Consultation Analysis VTS 3/10/07. Analysis of consultations How could consultations be analysed? How could we derive any models? Byrne & Long (1976),

Consultation Analysis

VTS 3/10/07

Analysis of consultations

How could consultations be analysed?How could we derive any models?

Byrne & Long (1976), “Doctors talking to patients”.

5 models of the consultation

Stott & Davis Pendleton et al Roger Neighbour Cambridge-Calgary John Heron

RCGP curriculum COT

Consultation models.doc

Stott & Davis - The unique potential of each primary care consultation

Dealing with the acute problem Dealing with chronic problems Opportunistic health promotion Modification of help-seeking

behaviour

Stott NC, Davis RH, “The Exceptional Potential in each Primary Care Consultation”, Journal of the Royal College of General Practitioners 1979; 29: 201–5

Stott & Davis - The unique potential..

What is the meaning of “Modification of help-seeking behaviour”? Not wasting resources – making better

use Empowering patients – encouraging self-

reliance and reducing dependency Controlling demands on NHS An example might be to suggest that

someone who repeatedly presents within 24 hours of the onset of a sore throat might consider self medication for future episodes

Stott & Davis - The unique potential..

What is the meaning of “Opportunistic health promotion?”

Timely advice Relevant to the presentation Directs attention to aetiological factors Evidence that it is more effective then

Pendleton et al – 7 tasks of the consultation

Why did the patient attend? Consider other problems Choose appropriate action(s) Share understanding Involve patient – management and responsibility Effective use of time & resources Establish/ maintain relationship with

patient

Pendleton et al, “The Consultation: an approach to learning and teaching”, Oxford Medical GP Series

Roger Neighbour - The Inner Consultation

Connecting Summarizing Handing Over Safety-netting House-keeping

Neighbour, R (1987), “The Inner Consultation”, Kluwer Academic

Cambridge-Calgary

Initiating the session Gathering information Explanation and planning Closing the session Kurtz SM, Silverman JD, Draper J (1998)

Teaching and Learning Communication Skills in Medicine. Radcliffe Medical Press ( Oxford)

Silverman JD, Kurtz SM, Draper J (1998) Skills for Communicating with Patients. Radcliffe Medical Press (Oxford)

John Heron - interventions

Six types of intervention:

AuthoritativePrescriptive – directing patient’s behaviourInformative – imparting informationConfronting – raising patient’s awareness

FacilitativeCathartic – enabling abreaction of painful

emotionCatalytic – eliciting Supportive – affirming patient’s worth

Heron – interventions 2

Prescriptive - Directs the behaviour of the patient - treatment and follow up

Informative – Imparts knowledge, information and meaning to patient

Confronting - Raises the patient’s consciousness about some limiting factor

Cathartic - Enables patient to abreact painful emotion

Catalytic - Seeks to elicit self discovery

Supportive - Affirms worth & value of patient

Heron – interventions 3

Degenerate Intervention Fails in one or more of these aspects Practitioner lacks personal development, training, experience,

awareness or combination of these

Unsolicited Insensitive blundering into territory - intrusive

Manipulative Motivated by self interest regardless of needs of patient From stress, lack of control, lack of awareness Facipulation - using facilitation to manipulate a desired

outcome

Compulsive

Unskilled

Heron J, “Helping the Client: A Creative Practical Guide”, 2001 (First published 1975)

RCGP Curriculum Statement 2: The General Practice Consultation

Six core competencies:

Primary Care Management Person-Centred Care Specific Problem-Solving Skills A Comprehensive Approach Community Orientation A Holistic Approach

Being a GP.pdf

Competencies following on from the RCGP

curriculum statement:

Communication and consultation skills

Practising holistically Data gathering and interpretation Making a diagnosis / decisions Clinical management

What is the aim…..

A doctor who is competent to practise independently as an unsupervised GP

Assessed by…..

COT

CSA

Assessing the consultation for the COT

Insufficient evidence Needs further

development Competent Excellent

Units of Competence and Performance Criteria

Discover the reason for the patient’s attendance Define the clinical problem(s) Explain the problem(s) to the patient Address the patient’s problem(s) Make effective use of the consultation

Performance Criteria

PC1: The doctor is seen to encourage the patient’s contribution at appropriate points in the consultation

PC2: The doctor is seen to respond to signals (cues) that lead to a deeper understanding of the problem

PC3: The doctor uses appropriate psychological and social information to place the complaint(s) in

context

PC4: The doctor explores the patient’s health understanding

Performance Criteria

PC5: The doctor obtains sufficient information to include or exclude likely relevant significant conditions

PC6: The physical /mental examination chosen is likely to confirm or disprove reasonable hypotheses

PC7: The doctor appears to make a clinically appropriate working diagnosis

PC8: The doctor explains the problem or diagnosis in appropriate language

Performance Criteria PC9: The doctor specifically seeks to confirm the

patient’s understanding of the diagnosis

PC10: The management plan (including any prescription) is appropriate for the working diagnosis

PC11: The patient is given the opportunity to be involved in significant management decisions

PC12: The doctor makes effective use of resources

PC13: The doctor specifies the conditions and interval for follow up or review