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Consultation Models 2

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  • 1. Consultation ModelsConsultation ModelsDr. Gertrude C. Holder, MD, Dip.,Dr. Gertrude C. Holder, MD, Dip.,ABFPABFPConsultantConsultantDept. Family MedicineDept. Family MedicinePMHPMHPRESENTER: MOKGWANE E SPRESENTER: MOKGWANE E SDOCTOR IN TRAININGDOCTOR IN TRAINING
  • 2. Consultation ModelsConsultation ModelsThe consultation is the central task ofThe consultation is the central task ofgeneral practicegeneral practiceConsultation skills form the basis of goodConsultation skills form the basis of goodpatient care.patient care.ConsultationConsultation skills can be learned andskills can be learned andrequires systematic training rather thanrequires systematic training rather thanjust experiencejust experience
  • 3. Consultation models &Consultation models &stylesstylesNo correct way to perform aNo correct way to perform aconsultationconsultationApproach varies according to situationApproach varies according to situation& participants& participantsDifferent consultation styles will beDifferent consultation styles will beeffective in different circumstances/effective in different circumstances/for different doctorsfor different doctors
  • 4. Consultation ModelsConsultation ModelsReasons for participating in a medicalReasons for participating in a medicalencounter 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 inorder to see more patientsorder to see more patients
  • 5. An Effective ConsultationAn Effective ConsultationImmediate Outcomes:Immediate Outcomes:– Patient’s clear understanding and recall of thePatient’s clear understanding and recall of theinformation 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 patientLong 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 toeffective communicationeffective communicationLack of timeLack of timeLanguage problemsLanguage problemsDiffering gender/age/ethnic or socialDiffering gender/age/ethnic or socialbackgroundsbackgrounds‘‘Sensitive’ issues to addressSensitive’ issues to address‘‘Hidden’ or differing agendasHidden’ or differing agendasPrior difficult meetingsPrior difficult meetingsLack of trustLack of trust
  • 7. Consultation Models-PendletonConsultation Models-PendletonTasksTasksTo define the reasons for the patients attendance including:To define the reasons for the patients attendance including:the nature and history of the problemthe nature and history of the problemtheir causetheir causethe patients ideas, concerns and expectationsthe patients ideas, concerns and expectationsthe effects of the problemthe effects of the problemTo consider other problems:To consider other problems:continuing problemscontinuing problemsrisk factorsrisk factorsTo choose with the patients an appropriate action form each problemTo choose with the patients an appropriate action form each problemTo achieve a shared understanding of the problems with the patientTo achieve a shared understanding of the problems with the patientTo 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 appropriateresponsibilityresponsibilityTo use time and resources appropriatelyTo use time and resources appropriatelyTo 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 thereason for the patient’s attendancereason for the patient’s attendanceExample: 55 year-old female teacher whoExample: 55 year-old female teacher whopresents with headache and tirednesspresents with headache and tiredness– The nature and history of the problemThe nature and history of the problemShe reports waking up extra early in the mornings over theShe reports waking up extra early in the mornings over thepast three weeks. She is irritable, and her teenage childrenpast three weeks. She is irritable, and her teenage childreneasily annoy her. She cries often. She still engages ineasily annoy her. She cries often. She still engages insexual activity with her husband but wishes he would leavesexual activity with her husband but wishes he would leaveher alone. She questions whether her students areher alone. She questions whether her students arebenefiting from her classes although she admits to tryingbenefiting from her classes although she admits to tryinghard.hard.
  • 9. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining thereason for the patient’s attendancereason for the patient’s attendanceAetiologyAetiologyShe says her 18 year old son wasShe says her 18 year old son wasinvolved in a motor cycle accident. This isinvolved in a motor cycle accident. This isthe third in one year. Previously hethe third in one year. Previously hesuffered light bruises. This time he wassuffered light bruises. This time he wasseverely battered and to quote her, “thankseverely battered and to quote her, “thankGod, the bike was totally destroyed and heGod, the bike was totally destroyed and heescaped with his life.”escaped with his life.”
  • 10. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining thereason for the patient’s attendancereason for the patient’s attendanceThe effect of the Problem;The effect of the Problem;– Her concerned husband urged her to visit theHer concerned husband urged her to visit thedoctor because she is obviously distraughtdoctor because she is obviously distraughtand not looking well. Her children too feel sheand not looking well. Her children too feel sheis over-reacting and her usually worrisomeis over-reacting and her usually worrisomenature has worsened.nature has worsened.
  • 11. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining thereason for the patient’s attendancereason for the patient’s attendanceHer ideasHer ideas– She feels her symptoms are due to herShe feels her symptoms are due to herconstant worrying. She admits that herconstant worrying. She admits that hermother was an incorrigible worrier and shemother was an incorrigible worrier and shehas acquired the same nature. She feelshas acquired the same nature. She feelshelpless to change her thought patterns.helpless to change her thought patterns.
