1. How do you teach the General Practice Consultation?
Dr Ian McKelvey

2. I underestimated two things when I opted to become a GP…
GP Receptionists
The Value of the Consultation

3. Consultation Models. Calgary Cambridge
Pendleton et al– The Consultation
Neighbour – The Inner Consultation
Stott and Davies – The exceptional potential of each primary care consultation
Byrne and Long – 6 phases
Helman’s ‘folk model’
McWhinney’s disease Illness Model
Counselling Model
The RCGP’s COT
McKelvey – The Consultation Hill.

4. ….they are all interchangeable and pretty much say the same thing!
In theory there is no difference between theory and practice; in practice there is.

6. Define reason for attendance nature and history of problems Aetiology
Roger Neighbour
Connecting
Summarising...physical, psychological, social.
Handing Over …influencing, negotiating, gift-wrapping, ‘my friend John’….
Safety-netting....?OK
Housekeeping.. Am I in good shape for the next patient?
Pendleton et al
Define reason for attendance
nature and history of problems
Aetiology
Ideas, Concerns, Expectations
Effects of problems
Consider other problems
Continuing problems
At risk factors
With patient, choose appropriate action for each problem
Achieve shared understanding of problem/s
Involve patient in management and encourage him to accept appropriate responsibility
Use resources appropriately
In the consultation
In the long term
Establish and maintain a relationship with the patient that helps achieve the other tasks

7. McWhinney’s disease-illness model
Patient presents at a particular time when have reached either their
‘limit of symptom tolerance’ or
‘limit of anxiety’
useful to move focus to patient agenda ( hospital doctor to GP)
Draws parallel between traditional medical model of illness and a patient centred perspective.
If you can understand which trigger is at work the consultation is more likely to be successful.

8. McWhinney Medical Parallel Patient Parallel HF On and on
Understanding of patients experience

9. Helman’s Folk Model
Patient comes to a doctor seeking answers to 8 questions….
What has happened?
Why has it happened?
Why to me?
Why now?
What would happen if nothing were done about it?
What should I do about it or whom should I consult for further help?
What can you (the doctor) do about it?
How can I stop it happening again?
Anthropological model and helps registrars gain insight into the patients agenda.

10. Stott and Davies. The Exceptional Potential in each primary care consultation
Management of presenting problems
Modification of help-seeking behaviours
Opportunistic Health Promotion
Management of continuing problems

11. Counselling Model Ultimate patient centred approach
‘Allow patient to explore in their own way and at own pace the origins, implications and solutions to their problem’
Doctor must have ability to keep own opinions and suggestions to themselves
Use techniques such as reflecting, interpreting and judicious use of silence in order to bring the patient to an insight which is his own and nobody else’s
PERHAPS NOT IDEAL TO EMBRACE PRIOR TO CSA
i.e. BOLLOCKS

12. Neighbour’s Consultation Model
4. Safety
netting
3. Handing Over
5. House
keeping
2. Summarising
1. Connecting

13. The centipede was happy, quite,
Until a toad in fun
Said, “Pray, which leg goes after which?”
This worked his mind to such a pitch
He lay distracted in a ditch
Considering how to run.

14. 1. Connecting Rapport Gambits & Curtain Raisers
Minimal cues – verbal and non-verbal
What is said & not said
Representational systems-V,A & K
Eye movements
3 cardinal mental thought processes
Speech censoring
Internal Speech
Acceptance Set
In chess, opening moves are ‘gambits’, but when patient enters room sometimes they come out with an unscripted ‘curtain raiser’. Eg “you are a difficult man to see – anyway, I’ve been getting these stomach pains…”

15. Rapport The ‘sine qua non’ of effective communication
Two people being mutually responsive to each others signals
Not the same as liking someone
Dr owes it to the patient
A process, not a state. Something you do, like tuning a radio
Reading the physical signs of someones mental state
Can be practiced by developing greater sensory awareness of the minimal cues by which people signal their thoughts and feelings.
Minimal cues….?

16. Minimal Cues - the physical signs of mental illness
Verbal – what’s said and not said
Non-verbal Auditory
Visual
Kinaesthetic
Imagine being invisible at a party….

17. Pedicates - Visual(V) Auditory (A) Kinaesthetic (K)
I see what you mean (V)
I hear what you are saying say (A)
I grasp what it is you are going through (K)
The future looks bleak. My life’s a mess (V)
We’re not in tune with each other any more. We just row and clash. (A)
I don’t know where to turn. I feel stuck in a rut. (K)

18. Eye movement Accessing Cues
Visual remembered
Visual constructed
Auditory remembered
Auditory constructed
Auditory internal dialogue
Kinaesthetic

20. 2. Summarising What information do we need? I, C, E. Feelings
Effects of symptoms, treatment etc
When should you elicit that information?
What signals can the patient give to suggest that
more information could be elicited?
How should we elicit the information?

21. 3.Handing Over Negotiating Give the patient options Influencing
in my opinion…
Use questions instead of statements
Reframing
Shepherding –
value laden phrases, eg admission or not
presuppositions eg tea or coffee
pre-empting
my friend John…
Gift Wrapping
Chunk & Check
How to give instructions – rule of 3.
Rule of 3…say what you are going to say, say it, then say what you’ve said.

