Medical Constructs and Grids To help you with the consultation Dr Ramesh Mehay, www.bradfordvts.co.uk

Consultation Models Byrne & Long Doctor – Patient Relationship Pendleton Define reason for attendance (patient’s ideas/concerns/expectations) Consider other problems Choose appropriate action for each problem Achieve shared understanding Involve patient/accept responsibility Use time/resources appropriately Establish/maintain relationship with patient Neighbour Connecting Summarising Handing Over Safety Netting Housekeeping Byrne & Long Doctor – Patient Relationship Discover reason for attendance Verbal/Physical Examination Doctor/Patient consider condition Doctor/Patient consider Treatment/Investigation Close consultation Stott & Davis Management of presenting problems Management of continuing problems Modification of help-seeking behaviour Opportunistic health promotion

The Clinical Method “HEIMR” “HEIRS” SOAP Hx (History) Ex (Examination) Ix (Investigation) Mx (Management) Rx (Prescribe) “HEIRS” History Examination Investigation Referral See again? SOAP Subjective Objective Assessment Plan

Considering Health & Disease Normal Range Patterns of Illness Natural History Prevention Early Diagnosis Diagnostic skills/techniques Management/Treatment

Child Development: PIE Physical Intellectual Emotional What is the normal range?

Considering the Illness: PP-SOF Always answer in terms of: Physical Psychological Social Occupational Family/Community Note: Disease = the specific medical condition a person has e.g. Osteoarthritis Illness = the impact of the disease on the person’s life eg not able to work, do stairs, go out, family has to help mobilise, husband is carer now, not working hence money problems, now also depressed, and so on.

Considering Human Behaviour Behaviour presenting to Doctor Behaviour in Relationships Behaviour in Family Behaviour in Doctor-Patient Relationship

The Doctor’s & Patient’s feelings Awareness Have your awareness levels just been raised? Has the patient’s awareness levels just been raised? Have either of you just had a moment of enlightenment? (Balint’s ‘flash’ moment) Power Are you feeling intimidated by the patient? Is the patient feeling intimidated by you? Anger Are you feeling angry with the patient – something they’ve said, done or doing? Is the patient feeling angry with something you have said, done or doing? Guilt Are you feeling guilty about something you wish you had done for the patient? Has the patient got guilt issues that need exploring? Stressed/Overwhelmed Do you feel stressed or overwhelmed by all the problems and woes the patient is telling you? Are they emotionally vomiting all over you? Is the patient feeling stressed, coerced or overwhelmed with what you are saying to them? Conflicts Is there a conflict between your agenda and the patient’s agenda? How do you resolve that conflict? Consider what both you and the patient are feeling in the consultation. It helps you step back a little and decide whether your approach is being affected by your feelings or the patient’s feelings. Consider sharing how the patient or consultation discussion is making you feel with the patient. Raising the patient’s awareness of how they make people feel might be therapeutic in itself.

Dealing with Anger: AFVER Avoid Confrontation Facilitate Discussion Ventilate Feelings Explore Reasons Refer/Investigate

Management Options – RAPRIOP Reassure Advice Prescribe Refer Investigate Observe (Preventative)

The Patient’s request You can either… Agree Disagree Negotiate

Breaking Bad News: “A KISS” Anxiety: try to elicit anxieties Knowledge: try to elicit knowledge Information: give information simply re treatment, prognosis, follow up Sympathy: give human contact (touch) Support: give practical help

Ethical problems Deontological (individuals) Ethical dilemmas usually present a conflict in terms of the individual patient’s rights (deontology) versus doing the ‘greatest good’ for society (utility). In one ethical scenario, you may feel more utilitarian than deontological and vice versa in another! Deontological (individuals) doing the right thing for the individual based on the duties of the doctor and the rights of the patient (and, of course, vice versa). That every patient is an individual human and every human has an equal human right irrespective of differences. Utilitarianism/Utility (populations) doing the right thing for the population examines moral dilemmas to make decisions based on outcomes; i.e. “the greatest good for the greatest number”

Ethical solutions: ABCDEF Autonomy Respect the patient’s right to determine their own destiny Every person is equal to each other – irrespective of differences. Beneficence “above all, do no harm” (non-maleficence) “do good where possible” (beneficence) Confidentiality & Consent May need contextual consideration Do not lie Be truthful and honest Don’t lie on the behalf of others Everybody else (i.e. Society) Principle of Utilitarianism Weigh up: doing the greatest good for the greatest number vs individual patient’s right. Fair Be fair (justice) Do the right thing (Aristotle’s principle of morality)

Considering Implications of something for the Practice This could be anything – a new service, new protocol, a doctor wanting to do a sabbatical, a practice nurse wanting to do a diploma etc. Staff groups Consider each of doctors, nurses, admin & others The work involved Maintaining quality/review Patients (effect on them) Finance Premises & Equipment Medico legal issues

Situation Problems Advantages Disadvantages Applied to: Doctor Patient Practice PHC Team Relatives Community Healthcare General Public