1. Consultation ModelsConsultation Models
Dr. Gertrude C. Holder, MD, Dip.,Dr. Gertrude C. Holder, MD, Dip.,
ABFPABFP
ConsultantConsultant
Dept. Family MedicineDept. Family Medicine
PMHPMH
PRESENTER: MOKGWANE E SPRESENTER: MOKGWANE E S
DOCTOR IN TRAININGDOCTOR IN TRAINING
2. Consultation ModelsConsultation Models
The consultation is the central task ofThe consultation is the central task of
general practicegeneral practice
Consultation skills form the basis of goodConsultation skills form the basis of good
patient care.patient care.
ConsultationConsultation skills can be learned andskills can be learned and
requires systematic training rather thanrequires systematic training rather than
just experiencejust experience
3. Consultation models &Consultation models &
stylesstyles
No correct way to perform aNo correct way to perform a
consultationconsultation
Approach varies according to situationApproach varies according to situation
& participants& participants
Different consultation styles will beDifferent consultation styles will be
effective in different circumstances/effective in different circumstances/
for different doctorsfor different doctors
4. Consultation ModelsConsultation Models
Reasons for participating in a medicalReasons for participating in a medical
encounter with a patient:encounter with a patient:
– 1. To satisfy your patient’s needs1. To satisfy your patient’s needs
– 2. To maintain your reputation as a good doc2. To maintain your reputation as a good doc
– 3. To make as much money as possible3. To make as much money as possible
– 4. To see the patient as quickly as possible in4. To see the patient as quickly as possible in
order to see more patientsorder to see more patients
5. An Effective ConsultationAn Effective Consultation
Immediate Outcomes:Immediate Outcomes:
– Patient’s clear understanding and recall of thePatient’s clear understanding and recall of the
information relayed by the doctorinformation relayed by the doctor
– Patient’s commitment to your management regimePatient’s commitment to your management regime
– Reduced anxiety on the part of the patientReduced anxiety on the part of the patient
Long Term Outcomes:Long Term Outcomes:
– Patient’s adherence to the management planPatient’s adherence to the management plan
– Long-term improvements to healthLong-term improvements to health
– Development of patient’s own health understandingDevelopment of patient’s own health understanding
6. Potential barriers toPotential barriers to
effective communicationeffective communication
Lack of timeLack of time
Language problemsLanguage problems
Differing gender/age/ethnic or socialDiffering gender/age/ethnic or social
backgroundsbackgrounds
‘‘Sensitive’ issues to addressSensitive’ issues to address
‘‘Hidden’ or differing agendasHidden’ or differing agendas
Prior difficult meetingsPrior difficult meetings
Lack of trustLack of trust
7. Consultation Models-PendletonConsultation Models-Pendleton
TasksTasks
To define the reasons for the patient's attendance including:To define the reasons for the patient's attendance including:
the nature and history of the problemthe nature and history of the problem
their causetheir cause
the patient's ideas, concerns and expectationsthe patient's ideas, concerns and expectations
the effects of the problemthe effects of the problem
To consider other problems:To consider other problems:
continuing problemscontinuing problems
risk factorsrisk factors
To choose with the patients an appropriate action form each problemTo choose with the patients an appropriate action form each problem
To achieve a shared understanding of the problems with the patientTo achieve a shared understanding of the problems with the patient
To involve the patient in the management plan and encourage him to accept appropriateTo involve the patient in the management plan and encourage him to accept appropriate
responsibilityresponsibility
To use time and resources appropriatelyTo use time and resources appropriately
To establish or maintain a relationship with the patient which helps to achieve the other tasksTo establish or maintain a relationship with the patient which helps to achieve the other tasks
8. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining the
reason for the patient’s attendancereason for the patient’s attendance
Example: 55 year-old female teacher whoExample: 55 year-old female teacher who
presents with headache and tirednesspresents with headache and tiredness
– The nature and history of the problemThe nature and history of the problem
She reports waking up extra early in the mornings over theShe reports waking up extra early in the mornings over the
past three weeks. She is irritable, and her teenage childrenpast three weeks. She is irritable, and her teenage children
easily annoy her. She cries often. She still engages ineasily annoy her. She cries often. She still engages in
sexual activity with her husband but wishes he would leavesexual activity with her husband but wishes he would leave
her alone. She questions whether her students areher alone. She questions whether her students are
benefiting from her classes although she admits to tryingbenefiting from her classes although she admits to trying
hard.hard.
9. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining the
reason for the patient’s attendancereason for the patient’s attendance
AetiologyAetiology
She says her 18 year old son wasShe says her 18 year old son was
involved in a motor cycle accident. This isinvolved in a motor cycle accident. This is
the third in one year. Previously hethe third in one year. Previously he
suffered light bruises. This time he wassuffered light bruises. This time he was
severely battered and to quote her, “thankseverely battered and to quote her, “thank
God, the bike was totally destroyed and heGod, the bike was totally destroyed and he
escaped with his life.”escaped with his life.”
10. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining the
reason for the patient’s attendancereason for the patient’s attendance
The effect of the Problem;The effect of the Problem;
– Her concerned husband urged her to visit theHer concerned husband urged her to visit the
doctor because she is obviously distraughtdoctor because she is obviously distraught
and not looking well. Her children too feel sheand not looking well. Her children too feel she
is over-reacting and her usually worrisomeis over-reacting and her usually worrisome
nature has worsened.nature has worsened.
11. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining the
reason for the patient’s attendancereason for the patient’s attendance
Her ideasHer ideas
– She feels her symptoms are due to herShe feels her symptoms are due to her
constant worrying. She admits that herconstant worrying. She admits that her
mother was an incorrigible worrier and shemother was an incorrigible worrier and she
has acquired the same nature. She feelshas acquired the same nature. She feels
helpless to change her thought patterns.helpless to change her thought patterns.
12. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining the
reason for the patient’s attendancereason for the patient’s attendance
Her ConcernsHer Concerns
- She feels depressed. Worse, she says, “I- She feels depressed. Worse, she says, “I
feel I’m going out of my mind”. She knowsfeel I’m going out of my mind”. She knows
this is affecting her relationship with herthis is affecting her relationship with her
husband, and is making her jobhusband, and is making her job
intolerable. She is particularly concernedintolerable. She is particularly concerned
that she will be unable to complete thethat she will be unable to complete the
required 33 1/3 years needed to getrequired 33 1/3 years needed to get
retirement benefits.retirement benefits.
13. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining the
reason for the patient’s attendancereason for the patient’s attendance
Her ExpectationsHer Expectations
- She wants the doctor to give her- She wants the doctor to give her
medication to treat her depression andmedication to treat her depression and
help her to sleep. She came prepared tohelp her to sleep. She came prepared to
reject any referral to a psychiatrist.reject any referral to a psychiatrist.
14. Consultation ModelsConsultation Models
Description of Events Occurring in a Consultation (after ByrneDescription of Events Occurring in a Consultation (after Byrne
& Long 1976)& Long 1976)
Six phases that form a logical structure to theSix phases that form a logical structure to the consultation:consultation:
– The doctor establishes a relationship with the patientThe doctor establishes a relationship with the patient
– The doctor either attempts to discover, or actually discovers, the reasonThe doctor either attempts to discover, or actually discovers, the reason
for the patient's attendancefor the patient's attendance
– The doctor conducts a verbal or physical examination, or bothThe doctor conducts a verbal or physical examination, or both
– The doctor, or the doctor and the patient together, or the patient alongThe doctor, or the doctor and the patient together, or the patient along
(usually in that order of probability) consider(s) the condition(usually in that order of probability) consider(s) the condition
– The doctor, and occasionally the patient, details treatment or furtherThe doctor, and occasionally the patient, details treatment or further
investigationinvestigation
– The consultation is terminated - usually by the doctorThe consultation is terminated - usually by the doctor
15. Consultation ModelsConsultation Models
NeighbourNeighbour
A: Connecting: “Have we got a rapport?”A: Connecting: “Have we got a rapport?”
B: Summarizing (Clinical Process): “Can IB: Summarizing (Clinical Process): “Can I
demonstrate to the patient I have understooddemonstrate to the patient I have understood
why she has come?”why she has come?”
C: Handing Over: “Has the patient accepted theC: Handing Over: “Has the patient accepted the
management plan we agreed?”management plan we agreed?”
D: Safety-Netting: “Have I anticipated all likelyD: Safety-Netting: “Have I anticipated all likely
outcomes?”outcomes?”
E: Housekeeping: “Am I in good condition for theE: Housekeeping: “Am I in good condition for the
next patient?”next patient?”
