Biomedical <ul><li>Karl Popper’s ideas better reflect the  </li></ul><ul><li>reality of biomedical consultations,  </li></...
Anthropological Approach <ul><li>Anthropologists observe different  </li></ul><ul><li>cultures and then seek to make  </li...
Transactional Approach <ul><li>Parent – directive controlling nurturing </li></ul><ul><li>Adult – logically processes info...
Mindfulness <ul><li>Michael Balint worked with GPs to raise  </li></ul><ul><li>their emotional awareness of the  </li></ul...
Six Phases <ul><li>In our attempts to make </li></ul><ul><li>sense of the process of  </li></ul><ul><li>consulting we have...
Seven Tasks <ul><li>Pendleton  et al  (2003) The new  </li></ul><ul><li>consultation.  Oxford Ox. Uni. </li></ul><ul><li>P...
Neighbour R (1987)  The Inner Consultation  Lancaster, MTP press <ul><li>Neighbour seeks to make us </li></ul><ul><li>unco...
Participative – Launer J. (2002)  Narrative-Based Primary Care  Oxford, Radcliffe   M P <ul><li>Patients and doctors tell ...
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Modelling Consultations

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This the introductory presentation on the theory that underpins the consultation between doctor and patient. I would value any comments on these presentations: my hope is that your interest will lead to deeper insight into the process of consulting and to a sense of driving the quality of the interaction forward for the benefit of all parties.

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Modelling Consultations

  1. 2. Biomedical <ul><li>Karl Popper’s ideas better reflect the </li></ul><ul><li>reality of biomedical consultations, </li></ul><ul><li>because clinicians are seeking to </li></ul><ul><li>disconfirm their working diagnoses </li></ul><ul><li>(falsificationism). Diagnosis is </li></ul><ul><li>verisimilitudinal: it only approximates to </li></ul><ul><li>reality until a better diagnosis is available </li></ul><ul><li>(e.g. diagnostic drift). </li></ul><ul><li>Basic premise: Illness is a function of </li></ul><ul><li>disease. Diagnosis directs treatment. </li></ul><ul><li>This logic underpins the tenets of </li></ul><ul><li>Evidenced Based Medicine. </li></ul><ul><li>However, biomedical reasoning fails to </li></ul><ul><li>address patients’ fears, hopes and </li></ul><ul><li>expectations. </li></ul><ul><li>The process is primarily inductive: </li></ul><ul><li>History </li></ul><ul><li>Examination </li></ul><ul><li>Making Provisional Diagnosis </li></ul><ul><li>Testing the Hypothesis </li></ul><ul><li>And thereby deducing a definitive diagnosis. </li></ul><ul><li>Elstein et al 1978 in praxis the </li></ul><ul><li>provisional diagnosis is made </li></ul><ul><li>early within the consultation. </li></ul><ul><li>Thus clinicians are using history </li></ul><ul><li>and examination to validate their </li></ul><ul><li>working diagnosis. </li></ul><ul><li>Elstein et al (1978) Medical Problem </li></ul><ul><li>Solving: an analysis of clinical reasoning. </li></ul><ul><li>Cambridge MA: Harvard University Press. </li></ul>
  2. 3. Anthropological Approach <ul><li>Anthropologists observe different </li></ul><ul><li>cultures and then seek to make </li></ul><ul><li>sense of their observations. </li></ul><ul><li>Their observations is that the healing ritual </li></ul><ul><li>is a function of making a diagnosis, </li></ul><ul><li>prescribing a remedy and pronouncing the </li></ul><ul><li>problem cured! </li></ul><ul><li>The patient plays the sick role to </li></ul><ul><li>the doctors healing role. </li></ul><ul><li>Aesculapean Authority </li></ul><ul><li>Patient’s beliefs are based on the </li></ul><ul><li>charismatic nature of their healers </li></ul><ul><li>(and politicians?). </li></ul><ul><li>Healers are all knowing </li></ul><ul><li>Healing is vocational </li></ul><ul><li>Healing is magic. </li></ul><ul><li>There are some assumptions </li></ul><ul><li>here, but sapiential, moral and </li></ul><ul><li>charismatic authority would increase </li></ul><ul><li>the placebo response. Patient </li></ul><ul><li>expectations are being met. </li></ul><ul><li>However, this therapeutic alliance </li></ul><ul><li>is not sustainable, but (rarely) it may be </li></ul><ul><li>appropriate to play the role of healer </li></ul><ul><li>for an individual patient. </li></ul>
