1. Medical Constructs and Grids
To help you with the consultation
Dr Ramesh Mehay,

2. 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

3. 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

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

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

6. 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.

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

8. 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.

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

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

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

12. 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

13. 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”

14. 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)

15. 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

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