THE CONSULTATION

1. THE CONSULTATION Louise Beck

2. The Consultation in General Practice Cornerstone of GP Complex interaction Numerous models

3. Early models - �doctor-centred� Recent models - �patient-centred� No one correct way!

4. Potential Barriers lack of time language problems gender, age, ethnic or social background �sensitive� issues �hidden� or differing agendas prior difficult meeting lack of trust

5. Consultation length UK - 7 minutes average Increased over last 30 years Certain groups have longer consultations

6. Consultation length Benefits of longer consultations increased pt and Dr satisfaction improved Dr-pt communication increased identification of psychosocial problems & health promotion decreased reconsultation rates decreased prescriptions for minor illnesses

7. Consultation rate 2.5-6 consultations per pt per year Various factors affect consultation rate new pts elderly pts social deprivation time of year increased health promotion

8. Consultation rate increased list size personal lists not prescribing for minor ailments

9. Consultation models Medical �organic� model hx examination Ix Rx Follow-up

10. Consultation models Early 1970s, the RCGP suggested consultations should be divided into physical aspects psychological aspects social aspects

11. Balint, 1957 Dr-pt relationship is fundamental Key concepts & phrases the Dr as a drug the child as the presenting complaint elimination by physical examination collusion of anonymity the mutual investment company the flash

12. Byrne & Long, 1976 Phase I - Dr establishes relationship with pt Phase II - Dr attempts to discover/actually discovers reason for attendance Phase III - Dr conducts verbal +/- physical examination

13. Phase IV - Dr or Dr & pt or pt consider the condition Phase V - Dr details Rx and Ix Phase VI - consultation is terminated

14. Stott & Davis, 1979 Mx of presenting problems Modification of help-seeking behaviour Mx of continuing problems Opportunistic health promotion

15. Helmann�s folk model, 1981 What has happened? Why? Why me? Why now? What would happen if nothing were done about it? What should I do & who should I consult for further help?

16. Pendleton, Schofield, Tate & Havelock, 1984 Define reason for attendance Consider other problems Choose appropriate action Achieve shared understanding Involve the patient in Mx Use time and resources appropriately Establish & maintain relationship

17. Neighbour, 1987 Connecting Summarizing Handing over Safety netting Housekeeping

18. Tate Discover reason for attendance Define the clinical problem Explain the problem to the patient Make effective use of the consultation Others- Rosenstock, Becker & Maiman, Heron,

19. Heartsink patients Identified by O�Dowd in late 1980s But have no doubt existed as long as a practitioner is willing to listen!

20. Heartsink patients Characterized by frequent presentation Highly complex Often multiple problems (some real, others not) Problem relates to the GP�s perception of patients as well as the patients themselves

21. Management strategy Detailed r/v of notes Awareness of your own reaction Agreed patient contacts Agree agenda within consultation Acknowledge that they can be genuinely ill Avoid unnecessary Ix & referral

22. Management strategy Consider psychiatric diagnoses Planned but careful confrontation