  3. 4. Transactional Approach <ul><li>Parent – directive controlling nurturing </li></ul><ul><li>Adult – logically processes information </li></ul><ul><li>Child has an intuitive grasp of enjoying life </li></ul><ul><li>Understand your role </li></ul><ul><li>and that of the patient </li></ul><ul><li>within an enacted </li></ul><ul><li>consultative game. </li></ul><ul><li>An Exemplar </li></ul><ul><li>There are many types of </li></ul><ul><li>games played, such as the </li></ul><ul><li>critique of a course of action </li></ul><ul><li>as to why a plan will not work – </li></ul><ul><li>thus seeking to protect child </li></ul><ul><li>from lifestyle changes. The move </li></ul><ul><li>to co-create the management </li></ul><ul><li>plans enables clinicians to </li></ul><ul><li>influence and negotiate a </li></ul><ul><li>therapeutic alliance, where all </li></ul><ul><li>parties to a consultation work </li></ul><ul><li>synergistically. If you are directive </li></ul><ul><li>of management plans you are </li></ul><ul><li>playing parent to the patients child. </li></ul>
  4. 5. Mindfulness <ul><li>Michael Balint worked with GPs to raise </li></ul><ul><li>their emotional awareness of the </li></ul><ul><li>dynamics within consultations. His </li></ul><ul><li>approach may ask the doctor to interpret </li></ul><ul><li>their emotional reaction to a </li></ul><ul><li>patients story (flash technique). </li></ul><ul><li>Psychoanalysis gives useful insight into </li></ul><ul><li>The nature of trust and dependency within </li></ul><ul><li>relationships’. Including understanding of </li></ul><ul><li>trust and dependency within the </li></ul><ul><li>consultative therapeutic alliance </li></ul><ul><li>The therapist skill is to pace the </li></ul><ul><li>psychodynamic so to as enable the </li></ul><ul><li>analysand to be able to grow to emotional </li></ul><ul><li>maturity at a sustainable pace. </li></ul><ul><li>Psychoanalysis has a huge </li></ul><ul><li>Literature and has evolved </li></ul><ul><li>to being more about the co- </li></ul><ul><li>construction of meaning, </li></ul><ul><li>rather than being interpretive. </li></ul><ul><li>Michael Jacobs (1998) The </li></ul><ul><li>Presenting Past. The core </li></ul><ul><li>of psychodynamic counselling and therapy </li></ul><ul><li>2 nd Ed. Maidenhead Open University </li></ul><ul><li>Press is an accessible introduction to this </li></ul><ul><li>topic. </li></ul><ul><li>General practitioners can catalyse </li></ul><ul><li>meaningful insight for their patients by </li></ul><ul><li>being more emotionally intelligent within </li></ul><ul><li>their ultra-short consultations over the </li></ul><ul><li>ultra-long time of their careers. </li></ul>
  5. 6. Six Phases <ul><li>In our attempts to make </li></ul><ul><li>sense of the process of </li></ul><ul><li>consulting we have </li></ul><ul><li>developed our own </li></ul><ul><li>language – Discursive </li></ul><ul><li>Formulation. Each of our </li></ul><ul><li>models provides some key </li></ul><ul><li>insights into the process of </li></ul><ul><li>consulting. </li></ul><ul><li>Byrne and Long (1976) </li></ul><ul><li>Doctors talking to patients </li></ul><ul><li>(2500) London, HMSO </li></ul><ul><li>The phases: we establish </li></ul><ul><li>rapport (1), the reason </li></ul><ul><li>for the patients attendance </li></ul><ul><li>(2), Systematic examination </li></ul><ul><li>(3), Dr and patient consider </li></ul><ul><li>Management (4), Agree a </li></ul><ul><li>Plan (5), Doctor usually </li></ul><ul><li>terminates consultation (6). </li></ul><ul><li>So how is this insightful? </li></ul><ul><li>Describes the verbal reality of GP consultations </li></ul><ul><li>Discovers that consultations tend to be doctor-centric </li></ul><ul><li>Emphasis on the importance of addressing patient beliefs. </li></ul>
  6. 7. Seven Tasks <ul><li>Pendleton et al (2003) The new </li></ul><ul><li>consultation. Oxford Ox. Uni. </li></ul><ul><li>Press. This model and the Cambridge </li></ul><ul><li>Calgary model seek to provide a </li></ul><ul><li>structure for consultations. This then </li></ul><ul><li>provides a means of assessing how </li></ul><ul><li>well students perform within the </li></ul><ul><li>structured consultation. However, </li></ul><ul><li>these are clever constructs, as at </li></ul><ul><li>their heart of the methodologies </li></ul><ul><li>require that the consultation is </li></ul><ul><li>inclusive of the patient’s ideas, </li></ul><ul><li>concerns and expectations. </li></ul><ul><li>Thus the consultation is grounded in </li></ul><ul><li>the