1. Consultation Models
Dr Darren Tymens, 2003

2. Consultation Models
"Bad consultations result from having insufficient clinical knowledge, from failing to relate to patients or from failing to understand the patient's behaviour, his perception of his illness or its context“
- JGR Howie (1985)

3. Consultation Models Descriptive Normative Conceptual Practical
A model is a perspective or simplification. It is not right or wrong, just more or less useful.
Models of GP consulting are similar in their attempt to broaden the conventional medical approach to include psychosocial issues, the family, and the physician. 
Some models are descriptive - they say what has been or can be observed in consultations. e.g. (Byrne & Long, Calgary Cambridge). 
Others are normative - they say what should happen in a good consultation.  ( e.g. MRCGP, Stott and Davis, Pendleton, Neighbour, Patient-centred) 
Some are conceptual frameworks with no description of methods or behaviours for implementation (e.g. Stott and Davis). 
Others focus on practical behaviours within a less developed framework (e.g. Pendleton).

4. The Biomedical Model
Take an accurate and relevant history (OBSERVATION).
Perform an accurate and relevant examination (OBSERVATION).
Make a provisional diagnosis (HYPOTHESIS).
Order and interpret the results of appropriate investigations (HYPOTHESIS TESTING).
Make a definitive diagnosis (DEDUCTION).
The biomedical approach
Take an accurate and relevant history (OBSERVATION).
Perform an accurate and relevant examination (OBSERVATION).
Make a provisional diagnosis (HYPOTHESIS).
Order and interpret the results of appropriate investigations (HYPOTHESIS TESTING).
Make a definitive diagnosis (DEDUCTION).
This reductionist Model is what most people pick up from Medical School.
What are the problems with the model?
It is reductionist: patients are seen and treated in terms of signs, symptoms and diagnoses and labelled accordingly.
It is doctor-centred: there is no mention of the patient’s feelings, beliefs, and opinions, any sharing of information or agreement of a management plan.
It flounders when no objective physical disorder is unearthed.
It does not recognise the importance of non-verbal communication.
It omits the therapeutic use of the doctor-patient relationship.
It fails to recognise that a consultation can be one of a series as is often the case in general practice.
It over-emphasises the importance of decisions based on personal clinical experience: these are apt to bias because of the limited number of patients any one doctor can experience.

5. M Balint (1957) The Doctor, His Patient and The Illness
The Apostolic Function
The Drug Doctor
The Sick Role
The Long Consultation
Michael Balint observed in 1957 that a doctor's personality interacts with medical training to produce a unique way of dealing with patients. Doctors tend to avoid examining their own behaviour and so a fixed style develops.
Balint called this the 'Apostolic Function'. This incorporates the doctor's beliefs about how patients ought to behave when ill, how they should behave with doctors and how they should cooperate in their cure.
Balint referred to the ‘Drug Doctor' to describe the powerful therapeutic effect of doctors as people, that is the effect of the doctor's personality apart from the treatments they prescribe.
Traditionally, the patient adopts the Sick Role and hands over partial or complete responsibility for his well-being to the doctor. This role allows the patient to drop out of other roles, such as that of breadwinner, and be treated in a dependent, cossetted way. The sick role also requires the patient to seek recovery; otherwise social disapproval and withdrawal of privileges may follow.
Balint promoted the use of the ‘Long Consultation' at a time when the average consultation took six minutes. He gave the patient an hour after surgery to explore the underlying psychosocial causes behind frequent attendances and repeated failures to resolve a problem
A single long session can give insights to the doctor and enough support to the patient to lead to a new rapport and often a resolution of the problem.

6. Berne (1964) Games People Play / Transactional Analysis
Parent / Adult / Child
At any given moment we are in one of three states of mind, one based on a rational assessment of our situation, the other two based on memories recorded mostly in early childhood. These states are named (critical or nurturing) Parent, Adult and (dependent or spontaneous) Child. The Adult is the thinking person, while Parent and Child are replayed memories of what happened to us (mostly at the hands of our parents) and of the feelings we had as a small child.
The two participants in a transaction are therefore each in one of these three states. Consultations conducted between a paternalistic (Parental) doctor and a submissive (Child-like) patient is seldom in the best interests of either but produces no conflict. Conflict will occur however if the patient doesn't accept this position and adopts either an authoritarian role back (Parent) or an unexpectedly questioning (Adult) stance. Best understanding is achieved by Adult to Adult consultations where the two parties respect each others' autonomy.
Games are behaviours used in a bid to feel better by making someone else feel worse. Recognising a game and not playing it prevents the doctor from being manipulated into accepting responsibility for the results of the patient's own behaviour.
For instance, in the game 'Poor Me - Yes, But' the patient presents a problem but always has reasons why proffered solutions are not acceptable. Thus the doctor is proved useless, the point of the game. Some games are deadly as some people will even commit suicide to hurt and 'win'.