22. 4. Safety Netting
“General Practice is the Art of Managing Uncertainty”
If I am right, what do I expect to happen?
Worst case scenario
Instructions to patient
F/U - What if patient doesn’t come back?
How will I know if I am wrong?
What will I do then?
What to say to the patient

23. 5. House Keeping
Long term
In between Patients
During Consultations

24. CSA and nMRCGP 13 cases Own room
10 minutes each. 2 minutes between each case
A practical assessment of consulting skills
Expensive £1,260 a throw.
Examiner sits in the corner
Break in the middle after 7 patients of 15 mins
No marks will be gained after 10 mins when buzzer sounds
No 1-2 minute warning buzzer
“shows poor time management” is a reason they can fail you at any station…..and they will

25. CSA Each case is marked on 3 domains
data gathering, examination and clinical assessment skills
Clinical management skills
Interpersonal skills
All domains have equal weighting
Do not spend 8 minutes on history and examination…you will fail this station

27. The Consultation Hill. “seek first to understand, then be understood”
Shared Summit
Preparation
Ascent
Descent
Reflection
“seek first to understand, then be understood”

28. Preparation Personal preparation System preparation
patient access, phone, booking systems, reception staff, waiting room, toilets, IT system, forms, equipments, consultation room, PILs, telephone interruption policy.
Personal preparation
Be rested, mentally and physically. If late, don’t rush. Offload ‘baggage’. Identify personal prejudices and stresses and leave outside the clinical encounter

29. Ascent Reason for attendance/ information gathering ICEs
Why here, why now?
Preferred representational system? (VAK)
Acceptance set?
Rapport
History and Examination
Largely patient led
Dr – listening, facilitating, encouraging, interpreting, clarifying, empathising (actively)
End by ‘summarising’ to reach shared summit. (beware of reaching the wrong summit if Dr and patient don’t share same understanding of patients reasons for attending)
Dr should by the end have established a ‘working diagnosis’ and formulated an action plan.

30. Shared Summit
Pause, take in the air, enjoy the view of a shared understanding. ( pause, slow intake of breath, reflective look, shift in body posture, change of tone, rate, volume of speech)
Can be identified and acknowledged
May be most exposed here, so Dr must be preparing for a safe descent down a devised route which is now more Dr led.
Route planned so can negotiate and ‘hand over’ using information gained on the ascent
Need to get here in 7-8 minutes for the CSA!

31. Descent
Tailored explanation of the problem and a solution offered, incorporating and using patients already established health beliefs and understanding, which can be sensitively modified if appropriate.
Management plan proposed and seek approval from the patient (acceptance set)
Confirm patients understanding and define their responsibility and involvement in the process. This will increase compliance
What if it goes wrong? Acknowledge this and plan another assault on the consultation hill?
Foothills include ‘safety netting’
Acceptance set…calliibrate what the patient does when they say ‘yes’ and ‘no’ by lobbing in some leading questions early and watching how they respond eg ‘the right shoulder’…’yes’

32. Reflection Always something to be learnt from any clinical encounter
PUNs and DENs (Eve ; discovering learning needs in GP)
It’s a lifetime of learning….!

33. My last word, ….honest
You need to reflect upon how your work affects your physical, mental, spiritual and emotional state ….
….as healthy doctors are more likely to provide good medical care.
Kit fit, let the journey be safe for both you and patient, enjoy the challenge of the consultation hill and strive to make the next trip more successful.
‘In general practice the consultation is a journey, not a destination’….Roger Neighbour

34. So how do you teach all this….?
Joint surgeries
Video analysis
Role Play
Has to be experiential…
Trainee has to identify the area to work on and feel it important enough to improve/work on. Can use SET-GO (what I Saw, what Else did you see, what do you Think,,clarify Goal, any Offers how to get there.
Do it in bite sized chunks – Work on one task per week

35. Ideas
‘Tell me about what you think is causing it.’
‘What do you think might be happening?’
‘Have you any ideas about it yourself?’
‘Do you have any clues; any theories?’
‘You’ve obviously given this some thought, it would help me to know what you were thinking it might be’.
Concerns
‘What are you concerned that it might be?’
‘Is there anything particular or specific that you were concerned about?’
‘What was the worst thing you were thinking it might be?’
‘In your darkest moments ...‘
Expectations
‘What were you hoping we might be able to do for this?’
‘What do you think might be the best plan of action?’
‘How might I best help you with this?’
‘You’ve obviously given this some thought, what were you thinking would be the best way of tackling this?’
Effects on Life
…..the 50p game.

36. Gathering data to understand the patient's problems
The Three Function Approach to the Medical Interview (1989) Cohen-Cole and Bird have developed a model of the consultation that has been adopted by The American Academy on Physician and Patient as their model for teaching the Medical Interview.
Gathering data to understand the patient's problems
Developing rapport
Education and motivation
Open-ended question
Open to closed cone
Facilitation
Checking
Survey of problems
Negotiate priorities
Clarification and direction
Summarising
Elicit patient's expectations
Elicit patient's ideas about aetiology
Elicit impact of illness on patient's quality of life
Reflection
Legitimation
Support
Partnership
Respect
Education about illness
Negotiation and maintenance of a treatment plan
Motivation of non-adherent patients
Neighbours 9 rules of thumb of ‘How to give instructions’