1. CONSULTATION SKILLS
Dr. Ekram A Jalali

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. Diagnosis in PHC Pattern of recognition
Hypothetical deductive reasoning method
Using clinical epidemiology
Living with uncertainty
50% No diagnosis

14. 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

15. 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

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

17. 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

18. 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

19. 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

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

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

22. 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

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

24. Behaviors which brake the relationship
Interruption
Close ended question

25. Thank You