Consultation Models
Introduction
• Models enable the Dr to think where in the
consultation the problems are,
• There are lots of models.
• Task orientated, Skills based,
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• Some are based on the doctor patient
relationship, or the patients perspective of
illness.
What models do you know?
Consultation models
• 1957 M Balint - The Doctor, His Patient and The Illness
• 1964 E Berne - Games People Play
• 1975 Becker & Maiman - Sociobehavioural Determinants of
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Compliance ...
1975 J Heron - Six Category Intervention Analysis
1976 Byrne & Long - Doctors Talking to Patients
1977 RCGP definition - Physical, psychological & social ...
1979 Stott & Davis - The Exceptional Potential in Each Primary Care
Consultation
1981 C Helman - Disease vs Illness in Gen Practice
1984 Pendleton et al - The Consultation
1987 R Neighbour - The Inner Consultation
1987 R C Fraser - Clinical Method: A Gen Pract Approach
1996 Kurtz & Silverman The Calgary-Cambridge Observation Guide
to The Consultation
Traditional medical model
The classic medical diagnostic process
involves the following steps:
• observation - history and examination
• hypothesis -provisional diagnosis
• hypothesis testing - investigations
• deduction - definitive diagnosis.
Balint -1957
• Hungarian doctor and psychoanalyst
• Founded with his wife Enid in the 1950
• This experince led to his book “The Doctor, his
Patient and the Illness“
• Balint groups
Balints consultation approach
• Psycological problems are often
manifested physically and physical
disease has psychological consequences
• Passing responsibility of dealing with a
problem on to someone else was
defined by Balint as“collusion of
anonymity“
Balints consultation approach
• Doctors have a therapeutic role in the
consultation : drug doctor
• Doctors feelings have a function in the
consultation
• Balint describes the „Flash technique“: the
doctor becomes aware of his feelings and
interprets this back to the patient
Transactional Analysis
Eric Berne
1964
T-A model
This model discusses the 3 “ego-states”
• Parent - critical/caring.
• Adult – logical.
• Child – dependent.
Believes human psyche is influenced by
mother and infant intimacy and that infant
style intimacy can develop in certain
relationships including dr-pt.
T-A model
Useful to recognise when a dr-pt
relationship develops into a parent-child
dynamic.
Consultations may develop into games
where the pts interests are not served.
Need to try to recognise the new dynamic
and try to have both dr and pt take on
the adult role.
DVD case 5
Helman
• 1) What has happened? This includes organising the symptoms and signs
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into a recognisable pattern, and giving it a name or identity.
2) Why has it happened? This explains the aetiology or cause of the
condition.
3) Why has it happened to me? This tries to relate the illness to aspects
of the patient, such as behaviour, diet, body-build, personality or heredity.
4) Why now? This concern the timing of the illness and its mode of onset
(sudden or slow)
5) What would happen to me if nothing were done about it? This
considers its likely course, outcome, prognosis and dangers.
6) What are its likely effects on other people (family, friends,
employers, workmates) if nothing were done about it? This includes
loss of income or of employment, or a strain on family relationships.
7)What should I do about it or to whom should I turn for further
help? Strategies for treating the condition, including self-medication,
consultation with friends or family, or going to see a doctor.
Roger Neighbour – The Hand
• 5 checkpoints
– Connecting
– Summarising
– Handing-over
– Safety-netting
– Housekeeping
• Inner consultation
– “2 heads” – the Organiser and the Responder
Role play in 2 groups, one group
looking at Helmans model, the
other looking at Neighbours model
• Helmans
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What has happened?
Why has it happened?
Why has it happened to me?
Why now?
What would happen to me if
nothing were done?
What are its likely effects on
other people (family, friends)
if nothing were done
7)What should I do about it or
to whom should I turn for
further help?
• Neighbour
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Connecting
Summarising
Handing-over
Safety-netting
Housekeeping
–Pendleton, Schofield, Tate and Havelock (1984)
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(1)
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(5)
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(7)
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
To consider other problems:
i)
continuing problems
ii)
at-risk factors
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
To establish or maintain a relationship with the patient which helps to achieve the
other tasks.
consulting styles
In the doctor-centred consulting style, the doctor:
• dominates the consultation
• asks direct, closed questions
• rejects the patient's ideas
• evades the patient's questions
In the patient-centred consulting style, the doctor:
• asks open questions
• actively listens
• challenges and reflects the patients' words and
behaviour to allow them to express themselves in their
own way
The Calgary-Cambridge approach to
communication skills teaching (1996)
• Suzanne Kurtz & Jonathan Silverman
• Doctors and patients tend to carry out the four
tasks of initiating the session, gathering
information, giving information and closing the
session roughly in sequence while relationshipbuilding is performed continuously during the
other tasks.
Initiating the Session
Gathering information
Providing
Structure
Building the
relationship
Physical Examination
Explanation and planning
Closing the Session
Initiating the Session
• preparation
• establishing initial rapport
• identifying the reason(s) for the consultation
Gathering information
Providing
• exploration of the patient’s problems to discover the:
Structure
 biomedical perspective
• making
organisation
overt
Building the
relationship
 the patient’s perspective
 background information - context
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using
appropriate
non-verbal
behaviour
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developing
rapport
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involving
the patient
Physical examination
• attending to
flow
Explanation and planning
• providing the correct amount and type of information
• aiding accurate recall and understanding
• achieving a shared understanding: incorporating the patient’s
illness framework
• planning: shared decision making
Closing the Session
• ensuring appropriate point of closure
• forward planning