Consultation ModelsRamesh Mehay

Course Organiser, Bradford

Adapted from Neighbour’s “The Inner Consultation”

Aims n ObjectivesAims n Objectives

Aims Aims to introduce GPRs to several types of consultation to introduce GPRs to several types of consultation

models and how to integrate them into practicemodels and how to integrate them into practice

ObjectivesObjectives Why all this talk of modelsWhy all this talk of models What’s the point of making models of the consultationWhat’s the point of making models of the consultation What types of model there are What types of model there are What use is a model when you’ve made itWhat use is a model when you’ve made it

What are consultation skillsWhat are consultation skills

ThinkThink Behaviours that result in desired outcomesBehaviours that result in desired outcomes There are many behaviours that can result in the same There are many behaviours that can result in the same

outcome just like…….outcome just like……. There are many ways to skin a cat!There are many ways to skin a cat!

ModelsModels

Models are all around usModels are all around us Can you think of any? Life or Medical?Can you think of any? Life or Medical?

ChildhoodChildhood LanguageLanguage RecipesRecipes LogicLogic

Medical ModelMedical Model

So Why are Models so Important?So Why are Models so Important?

Patients don’t function simply as machinesPatients don’t function simply as machines They have feelings tooThey have feelings too

Doctors don’t function simply as machinesDoctors don’t function simply as machines They have feelings tooThey have feelings too

Every presenting complaint can be placed in a psycho-Every presenting complaint can be placed in a psycho-social context (RCGP)social context (RCGP)

Purpose of ALL modelsPurpose of ALL models

They make sense of sensationThey make sense of sensation

They help people toThey help people to UnderstandUnderstand Predict andPredict and ControlControl

Essential for mastering consultation skillsEssential for mastering consultation skills

what happens to them

THE MODELSTHE MODELS Tell the group an interesting Dr-patient story.Tell the group an interesting Dr-patient story. Now let’s try and apply a model to itNow let’s try and apply a model to it

Are there bits of the model you coveredAre there bits of the model you covered Are there bits of the model you did not cover but may Are there bits of the model you did not cover but may

have helped the consultation if you did?have helped the consultation if you did?

But let’s look at the old consultation model firstBut let’s look at the old consultation model first

The Old Consulting ModelThe Old Consulting Model

PatientPatient Patient accepts, respects and leaves Patient accepts, respects and leaves

Enters sick roleEnters sick role Dr advises Dr advises

(often in high class English)(often in high class English)

Enters surgeryEnters surgery Patient makes gifts Patient makes gifts

Ticket of admission Ticket of admission Dr rations his skill & Dr rations his skill & attentionattention

Temporarily hands over care to the DoctorTemporarily hands over care to the DoctorCLOTHED DOCTOR, NAKED PATIENTACTIVE DOCTOR, PASSIVE PATIENT

Classification of ModelsClassification of Models

Patient centred

Doctor centred

Behaviour orientated

Task orientated

Physical, Psych, SocialStott & DavisByrne & LongPendleton et al

HelmanHealth Belief Model

Byrne & Long (I)6-Category AnalysisTransactional Analysis

CounsellingBendixBalint

Michael Balint (1957)Michael Balint (1957)

““The Doctor, the patient and their illness” The Doctor, the patient and their illness” Physical, Psychological, Social AspectsPhysical, Psychological, Social Aspects Doctor’s apostolic functionDoctor’s apostolic function Entry ticketEntry ticket Hidden agendaHidden agenda Doctors have feelingsDoctors have feelings Collusion of anonymityCollusion of anonymity The “drug doctor”The “drug doctor”

Focusses on the doctor / patient relationshipFocusses on the doctor / patient relationship

J Spence (1960)J Spence (1960)

The Purpose & Practice of MedicineThe Purpose & Practice of Medicine Places the consultation at the heart of good practicePlaces the consultation at the heart of good practice

The RCGP (1972)The RCGP (1972)

The Future General Practitioner, Learning & TeachingThe Future General Practitioner, Learning & Teaching

Physical, Psychological & SocialPhysical, Psychological & Social Traditional consultation model: Active / PassiveTraditional consultation model: Active / Passive Hypothetico-deductive modelHypothetico-deductive model Holistic Model of the ConsultationHolistic Model of the Consultation

John Heron (1975)John Heron (1975)

Six Category Intervention analysisSix Category Intervention analysisInterventions can be: Interventions can be:

1 Prescriptive1 Prescriptive

2 Informative2 Informative

3 Confronting 3 Confronting

4 Cathartic 4 Cathartic

5 Catalytic 5 Catalytic

6 Supportive 6 Supportive

Authoritative

Facilitative

Eric Berne (1976)Eric Berne (1976)

Games People PlayGames People PlayTransactional analysisTransactional analysisParent, Adult, Child rolesParent, Adult, Child rolesThe Adult / Adult goalThe Adult / Adult goal

Byrne and Long (1976)Byrne and Long (1976)

Doctors Talking to PatientsDoctors Talking to Patients

Sequence of events in a consultation:Sequence of events in a consultation:

