Skills and Models for Consultation in Family Practice Dr. Riaz Qureshi Distinguished Professor Department of Family & Community Medicine King Saud University, Riyadh

Objectives To understand why consultation skills are important in Family Practice To discover, why communication skills development is essential in consultation To learn the essential features of a consultation in Family Practice To become familiar with consultation models in Family Practice

Consultation Skills Family Physicians often need to be bearers of the worst imaginable news They have to arrange complex and often uncertain information into something understandable They have to respond to differing needs of a hugely diverse range of patients and their families And they have to do much of this when they are busy and under pressure

Consultation Skills (Silverman et al. 1998) If a joint management plan, which the patient understands, feels comfortable with, and is prepared to adhere to, is not made: the patient is not likely to follow it and all our efforts in assessment and diagnosis are wasted (Silverman et al. 1998)

The Evidence Base Individual Consultation: For the doctor it is one of many routine encounters, something to be got through as fast as possible . But for the patient it may be the most important – and stressful – aspect of their week….or the last six months, as they wait anxiously for the appointment and their chance to see the doctor…… ” (Dr Julie Draper, an unpublished quote, Cambridge University Medical Training Workshop, December 2001)

The Evidence Base 54% of patient’s problems & concerns not elicited (Stewart et al, 1979) Doctors frequently interrupt their patients soon after their opening statement (mean time 18 seconds) so patients subsequently failed to disclose significant history points (Beckman and Frankel, 1984) Failing to discover the patients ideas, concerns & expectations (ICE) led to dysfunctional consultations (Byrne and Long, 1976)

Deficiencies in Communication Doctors may not obtain enough information about patients’ perspective Provide information in inflexible way Pay little attention in checking how well patients have understood Less than half of patients’ psychological morbidity is recognized

Blocking Behavior Offering advice and reassurance before the main problems have been identified Explaining away distress as normal Attending to physical aspects only Switching the topic “Jollying” patients along

Reasons for patients not disclosing problem Belief that nothing can be done Reluctance to burden the Doctor Desire not to appear pathetic or ungrateful Concern that it is not legitimate to mention them Doctors’ blocking behavior Worry that their fears about what is wrong with them will be confirmed Lack of confidentiality and trust

What is a failed consultation? No rapport Using medical jargon Not exploring the patients agenda Not eliciting relevant symptoms and signs No contingency plan(safety netting ) No summarization Failing to clarify and involving the patient Not exploring in socio-cultural & economic context

Problems in Communication: Limitations in our settings Shortage of time Language barrier – low literacy Firm misconceptions and myths Lack of awareness Not ready to take responsibility for his illness Socio-cultural, economic barriers Fatalistic attitude (It’s God’s will)

Barriers to Communication in Clinical Practice Personal Barriers Lack of training: undergraduate/postgraduate Undervaluing importance of communication Focus only on treating diseases Personal Limitations Organizational Barriers Lack of time Pressure of work Interruptions

Why Consultation Skills? When doctors use consultation skills effectively: Patients’ problems identified more accurately Patients more satisfied with their care Patients more likely to comply with treatment Patients’ distress & vulnerability to anxiety & depression are lessened

Why Consultation Skills? When doctors use consultation skills effectively Doctors’ well-being is improved Few clinical errors are made Patients are less likely to complain Reduced likelihood of doctors being sued Good communication is good for doctors good for patients and good for the health service

Consultation Models The Medical Model: Traditional model. History taking  Examination  Investigation  Diagnosis  Treatment  Follow-up. Does not recognize the complexity and diversity of the consultation in Family Practice.

Balint, 1957: The Doctor. His patient and The Illness----a philosophy rather than a consultation model. Psychological problems are often manifested physically. Doctors have feelings. Those feelings have a role in the consultation. Doctors need to be trained to be more sensitive to what is going on in the patient’s mind during a consultation. Reference: Churchill Livingstone (2000) ISBN:0443064601

Berne, 1964: Games People Play---describes how to recognize behaviours (‘games’) patients might use and roles patient and doctor might adopt—’Patient, Adult and Child’. Reference: Penguin Books (2004) ISBN:0140027688

