models of consultations by dr husam abu-siedo

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Consulting Skills :

Consulting Skills Hussam Abu-seido

MODELS OF CONSULTATION :

MODELS OF CONSULTATION Why all this talk of models? What’s the point of making models of the consultation, or of anything else in medicine, for that matter? What types of models are there? What use is a model when you’ve made it?

MODELS OF CONSULTATION :

MODELS OF CONSULTATION Model making is an essential step in mastering consultation skills. Models are all about us, all around us and all to do with us. Maps are models of real world

THE MEDICAL MODEL :

THE MEDICAL MODEL State of normal health Disease processes Diagnosis Management Successful therapy restores diseased processes to normal.

THE MEDICAL MODEL :

THE MEDICAL MODEL The one most thoroughly taught to medical students. Attractive because it stretches their intellects (which tend to be well developed anyway) and spares them much involvement of their feelings (of which they are much less sure). Shortcomings---the apparent disregard for the patient as a person.

OBJECTIVES :

OBJECTIVES 1. To demonstrate that consulting skills are different from, and supplementary to, the traditional skills in diagnosing and treating that were taught at the medical school. 2. “Models of consultation” look at some of the ways in which the consultation has been studied and analysed to make consulting skills easier for trainees to acquire. 3. Learn about Roger Neighbour’s “Five (en route) check points” along the way of each consultation.

MODELS OF CONSULTATION :

MODELS OF CONSULTATION “Doctor-Centred” or “Patient-Centred” Consultations “Task” or “behaviour” – orientated models focus on tasks to be achieved as opposed to the behavioural methods used in the consultation.

CLASSIFICATION OF CONSULTATION MODELS :

CLASSIFICATION OF CONSULTATION MODELS TASK ORIENTATED Phys,psych,social Helman Stott and Davis Health Belief Model Byrne and Long (i) Pendleton et al. DOCTOR PATIENT CENTRED CENTRED Byrne and Long (ii) Counselling 6-Category Analysis Bendix Transactional Analysis Balint BEHAVIOUR ORIENTATED

CLASSIFICATION OF CONSULTATION MODELS :

Physical, Psychological and Social Terms :

Physical, Psychological and Social Terms Triad derived from the Job definition of a GP formulated by the working party of The Royal College Of General Practitioners. The General Practitioner is a doctor who provides personal, primary and continuing medical care to individuals and families. He may attend his patients in their homes, in his consulting room or sometimes in hospital. He accepts the responsibility for making an initial decision on every problem his patient may present to him, consulting with specialists when he thinks it appropriate to do so… His diagnoses will be composed in physical, psychological and social terms. He will intervene educationally, preventively and therapeutically to promote his patient’s health.

Physical, Psychological and Social Terms :

Physical, Psychological and Social Terms Extend the doctor’s thinking process beyond consideration of the purely organic, to include the patient’s emotional, family, social and environmental circumstances in his diagnosis. If the doctor’s awareness of these factors is heightened, he is more likely to include them in his management.

CLASSIFICATION OF CONSULTATION MODELS :

Stott and Davis :

Stott and Davis Paper called (the exceptional potential in each primary care consultation). Four areas which could be systematically explored each time a patient consults. The presenting problem. Modify the patient health seeking behaviour. Review any of the patient’s long-term problems. Take the opportunity to undertake health promotion measures.

CLASSIFICATION OF CONSULTATION MODELS :

Byrne and Long (i) :

Byrne and Long (i) Patrick Byrne and Barrie Long published Doctors talking to patients: a study of the verbal behaviour of general practitioners consulting in their surgeries. 1976. Analysed more than 2000 tape recordings of consultations made by over 100 doctors. Derived a classification of the sequence of events in the consultation. Describe six phases forming a logical structure to the consultation. Admit the logical form rarely appears in practice and should be seen as an ideal.

Byrne and Long (i) :

Byrne and Long (i) The six phases are: The doctor establishes a relationship with the patient. The doctor either attempt to discover or actually discovers the reason for the patient’s attendance. The doctor conducts a verbal or physical examination or both. The doctor, or the doctor and the patient, or the patient ( in that order of probability ) consider the condition. The doctor, and occasionally the patient detail further treatment or further investigation. The consultation is terminated usually by the doctor.

Byrne and Long (i) :

Byrne and Long (i) Went on to look in more detail at those “dysfunctional” consultations. Consultations are particularly likely to go wrong if there are shortcomings in Phase II or Phase IV, or both.

CLASSIFICATION OF CONSULTATION MODELS :

Pendleton et al. :

Pendleton et al. Detail seven tasks, taken together, form comprehensive and coherent aims for any consultation. To define the reason for the patient’s attendance, including: (i) the nature and history of the problems (ii) their aetiology (iii) the patient’s ideas, concerns and expectations (iv) the effects of the problems.

