Consultation Models

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Consultation Models

• Aimee Lettis Karla Grebe

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The plan

• Why look at consultation models?
• Bit about the consultation
• Different approaches to the consultation
• The traditional medical model
• Examples of specific consultation models
• Analyse two video consultations using different
  models

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Why look at consultation models?

• Neighbour Berne
• Balint
• Helman
• Stott Davis
• Pendelton
• Fraser
• Heron Stewart etc.

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Why look at consultation models?

• Pivotal to everything we do as GPs
• Framework within which doctor patient interact
• By studying others models, we can develop our
  own style
• Gives us an insight into doctor-patient
  relationship patients perspective
• If done well, leads to better patient
  understanding concordance and fewer complaints

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Consultation models styles

• No correct way to perform a consultation
• Approach varies according to situation
  participants
• Different consultation styles will be effective
  in different circumstances/ for different doctors

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Aims of the consultation

• Establish constructive relationship with patient
• Enable effective communication
• Determine whether patient has any health
  problems/health promotion needs
• Find out (if possible) what caused them
• Assess patient familys emotions attitudes
  towards the problem
• Establish how problems might be managed
• Good communication essential in achieving these
  aims

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Potential barriers to effective communication

• Lack of time
• Language problems
• Differing gender/age/ethnic or social backgrounds
• Sensitive issues to address
• Hidden or differing agendas
• Prior difficult meetings
• Lack of trust

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Different approaches to consultation

• Medical
• Disease diagnosis of fundamental importance
• Sociological
• Aims to understand behaviour between doctors
  patients, accepting the concepts of values
  norms
• Eg. Is school refusal a disease?
• Anthropological
• Looks at effect of culture
• Distinguishes between illness disease (eg.
  Helmans folk model)

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Different approaches to consultation

• Transactional analysis
• Revolves around ego states of parent, child
  adult (eg. Berne 1964 The Games people play)
• Balint
• Psychological factors play important role
  doctors own personality influences consultation
• Social-psychological approach
• Patient doctors personality as well as their
  beliefs alter outcome of consultation (eg.
  Pendleton, Neighbour, Cambridge-Calgary)

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The traditional medical model

• History
• Examination
• Investigation
• Diagnosis
• Treatment
• Follow-up
• But.it has its limitations

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Being patient-centred..

• Seems to improve
• Patient satisfaction
• Concordance
• Health outcomes
• Certain models emphasize importance of this
• Balint
• Stewart
• In practice, doctor weaves between traditional
  medical model patients perspective of the
  illness
• Hopefully ending up with integrated
  understanding, shared by both

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Specific modelsRoger Neighbour The Inner
Consultation, 1987

• Connecting
• Building rapport
• Identifying patients views, beliefs
  expectations
• Summarising
• Explaining back to patient what they have told
  you
• Allows for correction/development of ideas
  understanding
• Useful tool if not going well!
• Handing over
• Agreeing on doctors and patients agendas
• Negotiating, influencing gift-wrapping
• Giving ownership responsibility of management
  plan to patient

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Specific modelsRoger Neighbour The Inner
Consultation, 1987

• Safety netting
• Considering What if?
• Could be follow-up, advice or referral
• For benefit of both doctor patient
• Housekeeping
• Doctor recognises importance of looking after
  oneself, eg. Coffee/going for a walk etc.
• Am I in good enough shape for the next patient?

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Specific modelsRoger Neighbour The Inner
Consultation, 1987

• Pros
• Good for acute problems
• Recognises importance of doctor looking after
  themselves
• Empowers patient

• Cons
• Doctor-centred

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Specific ModelsHelman Folk Model, 1981

• Suggested that patients form theory based on
  their experience, imagination peer group views
• Consult doctors in order to obtain answers to 6
  questions

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Specific ModelsHelman Folk Model, 1981

• What has happened?
• Why has it happened?
• Why to me?
• Why now?
• What would happen if nothing were done about it?
• What should I do about it or whom should I
  consult for further help?

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Specific ModelsHelman Folk Model, 1981

• Pros
• Very patient-centred
• Patient satisfied

• Cons
• Time
• Hard to apply to certain situations eg. Severe
  mental health

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Pendleton et al 1984 and 2003

• Pendleton, Schofield, Tate and Havelock (1984)
          
• The Consultation - An Approach to Learning and
  Teaching describe seven tasks which taken
  together form comprehensive and coherent aims for
  any  consultation. 
• 1)    To define the reason for the patients
  attendance, including 
•                         i)            the nature
  and history of the problems
•                         iii)            the
  patients ideas, concerns and expectations
•                         iv)            the
  effects of the problems 
• 2)    To consider other problems 
•                         i)            continuing
  problems
•                         ii)            at-risk
  factors           
• 3)    With the patient, to choose an appropriate
  action for each  problem 

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Pendleton et al 1984 and 2003

• 4)      To achieve a shared understanding of the
  problems with the patient 
• 5)      To involve the patient in the management
  and encourage him to accept appropriate
  responsibility 
• 6)      To use time and resources appropriately
•                        i)            in the
  consultation
•                        ii)            in the long
  term 
• 7)      To establish or maintain a relationship
  with the patient which helps to  achieve the
  other tasks. 

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Pendleton et al

• Pros
• Pt centred
• Ideas, concerns and expectations
• Encourages pt responsibility
• Incorporated in nMRCGP tasks for the
  consultation/COTs
• Cons
• Emergencies

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Calgary-Cambridge observation guide to the
consultation             

• Suzanne Kurtz Jonathan Silverman have developed
  a model of the consultation, encapsulated within
  a practical teaching tool, the Calgary Cambridge
  Observation Guide (1996, 2002).
• The structure (5 tasks)
• Gathering information
• Building the relationship
• Initiating the session
• Explanation and Planning
• Closing the session

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Calgary-Cambridge observation guide to the
consultation

• The Framework
• Initiating the session
• Establishing initial rapport
• Identifying the reason(s) for the consultation
• Gathering information
• Exploration of problems
• Understanding the patients perspective
• Providing structure to the consultation
• Building the Relationship
• Developing rapport
• Involving the patient
• Explanation and Planning
• Providing correct amount and type of information
• Aiding accurate recall and understanding
• Achieving a shared understanding incorporation
  the patients perspective
• Planning shared decision making
• Closing the session

I
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Summary

• The consultation is the cornerstone of general
  practice
• There are many models which can be used to
  analyse and shape consultations
• Try read more about some of them
• Aim is to develop your own style
• Different models can be used in different
  situations
• Patient-centred care seems to improve patient
  satisfaction health outcomes

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Some bedtime reading!

• Neighbour R (1987)
• The Inner consultation
• Helman C G (1981)
• Disease versus Illness in General Practice
• Also by Helman (2004), for some lighter reading
• Suburban Shaman tales from medicines
  frontline
• Pendleton et al (1984, 2003)
• The new consultation Developing
  doctor-patient communication