7. RCGP Model (1972) Physical, Psychological and Social ‘The Triaxial Model’
Extend thinking beyond organic
Consider Emotional, Family, Social and Environmental factors
'Physical, Psychological and Social’ (1972)
The RCGP model encourages the doctor to extend his thinking practice beyond the purely organic approach to patients, i.e. to include the patient's emotional, family, social and environmental circumstances.

8. Becker & Maiman (1975) Health Belief Model
Ideas
Concerns
Expectations
Becker and Maiman combined a number of patient beliefs and attitudes into a 'health belief model' which included:
the patient's interest in health matters, which may correlate with personality, class and social group
how vulnerable the patient feels to a particular disease and how severe he feels the threat to be
the patient's estimate of the benefits of treatment versus the costs, risks or inconvenience
the factors that prompt the patient to take action - such as developing alarming symptoms, advice from family or friends or reports in the media

9. Heron (1975) Types of Intervention
Prescriptive
Informative
Confronting
Cathartic
Catalytic
Supportive
John Heron, a humanist psychologist, developed a simple but comprehensive model of the six types of intervention a doctor, counsellor or therapist could use with a patient or client:
(1) Prescriptive - giving advice or instructions, being critical or directive 
(2) Informative - imparting new knowledge, instructing or interpreting 
(3) Confronting - challenging a restrictive attitude or behaviour, giving direct feedback within a caring context
  (4) Cathartic - seeking to release emotion in the form of weeping, laughter, trembling or anger 
(5) Catalytic - encouraging the patient to discover and explore his own latent thoughts and feelings 
(6) Supportive - offering comfort and approval, affirming the patient’s intrinsic value.
Each type of intervention can be looked at separately during training sessions as options throughout the consultation.

10. Byrne & Long (1976) 6 Phases of the Consultation
1. The doctor establishes a relationship with the patient
2. The doctor discovers or attempts to discover the reason for the attendance
3. The doctor conducts a verbal and/or physical examination
4. The doctor, the doctor and patient, or the patient (in that order of probability) consider the condition
5. The doctor and occasionally the patient detail further treatment or investigation
6. The consultation is terminated, usually by the doctor
Byrne and Long studied over 2000 audio recordings and in 1976 described six phases in the consultation which give it a logical structure.
The model is useful for analysing 'dysfunctional' consultations where the patient may be misunderstood and dissatisfied while the doctor may be frustrated.
Byrne and Long also described a spectrum of consulting styles, one extreme being doctor-centred and the other, patient-centred.

11. Byrne & Long (1976) Consultation Styles
doctor-centred
dominates the consultation
asks direct, closed questions
rejects the patient's ideas
evades the patient's questions
patient-centred
asks open questions
actively listens
challenges and reflects the patients' words and behaviour to allow them to express themselves in their own way
In the doctor-centred consulting style, the doctor:
dominates the consultation
asks direct, closed questions
rejects the patient's ideas
evades the patient's questions
In the patient-centred consulting style, the doctor:
asks open questions
actively listens
challenges and reflects the patients' words and behaviour to allow them to express themselves in their own way
The style can vary within a single consultation, for example open in seeking information but dogmatic over treatment.

12. Stott & Davis (1979) Areas to Explore
The identification & management of the presenting problem
Modification of the patient's help-seeking behaviour
The management of continuing problems
Opportunistic health promotion
Stott and Davis talked of “The exceptional potential in each primary care consultation” . They outlined four areas which can be explored each time a patient consults:
The identification & management of the presenting problem
The main task of every consultation is to find and treat the reason for the attendance: the nature of the problem, the effect on the patient, the patient's ideas concerns and expectations and an answer to the question, Why now?
2. Modification of the patient's help-seeking behaviour
'Doctor' means teacher. Teaching the natural history of minor illness and about self-medication is an important part of a long-term strategy for making best use of practice resources. Patients may need to be reminded how to make appropriate use of the practice's appointment system or out-of-hours cover. Every doctor-patient encounter plants the seeds of future patterns of illness behaviour which will affect the over-use (and under-use) of medical services.
3. The management of continuing problems
The GP, as the coordinator of the patients' health care, should consider reviewing any coexisting conditions at each consultation. The doctor's continuing interest in the patient's hypertension, diabetes, epilepsy or asthma is likely to produce better adherence to any management plans.
4. Opportunistic health promotion
Health promotion can be improved by taking action when the patient attends for other reasons. Vaccination, cervical screening, blood pressure checks and enquiring and advising about smoking or drinking habits can often be done or at least suggested. The doctor should not, however, become overzealous and insensitive to the patient's needs and wants but it is usually possible at least to ask the patient back to see the nurse 'for a checkup' if a gap is spotted.

