Consultation Models 2

Consultation ModelsConsultation ModelsDr. Gertrude C. Holder, MD, Dip., Dr. Gertrude C. Holder, MD, Dip.,

ABFPABFPConsultantConsultant

Dept. Family MedicineDept. Family MedicinePMHPMH

PRESENTER: MOKGWANE E SPRESENTER: MOKGWANE E SDOCTOR IN TRAININGDOCTOR IN TRAINING

Consultation ModelsConsultation Models

The consultation is the central task of The consultation is the central task of general practice general practice

Consultation skills form the basis of good Consultation skills form the basis of good patient care. patient care.

ConsultationConsultation skills can be learned and skills can be learned and requires systematic training rather than requires systematic training rather than just experience just experience

Consultation models & Consultation models & stylesstyles

No correct way to perform a No correct way to perform a consultationconsultation

Approach varies according to Approach varies according to situation & participantssituation & participants

Different consultation styles will be Different consultation styles will be effective in different circumstances/ effective in different circumstances/ for different doctorsfor different doctors


Reasons for participating in a medical Reasons for participating in a medical encounter with a patient:encounter with a patient:– 1. To satisfy your patient’s needs1. To satisfy your patient’s needs– 2. To maintain your reputation as a good doc2. To maintain your reputation as a good doc– 3. To make as much money as possible3. To make as much money as possible– 4. To see the patient as quickly as possible in 4. To see the patient as quickly as possible in

order to see more patientsorder to see more patients

An Effective ConsultationAn Effective Consultation

Immediate Outcomes:Immediate Outcomes:– Patient’s clear understanding and recall of the Patient’s clear understanding and recall of the

information relayed by the doctorinformation relayed by the doctor– Patient’s commitment to your management regimePatient’s commitment to your management regime– Reduced anxiety on the part of the patientReduced anxiety on the part of the patient

Long Term Outcomes:Long Term Outcomes:– Patient’s adherence to the management planPatient’s adherence to the management plan– Long-term improvements to healthLong-term improvements to health– Development of patient’s own health understanding Development of patient’s own health understanding

Potential barriers to Potential barriers to effective communicationeffective communicationLack of timeLack of time

Language problemsLanguage problems

Differing gender/age/ethnic or social Differing gender/age/ethnic or social backgroundsbackgrounds

‘‘Sensitive’ issues to addressSensitive’ issues to address

‘‘Hidden’ or differing agendasHidden’ or differing agendas

Prior difficult meetingsPrior difficult meetings

Lack of trustLack of trust

Consultation Models-Pendleton Consultation Models-Pendleton TasksTasks

To define the reasons for the patient's attendance including: To define the reasons for the patient's attendance including:

the nature and history of the problem the nature and history of the problem their causetheir causethe patient's ideas, concerns and expectations the patient's ideas, concerns and expectations the effects of the problem the effects of the problem

To consider other problems: To consider other problems:

continuing problems continuing problems risk factors risk factors

To choose with the patients an appropriate action form each problem To choose with the patients an appropriate action form each problem

To achieve a shared understanding of the problems with the patient To achieve a shared understanding of the problems with the patient

To involve the patient in the management plan and encourage him to accept appropriate To involve the patient in the management plan and encourage him to accept appropriate responsibility responsibility

To use time and resources appropriately To use time and resources appropriately

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

Pendleton’s Tasks: Defining the Pendleton’s Tasks: Defining the reason for the patient’s attendancereason for the patient’s attendance

Example: 55 year-old female teacher who Example: 55 year-old female teacher who presents with headache and tirednesspresents with headache and tiredness– The nature and history of the problemThe nature and history of the problem

She reports waking up extra early in the mornings over the She reports waking up extra early in the mornings over the past three weeks. She is irritable, and her teenage children past three weeks. She is irritable, and her teenage children easily annoy her. She cries often. She still engages in easily annoy her. She cries often. She still engages in sexual activity with her husband but wishes he would leave sexual activity with her husband but wishes he would leave her alone. She questions whether her students are her alone. She questions whether her students are benefiting from her classes although she admits to trying benefiting from her classes although she admits to trying hard. hard.


AetiologyAetiology

She says her 18 year old son was involved She says her 18 year old son was involved in a motor cycle accident. This is the third in a motor cycle accident. This is the third in one year. Previously he suffered light in one year. Previously he suffered light bruises. This time he was severely bruises. This time he was severely battered and to quote her, “thank God, the battered and to quote her, “thank God, the bike was totally destroyed and he escaped bike was totally destroyed and he escaped with his life.”with his life.”


The effect of the Problem;The effect of the Problem;– Her concerned husband urged her to visit the Her concerned husband urged her to visit the

doctor because she is obviously distraught doctor because she is obviously distraught and not looking well. Her children too feel she and not looking well. Her children too feel she is over-reacting and her usually worrisome is over-reacting and her usually worrisome nature has worsened.nature has worsened.


