The Consultation – Models,
Tasks, Skills
Dr Elke Hausmann GP ST1
GP group 28/09/2011
1
Interest in the consultation
• There is more to the consultation than a
patient presenting with a medical problem
for the doctor to solve
• Both Dr and patient are individuals in
particular contexts (family, community,
society) – problem may or may not be
medical
• Psychologists, psychoanalysts, social
scientists, philosophers, doctors…
2
Interest in the consultation
• What does happen? (empirical research)
• What should happen? (the ‘ideal
consultation’, based on particular values –
or what gives results, based on empirical
work)
• What could happen? (not all consultations
are the same – different tasks)
• Skills – allow the Dr to achieve a good
consultation
3
Balint 1957
Trained doctor and psychoanalyst – worked with GP groups
‘The doctor, his patient and the illness’
• Nearly all problems presenting to the Dr have a
psychological element to them
• Doctors have feelings and feelings have a
function in the consultation
• Explore psychological/emotional aspects of
consultation and use insight for benefit of the
patient
• The doctor as drug – the doctor has a
therapeutic role in all consultations, not only
those with a defined disease process
4
Berne 1958
Psychiatrist – ‘games people play’
• Transactional analysis
• Model of the human psyche: three ‘ego states’
• Critical or Caring Parent – commands, directs,
prohibits, controls, nurtures
• Logical Adult – sorts out info and works logically
• Spontaneous or Dependent Child – intuition, creativity,
spontaneity, enjoyment
• Parent-doctor and child-like patient? TA approach to
increase doctor’s repertoire, break out of repetitious
cycles of behaviour (‘games’)
5
RCGP triaxial model 1972
RCGP working party’s ‘job description’ of the GP
• ‘The Future General Practitioner’
• Consideration of the physical,
psychological and social condition of the
patient
• Not to think purely in terms of organic
illness
6
Heron 1975
Humanist psychologist – approach now used in business, education, public service etc
Six Category Intervention Analysis (3 doctor- and 3 patientcentred – authoritative and facilitative categories)
1. Prescriptive – giving explicit advice or instructions
2. Informative – imparting new knowledge (relevant to
patient? Enough? Not enough?)
3. Confronting – challenging a restrictive attitude or
behaviour, may cause upset – needs follow up!
4. Cathartic – seeking to release emotion (weeping,
laughter, trembling, anger) to move forward
5. Catalytic – encouraging the pat to discover and
explore his own latent thoughts and feelings
6. Supportive – offering comfort and approval, affirming
the pat’s intrinsic value – allow patient to cope better
7
Becker and Maiman 1975
Developed from Rosenstock 1966 for studying and promoting the uptake of health services (TB)
Health Belief Model – decision to consult depends on:
• Health motivation - The individual’s general interest in
health matters, acc to personality, soc class, ethnic
group etc
• Perceived vulnerability and perceived seriousness How vulnerable or threatened a pat feels to be by a
particular disease
• Perceived cost/benefits of an action - The individual’s
estimation of the beliefs of treatment weighed against
cost, risks and inconvenience
• Cues to action - Trigger factors, such as alarming
symptoms, advice from family or friends, messages from
the mass media, disruption of work and play
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Health Belief Model
Patients vary enormously in the way they accept
responsibility for their health (locus of control)
• Internal controller – patients who feel they control their
own health destiny, have firm idea of own diagnosis and
expectations of what Dr should do for them
• External controller – patients feel their likelihood of
developing illness or staying healthy is completely out of
their control, modifying lifestyle does not make a
difference
• Powerful other – patients who feel their health destiny
rests with a particular person (could be GP), respond to
their advice
9
Byrne
Founder member RCGP
+ Long
Psychologist
1976
Based on 2500 tape-recorded consultations from over 100 Drs in UK and NZ
• ‘Doctors talking to patients’ – doctor-centred
• Style of consultation depends on personality of
doctor and patient – doctor-dominated to virtual
monologue by patient
• Narrow repertoire of consultations skills –
doctors who ask more open questions see their
patients less frequently
• 6 stages to consultation (establish
relationship, discover reason for attendance,
history +/-examination, dr + pat consider
condition (illness), discussion of Rx or further Ix,
closing consultation)
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Stott and Davies 1979
Academic GPs
4 tasks that can take place in each consultation:
1.
2.
3.
4.
Managing the presenting complaint (eg sore throat)
Modifying health-seeking behaviour (eg selfmedication for future episode in pat presenting
repeatedly in 24 hrs for sore throat)
Managing ongoing problems (eg DM, depression)
Opportunistic health promotion (eg smoking,
weight, cervical smear, immunisation…)
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Helman 1981
GP and medical anthropologist – ‘Suburban Shaman’ 2006
Folk Model of Illness – illness vs disease
• what has happened?
