Consultation Analysis

1. Consultation Analysis VTS 3/10/07

2. Analysis of consultations How could consultations be analysed? How could we derive any models? Byrne & Long (1976), “Doctors talking to patients”.

3. 5 models of the consultation Stott & Davis Pendleton et al Roger Neighbour Cambridge-Calgary John Heron RCGP curriculum COT Consultation models.doc

4. Stott & Davis - The unique potential of each primary care consultation • Dealing with the acute problem • Dealing with chronic problems • Opportunistic health promotion • Modification of help-seeking behaviour • Stott NC, Davis RH, “The Exceptional Potential in each Primary Care Consultation”, Journal of the Royal College of General Practitioners 1979; 29: 201–5

5. Stott & Davis - The unique potential.. • What is the meaning of “Modification of help-seeking behaviour”? • Not wasting resources – making better use • Empowering patients – encouraging self- reliance and reducing dependency • Controlling demands on NHS • An example might be to suggest that someone who repeatedly presents within 24 hours of the onset of a sore throat might consider self medication for future episodes

6. Stott & Davis - The unique potential.. • What is the meaning of “Opportunistic health promotion?” • Timely advice • Relevant to the presentation • Directs attention to aetiological factors • Evidence that it is more effective then

8. Pendleton et al – 7 tasks of the consultation • Why did the patient attend? • Consider other problems • Choose appropriate action(s) • Share understanding • Involve patient – management and responsibility • Effective use of time & resources • Establish/ maintain relationship with patient • Pendleton et al, “The Consultation: an approach to learning and teaching”, Oxford Medical GP Series

10. Roger Neighbour - The Inner Consultation • Connecting • Summarizing • Handing Over • Safety-netting • House-keeping • Neighbour, R (1987), “The Inner Consultation”, Kluwer Academic

11. Cambridge-Calgary • Initiating the session • Gathering information • Explanation and planning • Closing the session • Kurtz SM, Silverman JD, Draper J (1998) Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press ( Oxford) • Silverman JD, Kurtz SM, Draper J (1998) Skills for Communicating with Patients. Radcliffe Medical Press (Oxford)

12. John Heron - interventions • Six types of intervention: • Authoritative • Prescriptive – directing patient’s behaviour • Informative – imparting information • Confronting – raising patient’s awareness • Facilitative • Cathartic – enabling abreaction of painful emotion • Catalytic – eliciting • Supportive – affirming patient’s worth

13. Heron – interventions 2 • Prescriptive - Directs the behaviour of the patient - treatment and follow up • Informative – Imparts knowledge, information and meaning to patient • Confronting - Raises the patient’s consciousness about some limiting factor • Cathartic - Enables patient to abreact painful emotion • Catalytic - Seeks to elicit self discovery • Supportive - Affirms worth & value of patient

14. Heron – interventions 3 • Degenerate Intervention • Fails in one or more of these aspects • Practitioner lacks personal development, training, experience, awareness or combination of these • Unsolicited • Insensitive blundering into territory - intrusive • Manipulative • Motivated by self interest regardless of needs of patient • From stress, lack of control, lack of awareness • Facipulation - using facilitation to manipulate a desired outcome • Compulsive • Unskilled • Heron J, “Helping the Client: A Creative Practical Guide”, 2001 (First published 1975)

15. RCGP Curriculum Statement 2: The General Practice Consultation • Six core competencies: • Primary Care Management • Person-Centred Care • Specific Problem-Solving Skills • A Comprehensive Approach • Community Orientation • A Holistic Approach • Being a GP.pdf

16. Competencies following on from the RCGP curriculum statement: • Communication and consultation skills • Practising holistically • Data gathering and interpretation • Making a diagnosis / decisions • Clinical management

17. What is the aim….. • A doctor who is competent to practise independently as an unsupervised GP

18. Assessed by….. • COT • CSA

19. Assessing the consultation for the COT • Insufficient evidence • Needs further development • Competent • Excellent

20. Units of Competence and Performance Criteria • Discover the reason for the patient’s attendance • Define the clinical problem(s) • Explain the problem(s) to the patient • Address the patient’s problem(s) • Make effective use of the consultation

21. Performance Criteria • PC1: The doctor is seen to encourage the patient’s contribution at appropriate points in the consultation • PC2: The doctor is seen to respond to signals (cues) that lead to a deeper understanding of the problem • PC3: The doctor uses appropriate psychological and social information to place the complaint(s) in context • PC4: The doctor explores the patient’s health understanding

22. Performance Criteria • PC5: The doctor obtains sufficient information to include or exclude likely relevant significant conditions • PC6: The physical /mental examination chosen is likely to confirm or disprove reasonable hypotheses • PC7: The doctor appears to make a clinically appropriate working diagnosis • PC8: The doctor explains the problem or diagnosis in appropriate language

23. Performance Criteria • PC9: The doctor specifically seeks to confirm the patient’s understanding of the diagnosis • PC10: The management plan (including any prescription) is appropriate for the working diagnosis • PC11: The patient is given the opportunity to be involved in significant management decisions • PC12: The doctor makes effective use of resources • PC13: The doctor specifies the conditions and interval for follow up or review