Her ideasHer ideas– She feels her symptoms are due to her She feels her symptoms are due to her

constant worrying. She admits that her constant worrying. She admits that her mother was an incorrigible worrier and she mother was an incorrigible worrier and she has acquired the same nature. She feels has acquired the same nature. She feels helpless to change her thought patterns.helpless to change her thought patterns.

Pendleton’s Tasks: Defining the Pendleton’s Tasks: Defining the reason for the patient’s attendancereason for the patient’s attendanceHer ConcernsHer Concerns

- She feels depressed. Worse, she says, “I - She feels depressed. Worse, she says, “I feel I’m going out of my mind”. She knows feel I’m going out of my mind”. She knows this is affecting her relationship with her this is affecting her relationship with her husband, and is making her job husband, and is making her job intolerable. She is particularly concerned intolerable. She is particularly concerned that she will be unable to complete the that she will be unable to complete the required 33 1/3 years needed to get required 33 1/3 years needed to get retirement benefits.retirement benefits.


Her ExpectationsHer Expectations

- She wants the doctor to give her - She wants the doctor to give her medication to treat her depression and medication to treat her depression and help her to sleep. She came prepared to help her to sleep. She came prepared to reject any referral to a psychiatrist.reject any referral to a psychiatrist.


Description of Events Occurring in a Consultation (after Byrne Description of Events Occurring in a Consultation (after Byrne & Long 1976)& Long 1976)

Six phases that form a logical structure to the Six phases that form a logical structure to the consultation:consultation:

– The doctor establishes a relationship with the patient The doctor establishes a relationship with the patient – The doctor either attempts to discover, or actually discovers, the reason The doctor either attempts to discover, or actually discovers, the reason

for the patient's attendance for the patient's attendance – The doctor conducts a verbal or physical examination, or both The doctor conducts a verbal or physical examination, or both – The doctor, or the doctor and the patient together, or the patient along The doctor, or the doctor and the patient together, or the patient along

(usually in that order of probability) consider(s) the condition (usually in that order of probability) consider(s) the condition – The doctor, and occasionally the patient, details treatment or further The doctor, and occasionally the patient, details treatment or further

investigation investigation – The consultation is terminated - usually by the doctor The consultation is terminated - usually by the doctor


NeighbourNeighbour A: Connecting: “Have we got a rapport?”A: Connecting: “Have we got a rapport?”B: Summarizing (Clinical Process): “Can I B: Summarizing (Clinical Process): “Can I demonstrate to the patient I have understood demonstrate to the patient I have understood why she has come?”why she has come?”C: Handing Over: “Has the patient accepted the C: Handing Over: “Has the patient accepted the management plan we agreed?”management plan we agreed?”D: Safety-Netting: “Have I anticipated all likely D: Safety-Netting: “Have I anticipated all likely outcomes?”outcomes?”E: Housekeeping: “Am I in good condition for the E: Housekeeping: “Am I in good condition for the next patient?”next patient?”


The Patient Centered Clinical Model:The Patient Centered Clinical Model:-describes specific behaviors necessary to develop an -describes specific behaviors necessary to develop an effective clinical method effective clinical method -physicians as well as patients needs are satisfied-physicians as well as patients needs are satisfiedThe six integrated components of the patient-centered The six integrated components of the patient-centered process: process: – Exploring both the disease and the illness experience Exploring both the disease and the illness experience – Understanding the whole person Understanding the whole person – Finding common ground regarding management Finding common ground regarding management – Incorporating prevention and health promotion Incorporating prevention and health promotion – Enhancing the patient-doctor relationship Enhancing the patient-doctor relationship – Being realistic Being realistic

Patient Centered ModelPatient Centered Model

Exploring the disease and Illness Exploring the disease and Illness ExperienceExperience– Explores signs and symptoms of disease to Explores signs and symptoms of disease to

formulate a differential diagnosisformulate a differential diagnosis– ‘‘Steeps’ the physician in the experience of Steeps’ the physician in the experience of

patients to understand illness from their point patients to understand illness from their point of viewof view

Exploring the disease and illness Exploring the disease and illness experienceexperience

KnowledgeKnowledge– Knowledge of common diseases; differential diagnosisKnowledge of common diseases; differential diagnosis– Understanding why we focus on organic manifestations of Understanding why we focus on organic manifestations of

sickness; practical understanding of the distinction between sickness; practical understanding of the distinction between disease and illness (ideas, feelings, expectations) disease and illness (ideas, feelings, expectations)

