CONSULTATION SKILLS

1. CONSULTATION SKILLS Dr. Ekram A Jalali

2. INITIATINGTHE 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. 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 Difficult Consultation

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

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

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

24. Behaviors which brake the relationship • Interruption • Close ended question

25. Thank You