13. Helman (1981) ‘Folk Model’ - Questions to be Answered
What has happened?
Why has it happened?
Why me?
Why now?
What would happen if nothing were done about it?
What should I do about it and who should I consult for further help?
Cecil Helman, a Medical Anthropologist, suggested that a patient with a problem comes to the doctor seeking answers to six questions:
What has happened?
2. Why has it happened?
3. Why me?
4. Why now?
5. What would happen if nothing were done about it?
6. What should I do about it and who should I consult for further help?

14. Pendleton (1984) the Doctor's Tasks
Define the reason for the patient's attendance
Consider other problems
Together choose an appropriate action for each problem
Achieve a shared understanding of problems
Involve the patient in the management of problems and encourage acceptance of appropriate responsibility
Use time and resources appropriately
Establish and maintain a relationship with the patient which helps to achieve the other tasks
Pendleton defined seven tasks forming the aims of each consultation. These identify what the doctor needs to achieve and deal with the use of time and resources:
1. Define the reason for the patient's attendance including:
the nature and history of the problems
their aetiology
the patient's ideas, concerns and expectations
the effects of the problem
2. Consider other problems including:
continuing problems
at-risk factors
3. Together choose an appropriate action for each problem
4. Achieve a shared understanding of problems
5. Involve the patient in the management of problems and encourage acceptance of appropriate responsibility
6. Use time and resources appropriately
in the consultation
in the long term
7. Establish and maintain a relationship with the patient which helps to achieve the other tasks
Ref: D Pendleton et al, The Consultation: an Approach to Learning and Teaching, 1984

15. Levenstein (1984) Patient-Centred Model
1. Exploring both the disease and the illness experience
2. Understanding the whole person
3. Finding common round regarding management
4. Incorporating prevention and health promotion
5. Enhancing the Doctor-Patient relationship
6. Being realistic
The Patient-Centered Clinical Method
The six interactive components of the patient-centered process:
1. Exploring both the disease and the illness experience
A.  Differential diagnosis
B.  Dimensionsof illness (ideas, feelings, expectations, and effects on function)
2.  Understanding the whole person
A.  The "person" (life history and personal and developmental issues)
B.  The context (the family and anyone else involved in or affected by the patient's illness; the physical environment)
3.  Finding common ground regarding management
A.  Problems and priorities
B.  Goals of treatment
C.  Roles of doctor and patient in management
4.  Incorporating prevention and health promotion
A.  Health enhancement
B.  Risk reduction
C.  Early detection of disease
D.  Ameliorating effects of disease
5.  Enhancing the patient-doctor relationship
A.  Characteristics of the therapeutic relationship
B.  Sharing power
C.  Caring and healing relationship
D.  Self-awareness
E.  Transference and countertransference
6.  Being realistic
A. Time
B.  Resources
C. Team building

16. Patient-Centred Model

17. Disease-Illness Model (1984)
This was later developed by MacWhinnney et al . into the ‘Disease-Illness Model’ popular in the US.
McWhinney and his colleagues at the University of Western Ontario have proposed a ""reformed clinical method". Their approach has also been called "patient-centred clinical interviewing" to differentiate it from the more traditional "doctor-centred" method that attempts to interpret the patient's illness only from the doctor's perspective of disease and pathology.
The disease-illness model below attempts to provide a practical way of using these ideas in our everyday clinical practice.
Patient presents problem
Gathering information
Parallel search of two frameworks
Illness framework Disease framework
Patient's agenda Doctor's agenda
Ideas Symptoms
Concerns Signs
Expectations Investigations
Feelings Underlying pathology
Thoughts
Effects
Understanding the Differential diagnosis
patient's unique
experience of illness
Integration
Explanation and planning
in terms the patient can understand and accept

18. Neighbour (1987) Checkpoints
Connecting: have we got rapport?
Summarising: could I demonstrate to the patient that I've sufficiently understood why he's come?
Handing over: has the patient accepted the management plan we have agreed?
Safety-netting: What if...?
Housekeeping
Connecting: have we got rapport?
2. Summarising: could I demonstrate to the patient that I've sufficiently understood why he's come:
the patient's reason for attending
the patient's ideas and feelings, concerns and expectations are explored and acknowledged adequately
listening and eliciting
the clinical process - assess, diagnose, explain, negotiate and agree
3. Handing over: has the patient accepted the management plan we have agreed?
4. Safetynetting: What if...? General practice is the art of managing uncertainty:
predict what could happen if things go well
allow for an unexpected turn of events
plans and contingency plans
5. Housekeeping: Am I in good condition for the next patient? - stress, concentration and equanimity

