1. THE CONSULTATION

2. OBJECTIVES:  Use different ways of communication skills which encourage patients’ participations in consultation by mastering the following skills: Establish eye contact Start with open-ended question and move to closed questions appropriately. Encourage patients with appropriate questioning Use "active listening" Use of silence appropriately

3. OBJECTIVES: Explore patient's idea, concern and expectation. Summarize information & check understanding Properly, inform patients about treatment options by discussing possible implication and checking if they want to be involved in decisions. Emphasize on the importance of following the agreed decisions about treatment and lifestyles. Use sympathy & empathy in appropriate ways. Apply Stott & Davis/Pendleton & Roger Neighbour models of consultation.

4. THE CONSULTATION Content: * Introduction ( a case) *Consultation skills *Decision of consultation *Model of consultation -Stott & Davis -Roger Neighbour -Pendleton * Improving consultation skills

5. DEFINITION

6. The occasion when, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trust. (Wright & Macadam)

7. DEFINITION It is a goal-seeking activity in which the goals of one party may or may not be clear to other party. (Byrne & Long)

8. CONSULTATION IN PHC Vs. CONSULTATION IN HOSPITAL

9. Sara is 38 years old lady, complaining of 2 weeks history of headache. How are you going to conduct this consultation?

10.  HISTORY PRESENTING COMPLAIN SYSTEMATIC REVIEW  EXAMINATION  INVESTIGATION  DIAGNOSIS  TREATMENT  FOLLOW-UP A case of 2 weeks headache Computerized Checklist of history Taking. HOSPITAL MODEL OF CONSULTATION (BIO – MEDICAL MODEL)

11. CHARACTERISTICS OF HOSPITAL MODEL  It is doctor centred and disease oriented.  A diagnosis must be arrived at "objectively" before treatment.  It takes long time  No consideration of the psychosocial dimensions explanation, health education, health promotion and treatment by reassurance

12. PHC Model of Consultation ( Bio-psychological Model )

13. Sara is 38 years old lady, divorced 2 weeks ago, looking after 5 children by herself, complaining of 2 weeks history of headache  Speculate how Sara think about her illness?  Her ideas???  Her concerns???  Her expectations???  The effect of the problem in her life??? What is most likely the diagnosis???

14. CHARACTERISTICS OF PHC CONSULTATION MODEL Patient – centred Holistic approach (Bio-psycho – social) Prevention & Health education Treatment by reassurance Appropriate use of time & resources

15. CONSULTATION SKILLS *Interviewing skills *History taking skills *Physical examination skills *Problem-solving skills

16. What people do about their symptoms?

18. WHY PTS. CONSULT THEIR DOCTORS? Symptoms of illness perceived by patient Nature of symptoms AnxietyPersonality of patient, anxiety, housing, environment stress Attempts to resolve anxiety Education, Family and community support Decision to consultHealth beliefs, expectation of doctor, Accessibility (appointment system, receptionists, etc) Consultation Factors influencing the decision to consult a doctor

20. MODELS OF CONSULTATION

21. MODELS OF CONSULTATION 1-STOTT & DAVIS 2- PENDLETON 3-ROGER NEIGHBOUR

22. STOTT AND DAVIS AC Management of presenting Modification of help-seeking problems behaviors BD Management of continuing Problems Opportunistic health promotion

23. NEIGHBOUR’S 5 CHECKPOINTS (Roger Neighbour “The Inner Consultation”) 1.CONNECTING. 2.SUMMARISING. 3.HANDING OVER. 4.SAFETY NETTING. 5.HOUSEKEEPING.

24. NEIGHBOUR’S 5 CHECKPOINTS 1.CONNECTING. Achieving rapport & empathy. 2.SUMMARISING. Demonstrate to patient you understand why he’s come, hopes, feeling, concerns & expectations. 3.HANDING OVER. Has the patient accepted the management plan we have agreed? Negotiating, influencing & gift-wrapping.

25. “THE INNER CONSULTATION” (CONTINUED) 4.SAFETY NETTING. Predicting what could happen – what if? Or have I anticipated all likely outcomes? 5.HOUSEKEEPING. Clearance of any emotional responses to patients we have seen or to those we are about to see. Am I in good condition for the next patient.

26. PENDLETON’S MODEL

27. Seven Tasks: 1. The define the reasons for the Patient’s attendance, including: (i) The nature and history of the problems; (ii) Their aetiology; (iii) The Patient’s ideas, concerns & expectations; (iv)The effects of the problems. 2.To consider other problems: (I) Continuing problems; (ii)At risk factors.

28. 3. To choose with the Patient. 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. 7. To establish or maintain a relationship with the Patient which helps to achieve the other tasks.

30. IMPROVING CONSULTATION SKILLS

31. *Constant Learning and Practice * Feed Back: -Self monitoring/Peer review -Audio-visual technique -Role play

32. DYSFUNCTIONAL CONSULTATION

33. SIGNS OF DYSFUNCTIONAL CONSULTATION  Poor reputation among patients  Upset patients or doctors  Increasing complaints  Increasing critical events  Reduced job satisfaction

34. PATIENT FACTORS Hearing or linguistic difficulties Upset patients Psychiatric illness Loss of faith in the doctor (poor reputation, adverse incident etc) Patients that ‘violate’ the doctors values e.g. drug misusers or alcoholics Problem Patients

35. DOCTOR FACTORS:  Attitudes – a doctor centred consulter, burnt out depersonalisation, angry, defensive, ‘over caring’- always wanting to be liked or hard-line doctors.  Poor emotional housekeeping.  Skills – poor consultation or clinical skills resulting in an inappropriate management plan.  Knowledge – lack of knowledge leading to an inappropriate or suboptimal management plan.  Bored –lack of personal or professional development

36. PATIENT–DOCTOR FACTORS  Cultural issues  Failure to identify hidden agendas.  Failure to identify the patients fears, beliefs or expectations.  Failure to generate a management plan appropriate to the patient’s circumstances.

37. PRACTICE FACTORS:  Pressure of time – running late.  Poor systems (e.g. telephone access, appointments, admin).  Poor staffing, inappropriate skill mix etc which unnecessarily increase workload.  Unnecessary interruptions – telephone, staff, patients.  Physical factors - lay out of the room, lighting, extraneous noise.

38. THE CONCLUSION:  Consultation skills are learnt behavior.  For beginner a model to be kept in mind.  The consultation should be a discussion and sharing of ideas between two experts.  Each consultation should be tailored to fit the different needs of each patient.  Patient-centered consultation. Vs. Doctor-centered consultation.

39. DOCTOR SHOULD BE ABLE TO * Cure some time. *Relieve often. *Prevent hopefully. *Comfort always.