1.1. Establishing a relationshipEstablishing a relationship

2.2. Why has the patient comeWhy has the patient come

3.3. Verbal and/or physical examinationVerbal and/or physical examination

4.4. Considering the conditionConsidering the condition

5.5. Further investigation or treatmentFurther investigation or treatment

6.6. TerminationTermination

Stott & Davies (1979)Stott & Davies (1979)

The potential of each primary care consultationThe potential of each primary care consultation

1.1. The management of the presenting problemThe management of the presenting problem

2.2. Modification of help seeking behaviourModification of help seeking behaviour

3.3. Management of continuing problemsManagement of continuing problems

4.4. Opportunistic health promotionOpportunistic health promotion

Pendleton (1984)Pendleton (1984)

The consultation, an approach to learning and teachingThe consultation, an approach to learning and teaching11 Define the reasons for the patient’s attendanceDefine the reasons for the patient’s attendance22 Consider other problemsConsider other problems33 With the patient, choose an appropriate solution to With the patient, choose an appropriate solution to

each problemeach problem44 Achieve a shared understanding of the problemsAchieve a shared understanding of the problems55 Involve the patient in the management and encourage Involve the patient in the management and encourage

the patient to take responsibilitythe patient to take responsibility66 Use time and resources appropriatelyUse time and resources appropriately77 Establish or maintain the doctor patient relationshipEstablish or maintain the doctor patient relationship

Roger Neighbour (1987)Roger Neighbour (1987)

The Inner ConsultationThe Inner Consultation A journey with five checkpointsA journey with five checkpoints

11 ConnectingConnecting22 SummarisingSummarising33 Handing overHanding over4 Safety Netting4 Safety Netting5 House Keeping5 House Keeping

Housekeeping and safety netting are his original Housekeeping and safety netting are his original contributionscontributions

Lesser & Gask (1991)Lesser & Gask (1991)

Problem Based InterviewingProblem Based InterviewingEmphasises the detection of psycho-social distressEmphasises the detection of psycho-social distressProblem detection skills;Problem detection skills; Beginning the interviewBeginning the interview Picking up verbal cuesPicking up verbal cues Responding to verbal cuesResponding to verbal cues Picking up non-verbal cuesPicking up non-verbal cues Responding to non-verbal cuesResponding to non-verbal cues Demonstrating empathyDemonstrating empathy Exploring health beliefsExploring health beliefs Controlling the pace of the interviewControlling the pace of the interview

Lesser & GaskLesser & Gask

Problem management skills:Problem management skills: Allowing the patient to ventilateAllowing the patient to ventilate Negotiating with the patient to initiate changeNegotiating with the patient to initiate change Problem solving(like directive counselling)Problem solving(like directive counselling) Re-atrributingRe-atrributing Giving informationGiving information Special skills(special therapies)Special skills(special therapies)

Peter Tate (1994)Peter Tate (1994)

The Doctors Communication HandbookThe Doctors Communication Handbook

11 Discovery the reason for the patients attendanceDiscovery the reason for the patients attendance

2 2 Define the clinical problemDefine the clinical problem

33 Explain the problem to the patientExplain the problem to the patient

44 Explain the problems to the patientExplain the problems to the patient

55 Make effective use of the consultationMake effective use of the consultation

Calgary Cambridge - Silverman et Calgary Cambridge - Silverman et al (1988)al (1988)

5 Check Points5 Check Points

Helman’s ‘folk’ model (1981)Helman’s ‘folk’ model (1981)

Disease vs Illness in General PracticeDisease vs Illness in General Practice

A Patient comes to the Dr. seeking answers to 6 questionsA Patient comes to the Dr. seeking answers to 6 questions

1.1. What has happened?What has happened?2.2. Why has it happened?Why has it happened?3.3. Why to me?Why to me?4.4. Why now?Why now?5.5. What would happen if nothing were done about it?What would happen if nothing were done about it?6.6. What should I do about it or whom should I consult for What should I do about it or whom should I consult for

further help?further help?

Health Belief Model – Becker & Health Belief Model – Becker & Maiman (1975)Maiman (1975)

IdeasIdeas Concerns Concerns ExpectationsExpectations

““ICE”ICE”

Bendix (1982)Bendix (1982)

The Anxious PatientThe Anxious PatientNon-directive counsellingNon-directive counselling

SummarySummary Consultation models help us to decide what to do and Consultation models help us to decide what to do and

how to do ithow to do it There are so many models – confusing or adding There are so many models – confusing or adding

richness?richness? Try and read a couple of consultation booksTry and read a couple of consultation books The aim is to develop your own styleThe aim is to develop your own style Keep your model simpleKeep your model simple And…………make sure you can do something with itAnd…………make sure you can do something with it You may wish to use different models for different You may wish to use different models for different

situations eg Kayes Model for Breaking Bad Newssituations eg Kayes Model for Breaking Bad News

Highly RecommendedHighly Recommended

The Inner Consultation – Roger NeighbourThe Inner Consultation – Roger Neighbour The Dr-Pt Communication Handbook – Peter TateThe Dr-Pt Communication Handbook – Peter Tate SilvermanSilverman