19. Fraser (1987) Areas of Competence
1. Interviewing and history-taking
2. Physical examination
3. Diagnosis and problem-solving
4. Patient management
5. Relating to patients
6. Anticipatory care
7. Record-keeping
Interviewing and history-taking
To interview and take a history successfully, a GP needs to:
introduce self to the patient
put the patient at ease
listen attentively
seek clarification of words used by the patient
phrase questions simply and clearly
use silence appropriately
recognise verbal and non-verbal cues
identify the patient's reasons for consulting
elicit relevant and specific information from the patient and/or records to help choose from possible diagnoses
consider physical, psychological and social factors as appropriate
show a well-organised approach to information-gathering (see 'interviewing skills' esp Calgary-Cambridge guide)
2. Physical examination
The competent GP must be able to:
examine the patient and elicit relevant and discriminating physical signs correctly and sensitively
use instruments in a selective, competent and sensitive manner
use information obtained to confirm or refute working diagnoses
3. Diagnosis and problem-solving
The most important task of the consultation is to make the diagnosis, as this is crucial for prognosis and treatment. In general practice an understanding of the psychological and social aspects of a problem are as vital for making a successful diagnosis as a grasp of the purely physical features of illness.
For up to 50% of patients who present in general practice, a firm diagnosis based on pathology may not be possible. Where diagnosis at this level cannot be achieved, working diagnoses are often expressed at a lower level in terms of the patient's symptoms, signs or problems.
A diagnosis is the current statement of probability about the cause of an illness rather than of absolute certainty. As such it must be regarded as provisional unless more evidence is available or until there is no longer a need for a diagnosis at all.
Management decisions often have to be taken on an assessment of symptoms, signs or problems without a definite diagnosis being made.
4. Patient management
Patient management can be considered under the following broad headings:
Reassurance & explanation
Advice and counselling
Prescribing
Referral
Investigation
Observation & follow-up
Prevention
(RAPRIOP)
5. Relating to patients
Any experienced GP would give the following advice about the doctor's relationship with patients and their families:
be friendly but show professional and ethical behaviour
be sensitive to the patients' needs
be aware how attititudes affect co-operation and compliance
"Bad consultations result from having insufficient clinical knowledge, from failing to relate to patients or from failing to understand the patient's behaviour, his perception of his illness or its context"
6. Anticipatory care
Where appropriate, time should be taken during consultations to:
take any opportunity for health promotion and disease prevention
provide adequate explanation about aims and methods of prevention
win co-operation in a sensitive manner to promote change to a healthier lifestyle
7. Record-keeping
An accurate, legible and appropriate record of every doctor-patient encounter and referral should be kept.
The information recorded should include at least:
the date of the consultation
relevant history and examination findings
any measurements carried out (blood pressure, peak flow, weight etc)
the diagnosis or problem
an outline of the management plan
investigations ordered
follow-up arrangements
If a prescription is issued, a record should be made of the:
drug name
dose
quantity
special precautions given to to patient

20. Kurtz and Silverman (1996) Calgary-Cambridge Observation Guide
A. Initiating the session
B. Gathering information
C. Building the relationship
D. Giving information - explaining and planning
E. Closing the session
This simple five-point plan follows the sequence of events that take place in everyday clinical practice. Within the plan, each task is expanded into a framework for identifying the individual skills of the consultation.
Doctors and patients tend to carry out the four tasks of initiating the session, gathering information, giving information and closing the session roughly in sequence while relationship-building is performed continuously during the other tasks.
The tasks make intuitive sense, are easy to keep in mind and provide a basis for studying doctor-patient interactions and communication skills.
A. Initiating the session
i) Establishing initial rapport
ii) Identifying reasons for attendance
B. Gathering information
iii) Exploring the problems
iv) Understanding the patient's perspective
v) Providing structure to the consultation
C. Building the relationship
vi) Developing the rapport
vii) Involving the patient
D. Giving information - explaining and planning
viii) Providing the right amount and type of information
ix) Aiding accurate recall and understanding
x) Achieving a shared understanding: incorporating the patient's perspective
xi) Planning: shared decision-making
E. Closing the session

21. MRCGP Video Criteria Doctor encourages patient’s contribution.
Dr. responds to cues
Dr. elicits appropriate details to place complaint in social & psycho-logical context
Dr. explores patient’s health understanding    Merit
Dr. obtains sufficient information for no serious condition to be missed.
Dr. chooses an appropriate examination.
Dr. makes clinically appropriate working diagnosis.
Dr. explains diagnosis.
Dr. uses appropriate language.
Dr. takes account of patient’s belief   Merit.
Dr. confirms patient’s understanding   Merit.
Dr. uses appropriate management plan.
Dr. shares management options.
Dr. uses appropriate prescribing behaviour.
Dr. and patient appear to have established a rapport.