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

3. 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

4. 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

5. 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)

6. 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(Dr Julie Draper, an unpublished quote, Cambridge University Medical Training Workshop, December 2001)

7. 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)

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 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

15. 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

16. 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.

17. 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:

18. 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:

19. 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:

20. 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

21. 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

22. 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).

23. 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:

24. 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:

25. 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:

26. 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

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

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

29. 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.

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

31. 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

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

33. 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

34. 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.

35. Thank You