16. Consultation ModelsConsultation Models
The Patient Centered Clinical Model:The Patient Centered Clinical Model:
-describes specific behaviors necessary to develop an-describes specific behaviors necessary to develop an
effective clinical methodeffective clinical method
-physicians as well as patients needs are satisfied-physicians as well as patients needs are satisfied
The six integrated components of the patient-centeredThe six integrated components of the patient-centered
process:process:
– Exploring both the disease and the illness experienceExploring both the disease and the illness experience
– Understanding the whole personUnderstanding the whole person
– Finding common ground regarding managementFinding common ground regarding management
– Incorporating prevention and health promotionIncorporating prevention and health promotion
– Enhancing the patient-doctor relationshipEnhancing the patient-doctor relationship
– Being realisticBeing realistic
17. Patient Centered ModelPatient Centered Model
Exploring the disease and IllnessExploring the disease and Illness
ExperienceExperience
– Explores signs and symptoms of disease toExplores signs and symptoms of disease to
formulate a differential diagnosisformulate a differential diagnosis
– ‘‘Steeps’ the physician in the experience ofSteeps’ the physician in the experience of
patients to understand illness from their pointpatients to understand illness from their point
of viewof view
18. Exploring the disease and illnessExploring the disease and illness
experienceexperience
KnowledgeKnowledge
– Knowledge of common diseases; differential diagnosisKnowledge of common diseases; differential diagnosis
– Understanding why we focus on organic manifestations ofUnderstanding why we focus on organic manifestations of
sickness; practical understanding of the distinction betweensickness; practical understanding of the distinction between
disease and illness (ideas, feelings, expectations)disease and illness (ideas, feelings, expectations)
SkillsSkills
– Open-ended questionsOpen-ended questions
– Avoid behavior that cuts off patients telling their storyAvoid behavior that cuts off patients telling their story
– Elicit patients’ experience of illness; pay attention to feelings andElicit patients’ experience of illness; pay attention to feelings and
respond appropriatelyrespond appropriately
– Perform physical examinationPerform physical examination
AttitudesAttitudes
– Willingness to become totally involvedWillingness to become totally involved
19. Understanding the whole personUnderstanding the whole person
Knowledge:Knowledge:
– Understand the human condition, esp. the nature of sufferingUnderstand the human condition, esp. the nature of suffering
and response to sicknessand response to sickness
– The ‘person’ (life history and personal developmental issues)The ‘person’ (life history and personal developmental issues)
Skills:Skills:
– The context (the family and anyone else involved in or affectedThe context (the family and anyone else involved in or affected
by the patients’ illness; the physical environment)by the patients’ illness; the physical environment)
Attitude:Attitude:
– Respect for the fundamental worth of all personsRespect for the fundamental worth of all persons
– Shows respect for the cultural values of all ethnic groupsShows respect for the cultural values of all ethnic groups
20. Finding Common GroundFinding Common Ground
Knowledge:Knowledge:
– Know scientific treatment of diseasesKnow scientific treatment of diseases
– Awareness of patient autonomy and issues affecting patientAwareness of patient autonomy and issues affecting patient
compliancecompliance
Skills:Skills:
– Use conventional methods of treatment for problems; PrioritizeUse conventional methods of treatment for problems; Prioritize
– Empower patients to take an active role in their careEmpower patients to take an active role in their care
– Resolve conflictsResolve conflicts
AttitudeAttitude
– Willingness to collaborate with patients about managementWillingness to collaborate with patients about management
– Awareness of personal values and cultural differencesAwareness of personal values and cultural differences
21. Incorporating Prevention andIncorporating Prevention and
Health PromotionHealth Promotion
Knowledge:Knowledge:
– Practical understanding of continuity, comprehensive carePractical understanding of continuity, comprehensive care
– Effective screening and preventive strategies; Risk reductionEffective screening and preventive strategies; Risk reduction
Skills:Skills:
– Collaborate with patients to develop lifelong policies for healthCollaborate with patients to develop lifelong policies for health
promotion and disease preventivepromotion and disease preventive
– Enhance patients self-esteem and self-confidence in caring forEnhance patients self-esteem and self-confidence in caring for
themselvesthemselves
Attitudes:Attitudes:
– Interest in all three stages of preventionInterest in all three stages of prevention
– Invests time and energy to incorporate screening, preventionInvests time and energy to incorporate screening, prevention
and health promotionand health promotion
22. Enhancing the patient-doctorEnhancing the patient-doctor
relationshiprelationship
Knowledge:Knowledge:
– Awareness of emotional reactions to patientsAwareness of emotional reactions to patients
– Understand basic factors underlying an effective patient-doctorUnderstand basic factors underlying an effective patient-doctor
relationshiprelationship
– Working knowledge of transference and counter-transferenceWorking knowledge of transference and counter-transference
Skills:Skills:
– Communicate effectively verbally nonverballyCommunicate effectively verbally nonverbally
– Creates a sense of security and comfort; caring and healingCreates a sense of security and comfort; caring and healing
relationshiprelationship
Attitudes:Attitudes:
– Willingness to step into open-ended relationships with patientsWillingness to step into open-ended relationships with patients
– Exhibits long-term commitment to the well-being of patientsExhibits long-term commitment to the well-being of patients
23. Being RealisticBeing Realistic
Knowledge:Knowledge:
– Awareness of community resourcesAwareness of community resources
– Understand the severe limitations of medicineUnderstand the severe limitations of medicine
– Understand the task of medicineUnderstand the task of medicine
Skills:Skills:
– Organize time effectively and efficientlyOrganize time effectively and efficiently
– Zero in on the heart of the problemZero in on the heart of the problem
– Set reasonable goals and prioritiesSet reasonable goals and priorities
– Use follow up effectivelyUse follow up effectively
Attitudes:Attitudes:
– Awareness of personal limitationsAwareness of personal limitations
– Willingness to ask for helpWillingness to ask for help
24. Disease-Illness ModelDisease-Illness Model
Integrates the clinical or biophysical content withIntegrates the clinical or biophysical content with
an understanding for what symptoms mean toan understanding for what symptoms mean to
the patient within their own “life-world”the patient within their own “life-world”
Disease Framework – The doctors agendaDisease Framework – The doctors agenda
– HistoryHistory
– Physical examinationPhysical examination
– InvestigationsInvestigations
Illness Framework – The patients agendaIllness Framework – The patients agenda
– Patients’ ideas , expectations, feelingsPatients’ ideas , expectations, feelings
– Effect on functionEffect on function
– Understand patient’s unique experience of illnessUnderstand patient’s unique experience of illness