Skills and Models for Consultation in Family Practice Dr. Riaz Qureshi Distinguished Professor Department of Family & Community Medicine King Saud University,

Skills and Models for Consultation inFamily Practice

Dr. Riaz QureshiDistinguished Professor

Department of Family & Community MedicineKing Saud University, Riyadh

Objectives

To understand why consultation skills are important in Family Practice

To discover, why communication skills development is essential in consultation

To learn the essential features of a consultation in Family Practice

To become familiar with consultation models in Family Practice

Consultation Skills

Family Physicians often need to be bearers of the worst imaginable news

They have to arrange complex and often uncertain information into something understandable

They have to respond to differing needs of a hugely diverse range of patients and their families

And they have to do much of this when they are busy and under pressure

Consultation Skills

If a joint management plan, which the patient understands, feels comfortable with, and is prepared to adhere to, is not made:

the patient is not likely to follow it and

all our efforts in assessment and diagnosis are wasted

(Silverman et al. 1998)

The Evidence Base

Individual Consultation:

For the doctor it is one of many routine encounters, something to be got through as fast as possible .

But for the patient it may be the most important – and stressful – aspect of their week….or the last six months, as they wait anxiously for the appointment and their chance to see the doctor…… ”

(Dr Julie Draper, an unpublished quote, Cambridge University Medical Training Workshop, December 2001)

The Evidence Base

54% of patient’s problems & concerns not elicited (Stewart et al, 1979)

Doctors frequently interrupt their patients soon after their opening statement (mean time 18 seconds) so patients subsequently failed to disclose significant history points (Beckman and Frankel, 1984)

Failing to discover the patients ideas, concerns & expectations (ICE) led to dysfunctional consultations

(Byrne and Long, 1976)

Deficiencies in Communication

Doctors may not obtain enough information about

patients’ perspective

Provide information in inflexible way

Pay little attention in checking how well patients

have understood

Less than half of patients’ psychological morbidity

is recognized

Blocking Behavior Offering advice and reassurance before the main

problems have been identified

Explaining away distress as normal

Attending to physical aspects only

Switching the topic

“Jollying” patients along

Reasons for patients not disclosing problem

Belief that nothing can be done

Reluctance to burden the Doctor

Desire not to appear pathetic or ungrateful

Concern that it is not legitimate to mention

them

Doctors’ blocking behavior

Worry that their fears about what is wrong

with

them will be confirmed

Lack of confidentiality and trust

What is a failed consultation?

No rapport

Using medical jargon

Not exploring the patients agenda

Not eliciting relevant symptoms and signs

No contingency plan(safety netting )

No summarization

Failing to clarify and involving the patient

Not exploring in socio-cultural & economic context

Problems in Communication: Limitations in our settings

Shortage of time

Language barrier – low literacy

Firm misconceptions and myths

Lack of awareness

Not ready to take responsibility for his illness

Socio-cultural, economic barriers

Fatalistic attitude (It’s God’s will)

Barriers to Communicationin Clinical Practice

Personal Barriers

Lack of training: undergraduate/postgraduate

Undervaluing importance of communication

Focus only on treating diseases

Personal Limitations

Organizational Barriers

Lack of time

Pressure of work

Interruptions

Why Consultation Skills?

When doctors use consultation skills effectively:

Patients’ problems identified more accurately

Patients more satisfied with their care

Patients more likely to comply with treatment

Patients’ distress & vulnerability to anxiety & depression are lessened

Why Consultation Skills?

When doctors use consultation skills effectively

Doctors’ well-being is improved Few clinical errors are made Patients are less likely to complain Reduced likelihood of doctors being sued

Good communication is good for doctors good for patients and

good for the health service

Consultation Models

The Medical Model:

Traditional model. History taking Examination Investigation Diagnosis Treatment Follow-up.

Does not recognize the complexity and diversity of the consultation in Family Practice.

The Doctor. His patient and The Illness----a philosophy rather than a consultation model.

Psychological problems are often manifested physically. Doctors have feelings. Those feelings have a role in the

consultation. Doctors need to be trained to be more sensitive to what is

going on in the patient’s mind during a consultation.

Reference: Churchill Livingstone (2000) ISBN:0443064601

Balint, 1957:

Games People Play---describes how to recognizebehaviours (‘games’) patients might use and rolespatient and doctor might adopt—’Patient, Adultand Child’.

Reference: Penguin Books (2004) ISBN:0140027688

Berne, 1964:

Doctors Talking to Patients---6 aspects:

Doctor establishes a relationship with the patient. Doctor attempts to/actually discover the reason for

attendance. Doctor conducts verbal + physical examination. Doctor or doctor + patient or the patient consider

the condition. Doctor (occasionally the patient) detail treatment

and investigation. Consultation is terminated—usually by the doctor.

