ethnic or social backgrounds • ‘Sensitive’ issues to address • ‘Hidden’ or differing agendas • Prior difficult meetings • Lack of trust

8. Different approaches to consultation • Medical • Disease & diagnosis of fundamental importance • Sociological • Aims to understand behaviour between doctors & patients, accepting the concepts of values & norms • Eg. Is school refusal a disease? • Anthropological • Looks at effect of culture • Distinguishes between illness & disease (eg. Helman’s folk model)

9. Different approaches to consultation • Transactional analysis • Revolves around ego states of parent, child & adult (eg. Berne 1964 “The Games people play”) • Balint • Psychological factors play important role & doctor’s own personality influences consultation • Social-psychological approach • Patient & doctor’s personality as well as their beliefs alter outcome of consultation (eg. Pendleton, Neighbour, Cambridge-Calgary)

10. The traditional medical model • History • Examination • Investigation • Diagnosis • Treatment • Follow-up • But….it has it’s limitations…

11. Being patient-centred.. • Seems to improve: • Patient satisfaction • Concordance • Health outcomes • Certain models emphasize importance of this • Balint • Stewart • In practice, doctor weaves between traditional medical model & patient’s perspective of the illness • Hopefully ending up with integrated understanding, shared by both

12. Specific modelsRoger Neighbour – The Inner Consultation, 1987 • Connecting • Building rapport • Identifying patient’s views, beliefs & expectations • Summarising • Explaining back to patient what they have told you • Allows for correction/development of ideas & understanding • Useful tool if not going well! • Handing over • Agreeing on doctor’s and patient’s agendas • Negotiating, influencing & gift-wrapping • Giving ownership & responsibility of management plan to patient

13. Specific modelsRoger Neighbour – The Inner Consultation, 1987 • Safety netting • Considering “What if?” • Could be follow-up, advice or referral • For benefit of both doctor & patient • Housekeeping • Doctor recognises importance of looking after oneself, eg. Coffee/going for a walk etc. • “Am I in good enough shape for the next patient?”

14. Pro’s Good for acute problems Recognises importance of doctor looking after themselves Empowers patient Con’s Doctor-centred Specific modelsRoger Neighbour – The Inner Consultation, 1987

15. Specific ModelsHelman Folk Model, 1981 • Suggested that patients form theory based on their experience, imagination & peer group views • Consult doctors in order to obtain answers to 6 questions…

16. Specific ModelsHelman Folk Model, 1981 • What has happened? • Why has it happened? • Why to me? • Why now? • What would happen if nothing were done about it? • What should I do about it or whom should I consult for further help?

17. Pro’s Very patient-centred Patient satisfied Con’s Time Hard to apply to certain situations eg. Severe mental health Specific ModelsHelman Folk Model, 1981

18. Pendleton et al – 1984 and 2003 • Pendleton, Schofield, Tate and Havelock (1984)          “The Consultation - An Approach to Learning and Teaching” describe seven tasks which taken together form comprehensive and coherent aims for any  consultation.  1)    To define the reason for the patient’s attendance, including:                         i)            the nature and history of the problems                         iii)            the patient’s ideas, concerns and expectations                         iv)            the effects of the problems  2)    To consider other problems:                         i)            continuing problems                         ii)            at-risk factors            3)    With the patient, to choose an appropriate action for each  problem :

19. Pendleton et al – 1984 and 2003 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:                        i)            in the consultation                        ii)            in the long term  7)To establish or maintain a relationship with the patient which helps to  achieve the other tasks. :

20. Pendleton et al • Pros: • Pt centred • Ideas, concerns and expectations • Encourages pt responsibility • Incorporated in nMRCGP tasks for the consultation/COTs • Cons: • Emergencies

21. Calgary-Cambridge observation guide to the consultation:              • Suzanne Kurtz & Jonathan Silverman have developed a model of the consultation, encapsulated within a practical teaching tool, the Calgary Cambridge Observation Guide (1996, 2002). • The structure (5 tasks): • Gathering information • Building the relationship • Initiating the session • Explanation and Planning • Closing the session

22. Calgary-Cambridge observation guide to the consultation: • The Framework: • Initiating the session • Establishing initial rapport • Identifying the reason(s) for the consultation • Gathering information • Exploration of problems • Understanding the patient’s perspective • Providing structure to the consultation • Building the Relationship • Developing rapport • Involving the patient • Explanation and Planning • Providing correct amount and type of information • Aiding accurate recall and understanding • Achieving a shared understanding: incorporation the patient’s perspective • Planning: shared decision making • Closing the session • I

23. Summary • The consultation is the cornerstone of general practice • There are many models which can be used to analyse and shape consultations • Try & read more about some of them • Aim is to develop your own style • Different models can be used in different situations • Patient-centred care seems to improve patient satisfaction & health outcomes

24. Some bedtime reading! • Neighbour R (1987) The Inner consultation • Helman C G (1981) Disease versus Illness in General Practice • Also by Helman (2004), for some lighter reading… Suburban Shaman – tales from medicine’s frontline • Pendleton et al (1984, 2003) The new consultation: Developing doctor-patient communication