2. Consultation Models The Second Termers

3. Why the consultation? Pivotal to everything we do as GPs Gives insight into doctor-patient relationship Likely to feature in every module of the exam Leads to better patient understanding, better concordance, fewer complaints

4. “Poor communication about illness causes more suffering than any other problem except unrelieved pain”. Avril Stedeford - Facing Death 1984

5. Consulting in UK General Practice Average length of 7.5 minutes Fastest in Europe We will each do 200,000 during out careers

6. Why model the consultation? We subconsciously make models for anything we do regularly By studying other peoples models we can develop our own Helps us understand patient’s perspective Make us safer and more thorough

7. Hospital Model History Examination Investigations Diagnosis Management plan Follow-up

8. What if we cannot make a diagnosis? What if a patient doesn’t like the management plan? What if the patient has hidden agenda? What if the patient’s concerns are not addressed?

9. Dr. Roger “Karl” Neighbour President of RCGP The Inner Consultation 1984 5 checkpoints

10. Connecting Summarising Safety netting Handing over Housekeeping

11. Connecting Building rapport Identify patients views, beliefs and experiences

12. Summarising Explaining back to the patient what they have told you. Allows for correction, development of ideas/understanding Useful tool if things are not going well

13. Handing over Agreeing on a management plan Giving ownership and responsibility of that management plan to the patient

14. Safety-netting Considering “what if?” Can take form of follow- up, what to do if problem continues, referral. For benefit of patient and the Dr.

15. Housekeeping The Dr recognising the importance of looking after oneself. Coffee, going for a walk, check score in the cricket.

16. Neighbour’s model Pros: Good for acute problems Recognises importance of Dr looking after himself Empowers patient Cons: Dr centred

17. Helman’s “Folk Model” 1981 Medical Anthropologist Patients form a theory based on their –Experience –Imagination –Peer group views

18. Helman’s “Folk Model” WHAT has happened? WHY has it happened? Why to ME? Why NOW? What would happen if NOTHING DONE about it? What should I DO ABOUT IT or whom should I consult?

19. Helman’s “Folk Model” Pros: Very patient centred Patient satisfaction Cons: Time Hard to apply to certain situations e.g. severe mental health, elderly, emergencies.

20. Transactional Analysis 1964 Eric Berne Parent –Critical or caring Adult –Logical Child –dependent

21. Transactional Analysis Pros: Important to be aware of role Attempt to break patterns of behaviour Cons: Not always relevant

22. Stott & Davis 1979 4 areas can be systematically explored each time a patient consults

23. Stott & Davis Management of the PRESENTING PROBLEM Modification of HEALTH SEEKING BEHAVIOURS Management of CONTINUING PROBLEMS Opportunistic HEALTH PROMOTION

24. Stott & Davis Pros: QOF Long term benefits of modifying behaviour Cons: May miss psychological problems No account of patient’s health beliefs

25. Pendleton et al 1984, 2003 7 tasks

26. Pendleton et al DEFINE the reason for attendance Consider OTHER PROBLEMS With the patient chose an APPROPRIATE ACTION for each problem

27. Pendleton et al Achieve a SHARED UNDERSTANDING of the problems with the pt INVOLVE the pt in management decisions & encourage to TAKE RESPONSIBILITY Use TIME & RESOURCES appropriately ESTABLISH or maintain a RELATIONSHIP with the pt

28. PENDLETON 1.Define the reason for the patient’s attendance, including: Nature and history of problem Their aetiology Ideas concerns and expectations Effects of the problem 2.Consider other problems: Continuing problems At risk problems 3.With the patient, to choose 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: In the consultation In the long term 7.To establish or maintain a relationship with the patient which helps to achieve the other tasks

29. Pendleton et al Pros: Pt centred Ideas, concerns, expectations Encourages pt responsibility Basis for summative assessment videos Cons: Emergencies

30. In summary Numerous models Apply to different consultations Important to know NEIGHBOUR & PENDLETON plus one other