Consultation Models

Dr Darren Tymens, 2003

Consultation Models

"Bad consultations result from having insufficient clinical knowledge, from failing to relate to patients or from failing to understand the patient's behaviour, his perception of his illness or its context“

- JGR Howie (1985)

Consultation Models

• Descriptive• Normative• Conceptual• Practical

The Biomedical Model

• Take an accurate and relevant history (OBSERVATION).

• Perform an accurate and relevant examination (OBSERVATION).

• Make a provisional diagnosis (HYPOTHESIS). • Order and interpret the results of appropriate

investigations (HYPOTHESIS TESTING). • Make a definitive diagnosis (DEDUCTION).

M Balint (1957) The Doctor, His Patient and The Illness

• The Apostolic Function • The Drug Doctor• The Sick Role • The Long Consultation

Berne (1964) Games People Play / Transactional

Analysis

• Games• Parent / Adult / Child

RCGP Model (1972) Physical, Psychological and Social

‘The Triaxial Model’

• Extend thinking beyond organic • Consider Emotional, Family, Social and

Environmental factors

Becker & Maiman (1975) Health Belief Model

• Ideas• Concerns• Expectations

Heron (1975)Types of Intervention

• Prescriptive • Informative • Confronting • Cathartic • Catalytic • Supportive

Byrne & Long (1976)6 Phases of the Consultation

1. The doctor establishes a relationship with the patient

2. The doctor discovers or attempts to discover the reason for the attendance

3. The doctor conducts a verbal and/or physical examination

4. The doctor, the doctor and patient, or the patient (in that order of probability) consider the condition

5. The doctor and occasionally the patient detail further treatment or investigation

6. The consultation is terminated, usually by the doctor

Byrne & Long (1976)Consultation Styles

• doctor-centred– dominates the consultation – asks direct, closed questions – rejects the patient's ideas – evades the patient's questions

• patient-centred– asks open questions – actively listens – challenges and reflects the patients' words and

behaviour to allow them to express themselves in their own way

Stott & Davis (1979) Areas to Explore

• The identification & management of the presenting problem

• Modification of the patient's help-seeking behaviour

• The management of continuing problems• Opportunistic health promotion

Helman (1981)‘Folk Model’ - Questions to be Answered

• What has happened? • Why has it happened? • Why me? • Why now? • What would happen if nothing were done

about it? • What should I do about it and who should I

consult for further help?

Pendleton (1984)the Doctor's Tasks

• Define the reason for the patient's attendance• Consider other problems • Together choose an appropriate action for each

problem • Achieve a shared understanding of problems • Involve the patient in the management of problems

and encourage acceptance of appropriate responsibility

• Use time and resources appropriately • Establish and maintain a relationship with the patient

which helps to achieve the other tasks

Levenstein (1984)Patient-Centred Model

1. Exploring both the disease and the illness experience

2. Understanding the whole person

3. Finding common round regarding management

4. Incorporating prevention and health promotion

5. Enhancing the Doctor-Patient relationship

6. Being realistic

Patient-Centred Model

Disease-Illness Model (1984)

Neighbour (1987) Checkpoints

1. Connecting: have we got rapport?

2. Summarising: could I demonstrate to the patient that I've sufficiently understood why he's come?

3. Handing over: has the patient accepted the management plan we have agreed?

4. Safety-netting: What if...?

5. Housekeeping

Fraser (1987)Areas of Competence

1. Interviewing and history-taking

2. Physical examination

3. Diagnosis and problem-solving

4. Patient management

5. Relating to patients

6. Anticipatory care

7. Record-keeping

Kurtz and Silverman (1996) Calgary-Cambridge Observation Guide

A. Initiating the session

B. Gathering information

C. Building the relationship

D. Giving information - explaining and planning

E. Closing the session

MRCGP Video Criteria• Doctor encourages patient’s contribution. • Dr. responds to cues • Dr. elicits appropriate details to place complaint in social & psycho-

logical context • Dr. explores patient’s health understanding    Merit • Dr. obtains sufficient information for no serious condition to be missed. • Dr. chooses an appropriate examination. • Dr. makes clinically appropriate working diagnosis. • Dr. explains diagnosis. • Dr. uses appropriate language. • Dr. takes account of patient’s belief   Merit. • Dr. confirms patient’s understanding   Merit. • Dr. uses appropriate management plan. • Dr. shares management options. • Dr. uses appropriate prescribing behaviour. • Dr. and patient appear to have established a rapport.