concept of patient-centredness </li></ul><ul><li>Why has patient come today? </li></ul><ul><li>What fears, hopes and outlook does the patient bring today? </li></ul><ul><li>Frame patients options for the management of their problem </li></ul><ul><li>Develop a plan within the support structure of therapeutic alliance. </li></ul><ul><li>Consider other problems – the hidden agenda </li></ul><ul><li>Use time appropriately within this and future consultations </li></ul><ul><li>Establish and build a relationship with the patient. </li></ul><ul><li>The model presents method, but the </li></ul><ul><li>ideal is difficult to do within the time </li></ul><ul><li>constraints of practice. It is also difficult to </li></ul><ul><li>recall what task to do next. The doctor is </li></ul><ul><li>always an apprentice to the concept of the </li></ul><ul><li>perfect consultation. </li></ul>
  7. 8. Neighbour R (1987) The Inner Consultation Lancaster, MTP press <ul><li>Neighbour seeks to make us </li></ul><ul><li>unconsciously competent consulters. </li></ul><ul><li>We negotiate an achievable </li></ul><ul><li>consultation ( connection ), co- </li></ul><ul><li>construct a formulation scope </li></ul><ul><li>( summarising ) of the problems, we </li></ul><ul><li>seek to ensure that the medical story </li></ul><ul><li>( handing – over ) is accessible for the </li></ul><ul><li>patient ( gift wrapping ) and that </li></ul><ul><li>influencing and negotiating a plan is </li></ul><ul><li>patient-centred, safety netting </li></ul><ul><li>requires that we tell the patient when </li></ul><ul><li>to come back. Finally we housekeep </li></ul><ul><li>to ensure that we are emotionally </li></ul><ul><li>centred on our next patient. </li></ul><ul><li>This allows the consultation to be </li></ul><ul><li>coached in a holistic and humanising </li></ul><ul><li>way. The dimensions of consulting </li></ul><ul><li>effectively are summarised: </li></ul><ul><li>Personal Qualities – clinical ability, </li></ul><ul><li>warmth, caritas, empathy </li></ul><ul><li>Skills – active listening, </li></ul><ul><li>negotiating, influencing, explaining </li></ul><ul><li>Attitudes – self-awareness, </li></ul><ul><li>flexibility, an appreciation of diversity </li></ul><ul><li>See Naidoo P. (2008) Cases and </li></ul><ul><li>Concepts for the new MRCGP p272 </li></ul><ul><li>However, this agenda is about the </li></ul><ul><li>personal development of the doctor; </li></ul><ul><li>in a reflexive relationship all parties to the </li></ul><ul><li>consultation need to grow in their </li></ul><ul><li>understanding of life’s narrative </li></ul>
  8. 9. Participative – Launer J. (2002) Narrative-Based Primary Care Oxford, Radcliffe M P <ul><li>Patients and doctors tell stories. </li></ul><ul><li>Traditionally a doctor seeks to </li></ul><ul><li>understand the patient’s story </li></ul><ul><li>from a diagnostic standpoint; </li></ul><ul><li>in narrative based medicine the </li></ul><ul><li>doctors seeks to help the patient </li></ul><ul><li>reframe their life-narrative. </li></ul><ul><li>An exemplar, rituals (Obsessive </li></ul><ul><li>Compulsive Disorder) can be </li></ul><ul><li>seen as a learnt behaviour to help the </li></ul><ul><li>heroic patient deal with the </li></ul><ul><li>impossibility of their life situation. </li></ul><ul><li>The effect can be make consulting </li></ul><ul><li>become ultra short therapy over all too </li></ul><ul><li>shorter career (sorry a highly personal </li></ul><ul><li>view). </li></ul><ul><li>Sharing Cs: Conversation is </li></ul><ul><li>dialogical, problems are dissolved </li></ul><ul><li>rather than solved. You need to </li></ul><ul><li>have a committed interest to the </li></ul><ul><li>patients emotional agenda and </li></ul><ul><li>their use of language. Circularity </li></ul><ul><li>tracks the way interactions with </li></ul><ul><li>families evolve and transform. </li></ul><ul><li>Contexts situate narrative to </li></ul><ul><li>places. The overarching aim is to </li></ul><ul><li>co-create a better story, but also </li></ul><ul><li>to exercise caution in respecting the </li></ul><ul><li>way patients set realistic life goals. </li></ul><ul><li>The methodology is suited to practitioners </li></ul><ul><li>who seek to ask how can I help this </li></ul><ul><li>patient? There is a consultation space that </li></ul><ul><li>accommodates life’s complexity. </li></ul>

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