Reference: RCGP (1984) ISBN:0850840929

Byrne and Long, 1976

The consultation can be divided into ‘physical,psychological, and social’ aspects i.e. in generalpractice doctors should address emotional, family,social, and environmental factors in addition to thetraditional ‘organic’ medical approach.

Reference: JRCGP (1977) 27:117

RCGP, 1976:

‘Exceptional potential of the consultation’. 4 tasks:

Management of presenting problems.Management of continuing problems.

Modification of help-seeking behavior.Opportunistic health promotion.

Reference: JRCGP (1979) 29:201-5

Stott and Davis Model, 1979:

The doctor’s tasks:

Define the reason for patient’s attendance – Presenting problem.

Consider other problems (continuing problems and at-risk factors).

Choose an appropriate action for each problem (involves negotiation between doctor and patient).

Achieve a shared understanding of the problem (doctor and patient).

Pendleton et al, 1984:

Involve the patient in the management and encourage the patient to accept appropriate responsibility.

Use time and resources appropriately.

Establish and maintain a relationship between doctor and patient.

Reference: The New Consultation. Oxford University Press (2003) ISBN:0192632884

Pendleton et al, 1984: Cont’d

The Inner Consultation Checkpoints:

Connecting (doctor establishes rapport with the patient).

Summarizing (doctor clarifies the patient’s reasons for consulting)

Handing over (doctor and patient negotiate and agree a management plan).

Safety netting (doctor and patient plan for the unexpected---managing uncertainty).

Housekeeping (doctor is aware of his/her own emotions).

Reference: Petroc Press (1999) ISBN:1900603675

Neighbour, 1987:

Areas of competence:

Interviewing and history taking. Physical examination. Diagnosis and problem solving Patient management. Relating to patients. Anticipatory care Record keeping.

Reference: Clinical Method: A general practice approach. Butterworth Heinemann (1999) ISBN:0750640057

Fraser, 1992:

Moving from open to closed questioning

The Open-to-Closed Cone

Open ended questions to explore the field

Mid-way questions – directional statements

Closed questions – used following information gathering to focus in

Foundation

Illne

ss F

ram

ewor

k

Dis

ease

Fra

mew

ork

Explanation Planning

Do

cto

rs a

gen

da

Pat

ien

ts a

gen

da

Meeting + greeting Developing rapport

An architectural model of consultation

Outcome

Interventional Styles John Heron

Authoritarian

informativeprescriptiveconfronting

Facilitative

supportive

cathartic

catalytic

Advance preparation

Build a therapeutic relationship

Communicate well

Deal with patient & family reactions

Encourage and validate emotions

• Introduce yourself to everyone• Build rapport• Use touch when appropriate• Schedule follow-up appointments

• Assess and respond to the

patient and the family’s

emotional reaction• Be empathetic.• Do not argue with or criticize

colleagues.

Breaking Bad NewsThe ABCDE Mnemonic for Breaking Bad News• Arrange for adequate time, privacy and

no interruptions

(turn off Pager/phone or to silent mode)• Review relevant clinical information• Mentally rehearse, identify words or

phrases to use and avoid• Prepare yourself emotionally• Have family or support persons present

• Ask what the patient or family already

knows.• Determine what & how much the patient

wants to know.• Warn the patient that bad news is coming.• Proceed at the patient’s pace.• Avoid medical jargon.• Allow time to answer questions • Conclude each visit with a summary and

follow-up plan

• Explore what the news means to

the patient.• Offer realistic hope according to the

patient’s goals.• Use interdisciplinary resources.• Take care of your own needs; be

attuned to the needs of involved

house staff and office or hospital

personnel.

It is the patient who is angry, not you!

Do not leave the anger unexplored

Be supportive to your staff

Dealing with Anger

Handling patient confrontations:

Explore the anger towards the end of the consultation.

Recognize your weaknesses Verbal Communication Techniques:

Wish I couldAgree in principleBroken record

Nonverbal communications

Dealing with Anger

Consultation Duration

Longer consultations result in lesser prescription of drugs and more patient satisfaction.

Essentials of Consultation

Meeting & greeting History with good eye contact Starting with open ended questions Patient- centered approach –let the patient talk Summarizing & ICE Relevant exam & investigations (if needed) Patient involvement in management Safety- netting & follow up

CONCULSION

The traditional medical model does not recognize the complexity and diversity of the consultation in family practice.

The models proposed for consultation in family practice are many. Each views the process from a slightly different perspective.

The consultation model should match the individual needs of the patients and doctors.

Thank You