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Consultation Models

Consultation Models. The Second Termers. Why the consultation?. Pivotal to everything we do as GPs Gives insight into doctor-patient relationship Likely to feature in every module of the exam Leads to better patient understanding, better concordance, fewer complaints.

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Consultation Models

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  1. Consultation Models The Second Termers

  2. Why the consultation? • Pivotal to everything we do as GPs • Gives insight into doctor-patient relationship • Likely to feature in every module of the exam • Leads to better patient understanding, better concordance, fewer complaints

  3. “Poor communication about illness causes more suffering than any other problem except unrelieved pain”. Avril Stedeford - Facing Death 1984

  4. Consulting in UK General Practice • Average length of 7.5 minutes • Fastest in Europe • We will each do 200,000 during out careers

  5. Why model the consultation? • We subconsciously make models for anything we do regularly • By studying other peoples models we can develop our own • Helps us understand patient’s perspective • Make us safer and more thorough

  6. Hospital Model • History • Examination • Investigations • Diagnosis • Management plan • Follow-up

  7. What if we cannot make a diagnosis? What if a patient doesn’t like the management plan? What if the patient has hidden agenda? What if the patient’s concerns are not addressed?

  8. Dr. Roger “Karl” Neighbour • President of RCGP • The Inner Consultation 1984 • 5 checkpoints

  9. Connecting • Summarising • Safety netting • Handing over • Housekeeping

  10. Connecting • Building rapport • Identify patients views, beliefs and experiences

  11. Summarising • Explaining back to the patient what they have told you. • Allows for correction, development of ideas/understanding • Useful tool if things are not going well

  12. Handing over • Agreeing on a management plan • Giving ownership and responsibility of that management plan to the patient

  13. Safety-netting • Considering “what if?” • Can take form of follow-up, what to do if problem continues, referral. • For benefit of patient and the Dr.

  14. Housekeeping • The Dr recognising the importance of looking after oneself. • Coffee, going for a walk, check score in the cricket.

  15. Neighbour’s model Pros: • Good for acute problems • Recognises importance of Dr looking after himself • Empowers patient • Cons: • Dr centred

  16. Helman’s “Folk Model” • 1981 • Medical Anthropologist • Patients form a theory based on their • Experience • Imagination • Peer group views

  17. Helman’s “Folk Model” • WHAT has happened? • WHY has it happened? • Why to ME? • Why NOW? • What would happen if NOTHING DONE about it? • What should I DO ABOUT IT or whom should I consult?

  18. Pros: Very patient centred Patient satisfaction Cons: Time Hard to apply to certain situations e.g. severe mental health, elderly, emergencies. Helman’s “Folk Model”

  19. Transactional Analysis • 1964 Eric Berne • Parent • Critical or caring • Adult • Logical • Child • dependent

  20. Pros: Important to be aware of role Attempt to break patterns of behaviour Cons: Not always relevant Transactional Analysis

  21. Stott & Davis • 1979 • 4 areas can be systematically explored each time a patient consults

  22. Stott & Davis • Management of the PRESENTING PROBLEM • Modification of HEALTH SEEKING BEHAVIOURS • Management of CONTINUING PROBLEMS • Opportunistic HEALTH PROMOTION

  23. Pros: QOF Long term benefits of modifying behaviour Cons: May miss psychological problems No account of patient’s health beliefs Stott & Davis

  24. Pendleton et al • 1984, 2003 • 7 tasks

  25. Pendleton et al • DEFINE the reason for attendance • Consider OTHER PROBLEMS • With the patient chose an APPROPRIATE ACTION for each problem

  26. Pendleton et al • Achieve a SHARED UNDERSTANDING of the problems with the pt • INVOLVE the pt in management decisions & encourage to TAKE RESPONSIBILITY • Use TIME & RESOURCES appropriately • ESTABLISH or maintain a RELATIONSHIP with the pt

  27. PENDLETON • Define the reason for the patient’s attendance, including: • Nature and history of problem • Their aetiology • Ideas concerns and expectations • Effects of the problem • Consider other problems: • Continuing problems • At risk problems • With the patient, to choose an appropriate action for each problem. • To achieve a shared understanding of the problems with the patient. • To involve the patient in the management and encourage him to accept appropriate responsibility • To use time and resources appropriately: • In the consultation • In the long term • To establish or maintain a relationship with the patient which helps to achieve the other tasks

  28. Pros: Pt centred Ideas, concerns, expectations Encourages pt responsibility Basis for summative assessment videos Cons: Emergencies Pendleton et al

  29. In summary • Numerous models • Apply to different consultations • Important to know NEIGHBOUR & PENDLETON plus one other

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