  • 12. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining thereason for the patient’s attendancereason for the patient’s attendanceHer ConcernsHer Concerns- She feels depressed. Worse, she says, “I- She feels depressed. Worse, she says, “Ifeel I’m going out of my mind”. She knowsfeel I’m going out of my mind”. She knowsthis is affecting her relationship with herthis is affecting her relationship with herhusband, and is making her jobhusband, and is making her jobintolerable. She is particularly concernedintolerable. She is particularly concernedthat she will be unable to complete thethat she will be unable to complete therequired 33 1/3 years needed to getrequired 33 1/3 years needed to getretirement benefits.retirement benefits.
  • 13. Pendleton’s Tasks: Defining thePendleton’s Tasks: Defining thereason for the patient’s attendancereason for the patient’s attendanceHer ExpectationsHer Expectations- She wants the doctor to give her- She wants the doctor to give hermedication to treat her depression andmedication to treat her depression andhelp her to sleep. She came prepared tohelp her to sleep. She came prepared toreject any referral to a psychiatrist.reject any referral to a psychiatrist.
  • 14. Consultation ModelsConsultation ModelsDescription 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 reasonfor the patients attendancefor the patients 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 furtherinvestigationinvestigation– The consultation is terminated - usually by the doctorThe consultation is terminated - usually by the doctor
  • 15. Consultation ModelsConsultation ModelsNeighbourNeighbourA: Connecting: “Have we got a rapport?”A: Connecting: “Have we got a rapport?”B: Summarizing (Clinical Process): “Can IB: Summarizing (Clinical Process): “Can Idemonstrate to the patient I have understooddemonstrate to the patient I have understoodwhy she has come?”why she has come?”C: Handing Over: “Has the patient accepted theC: Handing Over: “Has the patient accepted themanagement plan we agreed?”management plan we agreed?”D: Safety-Netting: “Have I anticipated all likelyD: Safety-Netting: “Have I anticipated all likelyoutcomes?”outcomes?”E: Housekeeping: “Am I in good condition for theE: Housekeeping: “Am I in good condition for thenext patient?”next patient?”
  • 16. Consultation ModelsConsultation ModelsThe Patient Centered Clinical Model:The Patient Centered Clinical Model:-describes specific behaviors necessary to develop an-describes specific behaviors necessary to develop aneffective clinical methodeffective clinical method-physicians as well as patients needs are satisfied-physicians as well as patients needs are satisfiedThe six integrated components of the patient-centeredThe six integrated components of the patient-centeredprocess: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 ModelExploring the disease and IllnessExploring the disease and IllnessExperienceExperience– Explores signs and symptoms of disease toExplores signs and symptoms of disease toformulate a differential diagnosisformulate a differential diagnosis– ‘‘Steeps’ the physician in the experience ofSteeps’ the physician in the experience ofpatients to understand illness from their pointpatients to understand illness from their pointof viewof view
  • 18. Exploring the disease and illnessExploring the disease and illnessexperienceexperienceKnowledgeKnowledge– 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 ofsickness; practical understanding of the distinction betweensickness; practical understanding of the distinction betweendisease 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 andrespond appropriatelyrespond appropriately– Perform physical examinationPerform physical examinationAttitudesAttitudes– Willingness to become totally involvedWillingness to become totally involved
  • 19. Understanding the whole personUnderstanding the whole personKnowledge:Knowledge:– Understand the human condition, esp. the nature of sufferingUnderstand the human condition, esp. the nature of sufferingand 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 affectedby 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 GroundKnowledge:Knowledge:– Know scientific treatment of diseasesKnow scientific treatment of diseases– Awareness of patient autonomy and issues affecting patientAwareness of patient autonomy and issues affecting patientcompliancecomplianceSkills: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 conflictsAttitudeAttitude– 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 andHealth PromotionHealth PromotionKnowledge:Knowledge:– Practical understanding of continuity, comprehensive carePractical understanding of continuity, comprehensive care– Effective screening and preventive strategies; Risk reductionEffective screening and preventive strategies; Risk reductionSkills:Skills:– Collaborate with patients to develop lifelong policies for healthCollaborate with patients to develop lifelong policies for healthpromotion and disease preventivepromotion and disease preventive– Enhance patients self-esteem and self-confidence in caring forEnhance patients self-esteem and self-confidence in caring forthemselvesthemselvesAttitudes: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, preventionand health promotionand health promotion
  • 22. Enhancing the patient-doctorEnhancing the patient-doctorrelationshiprelationshipKnowledge: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-doctorrelationshiprelationship– Working knowledge of transference and counter-transferenceWorking knowledge of transference and counter-transferenceSkills: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 healingrelationshiprelationshipAttitudes: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 RealisticKnowledge: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 medicineSkills: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 effectivelyAttitudes:Attitudes:– Awareness of personal limitationsAwareness of personal limitations– Willingness to ask for helpWillingness to ask for help
  • 24. Disease-Illness ModelDisease-Illness ModelIntegrates the clinical or biophysical content withIntegrates the clinical or biophysical content withan understanding for what symptoms mean toan understanding for what symptoms mean tothe 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– InvestigationsInvestigationsIllness 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