2. CONSULTATION
Dr.Hashim Rida Fida

3. CONSULTATION Definition Consultation Skill Initiating the consultation
Models of consultation
Difficult consultations
Dr.Hashim.Rida.FIDA

5. Definition
Most text books describe interviewing as a diagnostic procedure which is a systematic process of data-gathering designed to identify problems and to arrive at a conclusion,leading ultimately to a treatment plan. This is only partly true. To achieve its maximum value, the consultation should be therapeutics.
Dr.Hashim.Rida.FIDA

6. The most important skill of family physician is ability to interview patient effectively as follow ; 1.To provide health care to all patients, regardless of their age, sex, socio-economic standing and disease status. 2.To treat disease and promote healthy lifestyles in individuals and communities. 3.To provide comprehensive, continuous care, bearing in mind the cultural, social, psychological and economic factors that influence health and disease. 4.To provide care either directly or through other members of the team, depending on the needs of the patient and the resources of the community.
Dr.Hashim.Rida.FIDA

7. INITIATING THE CONSULTATION
OBJECTIVES
Establishing a supportive environment
Developing an awareness of the patient’s emotional state
Identifying as far as possible all the problems or issues that the patient has come to discuss
Establishing an agreed agenda or plan for the consultation
Enabling the patient to become part of a collaborative process

9. SKILLS
Preparation • Puts aside last task, attends to self comfort • Focuses attention and prepares for this consultation Establishing initial rapport • Greets patient and obtains patient’s name • Introduces self and clarifies role • Attends to patient’s physical comfort, demonstrates interest and respect

11. Identifying the reason(s) for the patient’s attendance
• Opening ended question:
identifies the problems or issues that the patient wishes to address (e.g. “What would you like to discuss today?”)
• Listening to the patient attentively without interrupting or directing patient’s response

13. Identifying the reason(s) for the patient’s attendance
Checking list of problems or issues that the patient wishes to cover (e.g. “so that’s headaches and tiredness, is there anything else you’d like to discuss today as well?”)
• Agenda setting: negotiates agenda and format of interview taking both patient’s and physician’s needs into account

15. INFORMATION GIVING, EXPLANATION AND PLANNING
Gauging the correct amount and type of information to give to each individual patient
Providing explanations that the patient can remember and understand
Providing explanations that relate to the patient’s illness framework

16. INFORMATION GIVING, EXPLANATION AND PLANNING
Using an interactive approach to ensure a shared understanding of the problem with the patient
Involving the patient and planning collaboratively to increase the patient’s commitment and adherence to
plans made
Continuing to build a relationship and provide a supportive environment

18. Models of consultation
1.Bio-medical model (hospital model). 2.Bio-psychosocial model. 3.Byrne and long model doctors styles. 4.Balint model. 5.Pendelton model 6.Stott an Davis. 7.Neighbour model.
Dr.Hashim.Rida.FIDA

19. Byrne and long model doctors styles.
Patient-centered
Use of patient’s knowledge
And experience
Doctor-centered
Use of doctor’s knowledge
And skills
Dr.Hashim.Rida.FIDA

20. Balint model The doctor as a drug Elimination by physical examination
The child as a presenting complaint
Inappropriate referral
Dr.Hashim.Rida.FIDA

21. Stott and Davis model
1.Management of Presenting Problem 2.Management of Continuous problem 3.Modifiation of help Seeking behavior 4.Opportunistic health promotion
Dr.Hashim.Rida.FIDA

22. Neighbour model
1.Connecting (establish a relationship) 2.Summarizing( physical. psycho ad social diagnosis) 3.Handling-over(management of presenting problem) 4.Safety-netting(anticipating care) 5.House-keeping(taking care of yourself)
Dr.Hashim.Rida.FIDA

24. Pendleton 7 Tasks To define the real reasons for pt attendance
To consider other problems
To choose with the pt. appropriate action for each problem
To achieve a share understanding
To involve pt. in the management
To use time & resources effectively
To establish & maintain Dr.-pt. relationship

25. Pendleton 7 Tasks To Explore the Real Reasons for Pt. Attendance
History
Nature of the problem
Etiology
Effect of the problem
Ideas
Concern
Expectation
Fears

27. Pendleton 7 Tasks
Skills Needed To Explore the Real Reasons for Pt. Attendance
Open ended questions
Indirect questions
Use of silence
Recognition of patient’s cues
Immediate response to patient’s cues
Confrontation
Reflection
Probing
Summarization

28. Pendleton 7 Tasks Practicing Consultation Skills
Establishing & maintaining Dr- Pt Relationship
Prior to consultation
Welcoming the patient
Initiating the interview
Showing interest
Balance between intimate relationship & professional relationship
Maintaining the relationship
Showing empathy
Legitimation
Showing support

29. Practicing Consultation Skills Ethical Considerations
Respecting patient autonomy
Confidentiality
Non judgmental attitude

31. Diagnosis in PHC Hypothetical Deductive Reasoning Method
Present Complain
+ Context of the consultation
+ Previous knowledge about the patient.
+ Verbal & non verbal cues
3-5 Hypotheses
(Dr. clinical + epidemiological knowledge
+ Dr. experience)
Inclusion or exclusion of hypotheses
(Dr. conducting verbal examination
or physical examination or selective investigations

32. Management Skills Negotiation skills Reassurance skills
Health Education
Counseling
Prescribing
Investigations
Referral
Follow up
Modification of help seeking behavior
Use of medical records
House keeping

35. Difficult consultation
10-20% of daily consultation are difficult. This difficulties are either due to; 1.Difficult patient 2.Difficult Doctor 3 .Difficult communication between the doctor and patient
Dr.Hashim.Rida.FIDA

37. Difficult Consultation
Different Patients Need Different Consultation Skills
Patient Reluctant to Talk Freely
Angry Patient
Demanding Patient
Talkative Patient
Poor Compliance

39. Difficult Consultation
Patient Reluctant to Talk Freely
Causes :
Patient Factors
Dr. Factors
Circumstances
Examples :
The topic
Cultural barrier
Social class barrier
Dr. authority
Time constrains
Presence of 3rd party

40. Difficult Consultation
Approach to Patient Reluctant to Talk Freely
Verbal Communication
Giving reason for the question.
Comments on the patient attitude
Generalization of the problem
Asking at the right time
Reflection
Mirroring
Confrontation

41. Difficult Consultation
Approach to Patient Reluctant to Talk Freely
Non - verbal Communication.
Showing sympathy & empathy
Showing real interest
Unhurried manner
Touch for reassurance
Use of physical examination

42. Difficult Consultation
Angry Patient Communication Skills
Empathy
Legitimation
Non-judgmental attitude
Respect patient autonomy
Support
Flexibility

44. Difficult Consultation
Demanding Patient communication Skills
Discuss the effect of the problem in the patient life
Focus on immediate concern
Deal with feelings

46. Difficult Consultation
Demanding Patient communication Skills
Comment on the process of the interview
Negotiate agenda & goals :
1. Set limit
2. Reinforcement
3. Compromise & Be flexible
Focus on patient as well as his demands & complaints

47. Difficult Consultation
Talkative Patient
Summarization
Prioritization
Use of touch
Sympathy & empathy

48. Behaviors which brake the relationship
Interruption
Close ended question

49. المعامله الحسنه لا تحتاج الى امكانيات

50. Thank You