Pendleton et al. :

Pendleton et al. 2. To consider other problems: (i) continuing problems (ii) at-risk factors. 3. With the patient, to choose an appropriate action for each problem. 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.

CLASSIFICATION OF CONSULTATION MODELS :

Helman :

Helman A patient with a problem comes to a doctor seeking answers to six questions: 1. What has happened? 2. Why has it happened? 3. Why to me? 4. Why now? 5. What would Happen if nothing were done about it? 6. What should I do about it or whom should I consult for further help?

CLASSIFICATION OF CONSULTATION MODELS :

Health Belief Model :

Health Belief Model Becker and Maiman synthesised a number of patient beliefs and attitudes into a “health belief model”. Patients’ decisions to accept or reject medical advice are affected by many factors. The beliefs and motivations the patient brings into the consultation significantly governs the understandings and intentions he takes away from it. From the doctor’s point of view, remember: Ideas / Concerns / Expectations ( ICE ).

Health Belief Model Elements :

Health Belief Model Elements The individual’s general interest in health matters, which might correlate with personality, social class, ethnic group. How vulnerable the patient feels himself to be to a particular disease, and how severe a threat the disease is believed to pose The individual’s estimate of the benefits of treatment weighed against the costs, risks or inconvenience of treatment Factors that prompt the individual to take action, such as the development of alarming symptoms, advice from family or friends, or items in the mass media

CLASSIFICATION OF CONSULTATION MODELS :

BYRNE AND LONG (ii) :

BYRNE AND LONG (ii) Analysis of verbal behaviours that doctors used when talking to patients. Gradation of styles from closed information gathering to non directive counselling depending on whether the doctor is more interested in developing his own line of thought or the patient’s.

BYRNE AND LONG (ii) :

BYRNE AND LONG (ii) Profiles of doctors’ consulting styles according to the frequency with which they used the various types of behaviour. Few of them demonstrate the capacity for variations of normal style and performance to meet the needs of those patients.

CLASSIFICATION OF CONSULTATION MODELS :

Six-Category Intervention Analysis :

Six-Category Intervention Analysis Described by John Heron in mid-1970s. Model of the array of interventions a doctor could use with a patient. These fall into six Categories.

Six-Category Intervention Analysis :

Six-Category Intervention Analysis The categories are: 1.Prescriptive – giving advice or instructions, being critical or directive 2.Informative – imparting new knowledge, instructing or interpreting 3.Confronting – challenging a restrictive attitude or behaviour, giving direct feedback within a caring context. 4.Cathartic – seeking to release emotion in the form of weeping, laughter, trembling or anger 5.Catalytic – encouraging the patient to discover and explore his own latent thoughts and feelings. 6.Supportive – offering comfort and approval, affirming the patient’s intrinsic value.

CLASSIFICATION OF CONSULTATION MODELS :

Transactional Analysis :

Transactional Analysis Eric Berne’s model of the human psyche. Three ego states Parent , Adult and Child. Critical or caring parent Logical adult Spontaneous or dependent child

Transactional Analysis :

Transactional Analysis Familiarity with TA introduces a welcome flexibility into the doctor’s repertoire which can break out of the repetitious cycles of behaviour (‘games’) into which some consultations can degenerate.

CLASSIFICATION OF CONSULTATION MODELS :

Counselling :

Counselling The extreme patient centred behaviour Allow the patient to explore in his own way and at his own pace the origins and implications of and solutions to his problem Requires the doctor ability to keep his own opinions and suggestions to himself. Instead to use reflecting, interpreting and judicious use of silence in order to bring the patient to an insight which is his own and nobody else’s.

CLASSIFICATION OF CONSULTATION MODELS :

Bendix :

Bendix The anxious patient ( practical book). Seven rules of thumb as the essential ingredients of counselling.

CLASSIFICATION OF CONSULTATION MODELS :

Balint :

Balint Michael Balint was a Hungarian psychoanalyst who in the 1950s led a series of case-discussion seminars with general practitioners at the Tavistock Clinic, London. The experience of this group formed the basis of one of the most important of all contributions to general practice literature: The Doctor, His Patient and the Illness. Explored the importance of the doctor patient relationship. The pharmacology of the drug “doctor”. Balint groups.

CONCLUSIONS :

CONCLUSIONS All you have to do now is go away and practise, make some video recordings of yourself consulting, and correct whatever faults you see.

CONCLUSIONS :

CONCLUSIONS The importance of making a diagnosis in physical, psychological and social terms. Clear about the patient’s reasons for attending. Deal with all Ideas, Concerns, and expectations.

CONCLUSIONS :

CONCLUSIONS Remember it is an opportunity for Health Education, screening and managing chronic disease. Treat patient as equal partner in the decision making. Get the right balance of being doctor-centred and patient-centred.