• why?
• why me?
• why now?
• what would happen if nothing were done?
• what should be done about it?
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Pendleton 1984
Social psychologist – PhD on analysis of the consultation
The doctor’s tasks - seven tasks model
1. Define reason for attendance (ICE, effects of
illness = patient’s agenda)
2. Consider other problems
3. Doctor and patient choose appropriate action
4. Share understanding with patient
5. Involve patient in management decisions
6. Use time (new) and resources well
7. Establish and maintain dr-pat relationship
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Tuckett et al 1985
Medical sociology – study of doctor-patient communication in GP
‘Meeting between experts’
• Consultation as meeting between two experts
• Doctor expert in medicine (underlying pathology,
differential diagnosis)
• Patient expert in own illnesses (unique illness
experience)
• Shared understanding is the aim
• Doctors should seek to understand the patient’s beliefs
• Doctors should address explanations in terms of the
patient’s belief system
Example: patient repeatedly comes in with chest pain, reassured it’s not cardiac – turns out his uncle recently
died of cancer of the oesophagus
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Neighbour 1987
Former RCGP president
‘The Inner Consultation’ – the doctor’s two heads:
organiser and responder (while being active
organiser it’s difficult being responsive and vice versa)
5 checkpoints:
1. Connecting – develop rapport/empathy
2. Summarising – reasons for attending, feelings,
concerns, expectations
3. Handing over – sharing agreed mx plan, hands
control back to pat
4. Safety-netting - making contingency plans
5. Housekeeping – getting ready for next pat
(new: safe doctoring and healthy doctor!)
15
Fraser 1992
Professor of GP in Leicester – ‘Clinical method – a General Practice approach’
Areas of competence:
• Interviewing and history taking
• Physical examination
• Diagnosis and problem-solving – current probability
about cause of illness rather than certainty
• Patient management (RAPRIOP –
reassurance/explanation, advice/counselling,
prescribing, referral, investigations, observation + followup, prevention)
• Relating to patients – friendly but professional
• Anticipatory care – health promotion/disease prevention
• Record-keeping
16
Tate 1994
Developed from Pendleton – retired GP and former Convenor of MRCGP examinations
‘The Doctor’s Communication Handbook’
• Importance of ideas, concerns,
expectations
• Updates strategies and skills in internetera
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Stewart and Roter 1997
American academics (John Hopkins University) – research using audiotapes
Gathering of info about patient’s problems along
two parallel pathways
• Patient’s agenda – exploring ideas, concerns,
expectations, feelings, thoughts and effects
culminating in an understanding of the patient’s
unique experience of the illness
• Doctor’s agenda – exploring symptoms, signs,
investigations and consideration of the
underlying pathology and diff diagnosis
• Need to be brought together for shared
understanding – allows for explanations,
planning and decision-making
18
Calgary-Cambridge 1996
Derives from Pendleton – evidence-based approach to integration of the ‘tasks’ of the consultation and
improving skills for effective communication
1.
2.
3.
4.
5.
Initiating the session (rapport, reasons for consulting,
establishing shared agenda)
Gathering information (patient’s story, open and
closed questions, identifying verbal and non-verbal
cues)
Building the relationship (developing rapport,
recording notes, accepting patients’ views/feelings and
demonstrating empathy and support)
Explanation and planning (giving digestible info and
explanations)
Closing the session (summarising and clarifying the
agreed plan)
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Launer 2002
London GP
model of the consultation – techniques to
help understanding the patient’s story:
‘Narrative-based’
• Circular questioning or picking up patients’ words to form
open questions and help patients to focus on meaning
• A focus on listening (avoid note-taking during
consultation)
• Exploring the context of the problem (family, work,
community)
• Conversations circularity co-creation curiosity contexts
caution
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To do in the next consultation
based on e-GP learning module on the consultation
•
•
•
•
•
•
•
•
check patient's understanding
try to see from patient's perspective
modify help-seeking
ideas, concerns, expectations
cues to hidden agenda?
summarise
safety-netting
negotiate agenda
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References
• www.patient.co.uk/doctor/ConsultationAnalysis.htm
• http://www.gptraining.net/training/communication_skills/consul
tation/index.htm
• http://www.yorksandhumberdeanery.nhs.uk/gene
ral_practice/documents/consultationmodelsindet
ail-BillBevington.doc
• The Condensed Curriculum Guide RCGP 2007
• e-GP learning module ‘Models of the
Consultation’
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