Byrne and Long, 1976 Doctors Talking to Patients---6 aspects: Doctor establishes a relationship with the patient. Doctor attempts to/actually discover the reason for attendance. Doctor conducts verbal + physical examination. Doctor or doctor + patient or the patient consider the condition. Doctor (occasionally the patient) detail treatment and investigation. Consultation is terminated—usually by the doctor. Reference: RCGP (1984) ISBN:0850840929

RCGP, 1976: The consultation can be divided into ‘physical, psychological, and social’ aspects i.e. in general practice doctors should address emotional, family, social, and environmental factors in addition to the traditional ‘organic’ medical approach. Reference: JRCGP (1977) 27:117

Stott and Davis Model, 1979: Management of presenting problems. ‘Exceptional potential of the consultation’. 4 tasks: Management of presenting problems. Management of continuing problems. Modification of help-seeking behavior. Opportunistic health promotion. Reference: JRCGP (1979) 29:201-5

Pendleton et al, 1984: The doctor’s tasks: Define the reason for patient’s attendance – Presenting problem. Consider other problems (continuing problems and at-risk factors). Choose an appropriate action for each problem (involves negotiation between doctor and patient). Achieve a shared understanding of the problem (doctor and patient).

Pendleton et al, 1984: Cont’d Involve the patient in the management and encourage the patient to accept appropriate responsibility. Use time and resources appropriately. Establish and maintain a relationship between doctor and patient. Reference: The New Consultation. Oxford University Press (2003) ISBN:0192632884

Neighbour, 1987: The Inner Consultation Checkpoints: Connecting (doctor establishes rapport with the patient). Summarizing (doctor clarifies the patient’s reasons for consulting) Handing over (doctor and patient negotiate and agree a management plan). Safety netting (doctor and patient plan for the unexpected---managing uncertainty). Housekeeping (doctor is aware of his/her own emotions). Reference: Petroc Press (1999) ISBN:1900603675

Fraser, 1992: Areas of competence: Interviewing and history taking. Physical examination. Diagnosis and problem solving Patient management. Relating to patients. Anticipatory care Record keeping. Reference: Clinical Method: A general practice approach. Butterworth Heinemann (1999) ISBN:0750640057

Moving from open to closed questioning The Open-to-Closed Cone Open ended questions to explore the field Mid-way questions – directional statements Closed questions – used following information gathering to focus in

Outcome Explanation Planning Illness Framework Disease Framework Doctors agenda Patients agenda Foundation Meeting + greeting Developing rapport An architectural model of consultation

Interventional Styles John Heron Authoritarian informative prescriptive confronting Facilitative supportive cathartic catalytic

Breaking Bad News The ABCDE Mnemonic for Breaking Bad News Arrange for adequate time, privacy and no interruptions (turn off Pager/phone or to silent mode) Review relevant clinical information Mentally rehearse, identify words or phrases to use and avoid Prepare yourself emotionally Have family or support persons present Advance preparation Build a therapeutic relationship Communicate well Deal with patient & family reactions Encourage and validate emotions Introduce yourself to everyone Build rapport Use touch when appropriate Schedule follow-up appointments Ask what the patient or family already knows. Determine what & how much the patient wants to know. Warn the patient that bad news is coming. Proceed at the patient’s pace. Avoid medical jargon. Allow time to answer questions Conclude each visit with a summary and follow-up plan Assess and respond to the patient and the family’s emotional reaction Be empathetic. Do not argue with or criticize colleagues. Explore what the news means to the patient. Offer realistic hope according to the patient’s goals. Use interdisciplinary resources. Take care of your own needs; be attuned to the needs of involved house staff and office or hospital personnel.

Dealing with Anger It is the patient who is angry, not you! Do not leave the anger unexplored Be supportive to your staff

Dealing with Anger Handling patient confrontations: Explore the anger towards the end of the consultation. Recognize your weaknesses Verbal Communication Techniques: Wish I could Agree in principle Broken record Nonverbal communications

Consultation Duration Longer consultations result in lesser prescription of drugs and more patient satisfaction.

Essentials of Consultation Meeting & greeting History with good eye contact Starting with open ended questions Patient- centered approach –let the patient talk Summarizing & ICE Relevant exam & investigations (if needed) Patient involvement in management Safety- netting & follow up

CONCULSION The traditional medical model does not recognize the complexity and diversity of the consultation in family practice. The models proposed for consultation in family practice are many. Each views the process from a slightly different perspective. The consultation model should match the individual needs of the patients and doctors.

Thank You