Consultation Models

The Second Termers

Why the consultation?• Pivotal to everything we do as GPs• Gives insight into doctor-patient

relationship• Likely to feature in every module of the

exam• Leads to better patient understanding,

better concordance, fewer complaints

“Poor communication about illness causes more suffering than any other problem except unrelieved pain”.

Avril Stedeford - Facing Death 1984

Consulting in UK General Practice

• Average length of 7.5 minutes• Fastest in Europe• We will each do 200,000 during

out careers

Why model the consultation?

• We subconsciously make models for anything we do regularly

• By studying other peoples models we can develop our own

• Helps us understand patient’s perspective

• Make us safer and more thorough

Hospital Model• History• Examination• Investigations• Diagnosis• Management plan• Follow-up

What if we cannot make a diagnosis?What if a patient doesn’t like the

management plan?What if the patient has hidden agenda?What if the patient’s concerns are not

addressed?

Dr. Roger “Karl” Neighbour

• President of RCGP• The Inner

Consultation 1984• 5 checkpoints

• Connecting• Summarising• Safety netting• Handing over• Housekeeping

Connecting• Building rapport• Identify patients

views, beliefs and experiences

Summarising• Explaining back to the

patient what they have told you.

• Allows for correction, development of ideas/understanding

• Useful tool if things are not going well

Handing over• Agreeing on a

management plan• Giving ownership and

responsibility of that management plan to the patient

Safety-netting• Considering “what if?”• Can take form of follow-

up, what to do if problem continues, referral.

• For benefit of patient and the Dr.

Housekeeping• The Dr recognising

the importance of looking after oneself.

• Coffee, going for a walk, check score in the cricket.

Neighbour’s model Pros:• Good for acute

problems• Recognises

importance of Dr looking after himself

• Empowers patient

Cons:

•Dr centred

Helman’s “Folk Model”• 1981• Medical Anthropologist• Patients form a theory based on their

– Experience– Imagination– Peer group views

Helman’s “Folk Model”• WHAT has happened?• WHY has it happened?• Why to ME?• Why NOW?• What would happen if NOTHING DONE

about it?• What should I DO ABOUT IT or whom

should I consult?

Helman’s “Folk Model”Pros:• Very patient

centred• Patient

satisfaction

Cons:• Time• Hard to apply to

certain situations e.g. severe mental health, elderly, emergencies.

Transactional Analysis• 1964 Eric Berne• Parent

– Critical or caring

• Adult– Logical

• Child– dependent

Transactional AnalysisPros:• Important to be

aware of role• Attempt to break

patterns of behaviour

Cons:• Not always

relevant

Stott & Davis• 1979• 4 areas can be

systematically explored each time a patient consults

Stott & Davis• Management of the PRESENTING

PROBLEM• Modification of HEALTH SEEKING

BEHAVIOURS• Management of CONTINUING

PROBLEMS• Opportunistic HEALTH PROMOTION

Stott & DavisPros:• QOF• Long term

benefits of modifying behaviour

Cons:• May miss

psychological problems

• No account of patient’s health beliefs

Pendleton et al• 1984, 2003• 7 tasks

Pendleton et al• DEFINE the reason for attendance

• Consider OTHER PROBLEMS

• With the patient chose an APPROPRIATE ACTION for each problem

Pendleton et al• Achieve a SHARED UNDERSTANDING of the

problems with the pt

• INVOLVE the pt in management decisions & encourage to TAKE RESPONSIBILITY

• Use TIME & RESOURCES appropriately

• ESTABLISH or maintain a RELATIONSHIP with the pt

PENDLETON1. Define the reason for the patient’s attendance,

including:• Nature and history of problem• Their aetiology• Ideas concerns and expectations• Effects of the problem

2. Consider other problems:• Continuing problems• At risk problems

3. With the patient, to choose an appropriate action for each problem.

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:• In the consultation• In the long term

7. To establish or maintain a relationship with the patient which helps to achieve the other tasks

Pendleton et alPros:• Pt centred• Ideas, concerns,

expectations• Encourages pt

responsibility• Basis for

summative assessment videos

Cons:• Emergencies

In summary• Numerous models• Apply to different consultations• Important to know NEIGHBOUR &

PENDLETON plus one other