SkillsSkills– Open-ended questionsOpen-ended questions– Avoid behavior that cuts off patients telling their storyAvoid behavior that cuts off patients telling their story– Elicit patients’ experience of illness; pay attention to feelings and Elicit patients’ experience of illness; pay attention to feelings and

respond appropriatelyrespond appropriately– Perform physical examinationPerform physical examination

AttitudesAttitudes– Willingness to become totally involvedWillingness to become totally involved

Understanding the whole personUnderstanding the whole person

Knowledge:Knowledge:– Understand the human condition, esp. the nature of suffering Understand the human condition, esp. the nature of suffering

and response to sicknessand response to sickness– The ‘person’ (life history and personal developmental issues)The ‘person’ (life history and personal developmental issues)

Skills:Skills:– The context (the family and anyone else involved in or affected The context (the family and anyone else involved in or affected

by the patients’ illness; the physical environment)by the patients’ illness; the physical environment)

Attitude:Attitude:– Respect for the fundamental worth of all personsRespect for the fundamental worth of all persons– Shows respect for the cultural values of all ethnic groupsShows respect for the cultural values of all ethnic groups

Finding Common GroundFinding Common Ground

Knowledge:Knowledge:– Know scientific treatment of diseasesKnow scientific treatment of diseases– Awareness of patient autonomy and issues affecting patient Awareness of patient autonomy and issues affecting patient

compliancecompliance

Skills:Skills:– Use conventional methods of treatment for problems; PrioritizeUse conventional methods of treatment for problems; Prioritize– Empower patients to take an active role in their careEmpower patients to take an active role in their care– Resolve conflictsResolve conflicts

AttitudeAttitude– Willingness to collaborate with patients about management Willingness to collaborate with patients about management – Awareness of personal values and cultural differencesAwareness of personal values and cultural differences

Incorporating Prevention and Incorporating Prevention and Health PromotionHealth Promotion

Knowledge:Knowledge:– Practical understanding of continuity, comprehensive carePractical understanding of continuity, comprehensive care– Effective screening and preventive strategies; Risk reductionEffective screening and preventive strategies; Risk reduction

Skills:Skills:– Collaborate with patients to develop lifelong policies for health Collaborate with patients to develop lifelong policies for health

promotion and disease preventivepromotion and disease preventive– Enhance patients self-esteem and self-confidence in caring for Enhance patients self-esteem and self-confidence in caring for

themselvesthemselves

Attitudes:Attitudes:– Interest in all three stages of preventionInterest in all three stages of prevention– Invests time and energy to incorporate screening, prevention Invests time and energy to incorporate screening, prevention

and health promotionand health promotion

Enhancing the patient-doctor Enhancing the patient-doctor relationshiprelationship

Knowledge:Knowledge:– Awareness of emotional reactions to patientsAwareness of emotional reactions to patients– Understand basic factors underlying an effective patient-doctor Understand basic factors underlying an effective patient-doctor

relationshiprelationship– Working knowledge of transference and counter-transferenceWorking knowledge of transference and counter-transference

Skills:Skills:– Communicate effectively verbally nonverballyCommunicate effectively verbally nonverbally– Creates a sense of security and comfort; caring and healing Creates a sense of security and comfort; caring and healing

relationship relationship

Attitudes:Attitudes:– Willingness to step into open-ended relationships with patientsWillingness to step into open-ended relationships with patients– Exhibits long-term commitment to the well-being of patients Exhibits long-term commitment to the well-being of patients

Being RealisticBeing Realistic

Knowledge:Knowledge:– Awareness of community resourcesAwareness of community resources– Understand the severe limitations of medicineUnderstand the severe limitations of medicine– Understand the task of medicineUnderstand the task of medicine

Skills:Skills:– Organize time effectively and efficiently Organize time effectively and efficiently – Zero in on the heart of the problemZero in on the heart of the problem– Set reasonable goals and prioritiesSet reasonable goals and priorities– Use follow up effectivelyUse follow up effectively

Attitudes:Attitudes:– Awareness of personal limitationsAwareness of personal limitations– Willingness to ask for helpWillingness to ask for help

Disease-Illness ModelDisease-Illness Model

Integrates the clinical or biophysical content with Integrates the clinical or biophysical content with an understanding for what symptoms mean to an understanding for what symptoms mean to the patient within their own “life-world”the patient within their own “life-world”Disease Framework – The doctors agendaDisease Framework – The doctors agenda– HistoryHistory– Physical examinationPhysical examination– InvestigationsInvestigations

Illness Framework – The patients agenda Illness Framework – The patients agenda – Patients’ ideas , expectations, feelingsPatients’ ideas , expectations, feelings– Effect on functionEffect on function– Understand patient’s unique experience of illnessUnderstand patient’s unique experience of illness

Date post:	14-Nov-2014
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Consultation Models 2

Health & Medicine