Consultation skills 2

1. Consultation skills 2 15.9.11

2. Programme • Challenges from last session • Calgary Cambridge model • Problems with Data Gathering. • Practice-video or role play.

3. Challenges-Patient Factors • Multiple problems/presentations • Rambling patients • Conflict • Knowledgeable patients • Thick notes-complex history • Doctors as patients • Third person in consultation

4. Challenges-Doctor Factors • Lack of knowledge • IT system • Unfamiliarity with workings of practice /locality • Distractions • Conflict

5. Challenges-Organisational/other Factors • IT • Prioritization • Interruptions-rebuilding rapport • Computer as a third person

6. How can we help these issues?

7. Why do patients consult? • Brainstorm?

8. CALGARY CAMBRIDGE MODEL

9. EXPANDED FRAMEWORK

10. DATA GATHERING EXPLANATION AND PLANNING RAPPORT CONCORDANCE BASIC MODEL

11. WHAT DO TRAINEES STRUGGLE WITH-DATA GATHERING • CUES-AND ACTING UPON -ECHO • HOLISM-MAKE NATURAL-NOT JUST –JOB AND FAMILY-IMPACT ON LIFE -USE IN EXPLANATION AND PLANNING • EMPATHY • DOCTOR CENTRED too early • Talk over patient –fail to wait for answer • LACK OF STRUCTURE- SUMMARISE VIDEO- http://youtu.be/MQFuLLX-KCY 314

12. Data gathering –open questions • Use pauses /silence • “Tell me more about?” • “Talk me through a typical day?” • Reflect on last statement • Echo –”chest pains”; “cancer” • What do you mean by ?

13. DATA GATHERING VIDEO-http://youtu.be/YsJQzsrh1ds WHY DO WE MISS CUES? • Include non verbal • What we hear; see and feel • “you look concerned about that?” WHY GIVE EMPATHY? HOW TO GIVE IT AND MEAN IT – REHEARSE-CUE “MY MOTHER DIED 6 MONTHS AGO”

14. ICE Why do we do it? Problems • Too formulaic-not natural • Asked at inopportune times • Not used at in explanations/shared management plan. • Let it flow from their dialogue /cues

15. A natural ICE IDEAS • What does all this mean to you? • What do you make of all this? • What do you think might be the cause? • (So you have had ******* for #### days) Have you any thoughts as to what might be going on? • Tell me what you mean by ******? • Have you considered what might be causing /contributing to these problems? • How/what do you think this has happened? • Some people with this problem find ......., has that been a problem for you?

16. CONCERNS • You mentioned a few things there, is there one particularly concerning you? • Are you worried about anything in particular? • Is there anything you’re worried this might be? • Anything else worrying you? • Do you have any specific worries about this?

17. EXPECTATIONS • Have you thought how I might be able to help? • Have you had any thoughts on investigation/treatment. • Have you had any thoughts on where you want to go from here?

18. COT 5 competence areas covered • Communication and consultation skills • Practising holistically • Data gathering and interpretation • Making a diagnosis /decisions • Clinical management

19. COT –PERFORMANCE CRITERIA PC1: The doctor is seen to encourage the patient’scontribution 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.ICE 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 hypotheses that could reasonably have been formed, OR is designed to address a patient’s concern.

20. COT –PERFORMANCE CRITERIA • PC7: The doctor appears to make a clinically appropriate working diagnosis • PC8: The doctor explains the problem or diagnosis in appropriate language. • 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, reflecting a good understanding of modern accepted medical practice. • PC11: The patient is given the opportunity to be involved in significant management decisions. • PC12: Makes effective use of resources • PC13: The doctor specifies the conditions and interval for follow-up or review

21. CSA-CURRICULUM AREAS • Primary Care Management - recognition and management of common medical conditions in primary care. • Problem Solving Skills - gathering and using data for clinical judgment, choice of examination, investigations and their interpretation. Demonstration of a structured and flexible approach to decision making • Comprehensive Approach - demonstration of proficiency in the management of co-morbidity and risk •  Person-centred Care - communication with patient and the use of recognised consultation techniques to promote a shared approach to managing problems. • Attitudinal Aspects - practising ethically with respect for equality and diversity, with accepted professional codes of conduct. • Clinical Practical Skills - demonstrating proficiency in performing physical examinations and using diagnostic/therapeutic instruments.

22. CSA-MARKING • Data gathering • Clinical management • Interpersonal skills

23. Video watching • IN PAIRS • VIDEO 1- CYSTITIS CASE • VIDEO 2- HEEL PAIN • WHAT WAS GOOD ? • WHAT COULD BE IMPROVED? • ANY LESSONS TO TAKE AWAY?

24. Role play • In 2-3 groups –at least 3 per group • 1 GP • 1 simulated patient • 1 observer/time keeper-note maker • Feedback to group after what went well/or not so well • Role play 1-Headache • Role play 2-Hypertension

25. Feedback rules • Ask opinion of GP and then simulator first. • Be positive first –what went well • What could be improved-give examples of how could do different. • Rehearse alternative skills • Be constructive and confidential.