Helman

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Consultation Models
The Second Termers
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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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• Poor communication about illness causes more
  suffering than any other problem except
  unrelieved pain.
• Avril Stedeford - Facing Death 1984

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Consulting in UK General Practice

• Average length of 7.5 minutes
• Fastest in Europe
• We will each do 200,000 during out careers

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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 patients perspective
• Make us safer and more thorough

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Hospital Model

• History
• Examination
• Investigations
• Diagnosis
• Management plan
• Follow-up

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• What if we cannot make a diagnosis?
• What if a patient doesnt like the management
  plan?
• What if the patient has hidden agenda?
• What if the patients concerns are not addressed?

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Dr. Roger Karl Neighbour

• President of RCGP
• The Inner Consultation 1984
• 5 checkpoints

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

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Connecting

• Building rapport
• Identify patients views, beliefs and experiences

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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

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Handing over

• Agreeing on a management plan
• Giving ownership and responsibility of that
  management plan to the patient

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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.

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Housekeeping

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

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Neighbours model

• Pros
• Good for acute problems
• Recognises importance of Dr looking after himself
• Empowers patient

• Cons
• Dr centred

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Helmans Folk Model

• 1981
• Medical Anthropologist
• Patients form a theory based on their
• Experience
• Imagination
• Peer group views

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Helmans 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?

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Helmans Folk Model

• Pros
• Very patient centred
• Patient satisfaction

• Cons
• Time
• Hard to apply to certain situations e.g. severe
  mental health, elderly, emergencies.

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Transactional Analysis

• 1964 Eric Berne
• Parent
• Critical or caring
• Adult
• Logical
• Child
• dependent

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Transactional Analysis

• Pros
• Important to be aware of role
• Attempt to break patterns of behaviour

• Cons
• Not always relevant

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Stott Davis

• 1979
• 4 areas can be systematically explored each time
  a patient consults

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Stott Davis

• Management of the PRESENTING PROBLEM
• Modification of HEALTH SEEKING BEHAVIOURS
• Management of CONTINUING PROBLEMS
• Opportunistic HEALTH PROMOTION

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Stott Davis

• Pros
• QOF
• Long term benefits of modifying behaviour

• Cons
• May miss psychological problems
• No account of patients health beliefs

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Pendleton et al

• 1984, 2003
• 7 tasks

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Pendleton et al

• DEFINE the reason for attendance
• Consider OTHER PROBLEMS
• With the patient chose an APPROPRIATE ACTION for
  each problem

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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

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PENDLETON

• Define the reason for the patients 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

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Pendleton et al

• Pros
• Pt centred
• Ideas, concerns, expectations
• Encourages pt responsibility
• Basis for summative assessment videos

• Cons
• Emergencies

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In summary

• Numerous models
• Apply to different consultations
• Important to know NEIGHBOUR PENDLETON plus one
  other