CONSULTATION MODELS
An overview
Dr Andrew Ashford
The Limes Medical Centre
Classification
TASK
ORIENTED
Phys, psych, social
Helman ‘folk model’
Stott and Davis
Health Belief Model
Byrne and Long
Neighbour
Pendleton et al
Calgary-Cambridge
DOCTOR
CENTRED
Byrne and Long (ii)
6-Category Analysis
Transactional Analysis
Counselling
Bendix
Balint
PATIENT
CENTRED
BEHAVIOUR
ORIENTED
(after Neighbour: The Inner Consultation)
(1) Royal College of GPs
• The Future General Practitioner Learning and Teaching - RCGP working
party 1972
• “… His diagnoses will be composed in
physical, psychological and social
(from the job definition of a GP)
terms.”
(2) Stott and Davis
A
B
Management of
presenting
problems
Modification of
help-seeking
behaviours
C
D
Management of
continuing
problems
Opportunistic
health
promotion
The potential in each primary care consultation (Stott and Davis 1979)
(3) Byrne and Long (i)
Phase I The doctor establishes a relationship with the patient
Phase II The doctor either attempts to discover or actually
discovers the reason for the patient’s attendance.
Phase III The doctor conducts a verbal or physical examination or
both.
Phase IV The doctor, or the doctor and the patient, or the patient
(in that order of probability) consider the condition.
Phase V The doctor, and occasionally the patient, detail further
treatment or further investigation.
Phase VI The consultation is usually terminated by the doctor.
(Doctors Talking to Patients - a study of the verbal behaviour of
general practitioners consulting in their surgeries)
(4) - Pendleton et al
(1)
To define the reason for the patient’s attendance, including:
(i) the nature and history of the problems:
(ii) their aetiology:
(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)
(4)
(5)
(6)
With the patient, to choose an appropriate action for each problem.
To achieve a shared understanding of the problems with the patient.
To involve the patient in the management and encourage him to accept
appropriate responsibility.
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.
(5) - Helman’s ‘folk model’
•
•
•
•
•
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 further about it?
(6) Health Belief Model
• General interest in health matters
• Level of vulnerability, level of threat
• Benefits of treatment v. costs, risks,
inconvenience
• Factors prompting action - symptoms,
advice, media
IDEAS…CONCERNS…EXPECTATIONS
(Becker and Maiman 1975: Socio-behavioural determinants of compliance
with medical care recommendations)
(6) Health Belief Model (ii)
The basic constructs:• Perceived susceptibility
• Perceived severity
• Perceived benefits
• Perceived barriers
plus
• Cues to Action
(7) Byrne and Long (ii)
Use of patient’s knowledge
and experience
Use of doctor’s special
skill and knowledge
Patient
centred
“Absent
doctor”
Boredom
Indifference
Not listening
Being “miles
away”
Confused
noise
Doctor
centred
Silence
Listening
Reflecting
Using silence
Seeking/using
patient ideas
Encouraging
Indicating
understanding
Clarifying
Reflecting
Offering
observation
Clarifying
and
Interpreting
Offering
observation
Summarising to
open up
Repeating for
confirmation
Seeking pt’s ideas
Placing events in
sequence
Challenging
Open-ended
question
Concealed
question
Analysing
and
Probing
Direct question
Correlational
question
Placing events in
sequence
Suggesting
Offering feelings
Exploring Openended question
Repeating for
confirmation
Gathering
information
Direct question
Closed question
Correlational
question
Self-answering
question
Suggesting
Placing events
in sequence
Repeating for
confirmation
Reassuring
Justifying self
Chastising
Summarizing to
close off
“Absent
patient”
Rejecting pt’s
offers
Rejecting pt’s
ideas
Evading pt’s
question
Drowning pt’s
words
Justifying self
Confused noise
(8) Six Category Intervention
• Prescriptive - giving advice or instructions, being
critical or directive
• Informative - imparting new knowledge, instructing or
interpreting
• Confronting - challenging a restrictive attitude or behaviour,
giving direct feedback within a caring context
• Cathartic -
seeking to release emotion in the form of
weeping, laughter trembling or anger
• Catalytic -
encouraging the patient to discover and
explore his own latent thoughts and feelings
• Supportive - offering comfort and approval, affirming the
patient’s intrinsic value
(John Heron 1975)
(9) - Miscellaneous
• Transactional Analysis (TA)
• Counselling
• Bendix - The Anxious Patient
• Balint - The Doctor, His Patient and
the Illness
(10) Neighbour - The Inner Consultation
5 CHECK POINTS:
• Connect
Am I on this patient’s wavelength?
• Summarize
Have I sufficiently understood the problem to be
able to summarize it back to them correctly?
• Handover
Is the patient clear about who is doing what
next?
• Saftynet
What should the patient do if events do not turn
out as expected?
• Housekeeping
Am I in a fit state for the next patient ?
Calgary-Cambridge (i)
THE TASKS
• Initiating the session
• Gathering Information
• Building the relationship
• Explanation and planning
• Closing the session
Expanded Framework
Gathering Information
Explanation and Planning
Closing the Session
Attending to Task
Building the Relationship
Initiating the Session
Calgary-Cambridge (ii)
THE EXPANDED FRAMEWORK
1. Initiating the session
– establishing initial rapport (1-3)
– identifying the reason(s) for the consultation
(4-7)
Calgary-Cambridge (iii)
2. Gathering information
– exploration of problems (8-14)
– understanding the patient’s perspective (1519)
– providing structure to the consultation (2023)
3. Building the relationship
– developing rapport (24-28)
– involving the patient (29-31)
Calgary-Cambridge (iv)
4. Explanation and planning
– providing the correct amount and type of
information (33-35)
– aiding accurate recall and understanding (3641)
– achieving a shared understanding:
incorporating the patient’s perspective (42-45)
– planning: shared decision making (46-51)
5. Closing the session (52-55)
Calgary-Cambridge (v)
Options in explanation and planning
– if discussing opinion & significance of
problems (56-59)
– if negotiating mutual plan of action (60-67)
– if discussing investigations and procedures
(68-70)
Calgary-Cambridge (vi)
70 Skills !! - are you ‘avin’ a laugh?
…Well, NO
1. Each one validated by research for a
specific purpose
2. Not all skills needed all the time
THE TOOLBOX ANALOGY
How to learn (and teach)
communication skills
• Experiental learning methods
• Problem-based learning methods
• Didactic methods
How to learn (and teach)
communication skills (ii)
Experiential
•
•
•
•
•
•
systematic delineation / definition of essential skills
observation
well-intentioned, detailed & descriptive feedback
video / audio recording & review
practice & rehearsal of skills
active small-group or one-to-one learning
How to learn (and teach)
communication skills (ii)
Problem-based learning
•
•
•
•
•
start with learner’s perceived needs - relevance
balance between self-directed & facilitator-directed
planned with negotiated / emergent objectives
practical problems from “real life”
learners direct pace
Conventional rules of feedback
• Positive first for safety
• Self-assessment first
• Recommendations not criticisms!
Agenda-led, outcome-based analysis