General Practice ST1 – GP Placement Introduction

Educational Solutions for Workforce Development

East DeaneryGeneral Practice ST1 – GP

Placement Introduction


East DeaneryGP SPECIALTY TRAINING

THREE or FOUR YEARS

YEAR ONE – 6 months medical specialties, 6 months GP

YEAR TWO – other specialties

YEAR THREE – Final GP year [or higher level specialty post(s) then final 4th year GP]


East DeaneryGP SPECIALTY TRAINING

FIRST SIX MONTHS IN GENERAL PRACTICE – THE BASICS

1. CONSULTATION + COMMUNICATION SKILLS

2. INFORMATION HANDLING & INFORMATION TECHNOLOGY

3. “DOING THE JOB”


East DeaneryCommunication Skills

Doctor –patient communication is central to clinical practice

Doctors perform consultations

in a professional lifetime

There are major problems in communication between doctors and patients

Effective communication is essential to high quality medicine

200 000200 000


East Deanery

Consultation

• Consultation Models + understanding

• Videos – Analysis & C.O.T.

• Role Play

• Learning as an Expert


East DeaneryCommunication

Do doctors actually want to improve their consultation skills?

How would you define, communication skills & consultation skills? How do they differ?

What factors make a successful consultation? – list

What are the barriers to effective consultation?



Need for extra effort, time and emotional commitment

Clinical skills – examination & practical procedures only

Communication skills – non-clinical aspect

Consultation skills = Clinical skills + Communication skills


East Deanery

Communication - What you need to achieve in a consultation?

Discover the reasons for a patients attendance

Define the clinical problems

Address the patients problems

Explain the problems to the patient

Make effective use of the consultation

“The Doctor’s Communication Handbook” -Peter Tait



CONTACT

COMPLAINT

CONTEXT

CONCERNS

CONSENSUS “The 5 Cs” Donald Gemmell


East DeaneryCOMMUNICATION

4 E’s & 2 F’s

Critical communication tasksENGAGE

EMPATHISE

EDUCATE

ENLIST

Biomedical tasksFIND the problem

FIX it

“Bayer educational model”



Calgary/Cambridge Model – Tasks

1. Initiating the session

2.Gathering information

3.Building the relationship

4.Explanation and planning

5.Closing the session



“Pendleton’s Rules”• Briefly clarify any matters of fact• Encourage the learner to go first• Consider what has been done well first• Make recommendations rather than state

weaknesses



“ALOBA” – agenda led outcome based analysis

• Discover and record the learner’s agenda before looking at consultation

• Look at consultation

• Self-assessment by learner according to stated agenda

• Group is invited to add ideas

• Range of suggestions of ways to improve created

• Learner selects from range what they would like to try next time



2 dimensional - doctor centred v. patient centred

3 dimensional – physical, psychological, social

4 dimensional – presenting problem, continuing problems, modifying health-seeking behaviour, health promotion

5 dimensional – connecting, summarising, hand-over, safety-netting, housekeeping (& 5 Cs)



6 dimensional – PHASES > relationship, agenda, examination, consideration, treatment, closure; HEALTH BELIEFS > What? Why? Why me? Why now? What if? What next?

7 dimensional – agenda, other problems, choice of action, shared understanding, involvement, use of resources, maintaining relationships.



Miller (1990) – Pyramid of clinical competence

DOES

SHOWS HOW

KNOWS HOW

KNOWS



DOES – sit in or video – real patients, role play or simulated patients

SHOWS HOW

KNOWS HOW – face to face tutorial (formative) oral exam (regulative)

KNOWS – questionnaire or rating scales



COMPETENCE knows how to do (can do)

PERFORMANCE actually puts into practice (does)



QUALITY IMPROVEMENT

Peer review

Self assessment

(Teacher/Trainer feedback)



Communication is a core clinical skill – an essential component of clinical confidence

Knowledge, communication skills, physical examination and problem solving are the four essential components of clinical competence

Without appropriate communication skills, our knowledge and intellectual efforts are wasted

Communication turns theory into practice



Defining the broad type of communication skills

CONTENT SKILLS

PROCESS SKILLS

PERCEPTUAL SKILLS



CONTENT SKILLS

What doctors communicate – the substance of their questions and responses; the information they gather and give; the treatments they discuss.



PROCESS SKILLS

How they do it – the ways they communicate with patients; how they go about discovering the history or providing information; the verbal and non-verbal skills they use; how they develop the relationship with the patient; the way they organise and structure communication



PERCEPTUAL SKILLS

What they are thinking and feeling – their internal decision making, clinical reasoning and problem solving; their awareness of feelings and thoughts about the patient, the illness and other issues that may be concerning them; aware of their own self-concept and confidence, of their own biases, attitudes, intentions, and distractions


East Deanery

Communication Skills - Video

Beliefs Hopes Fears Hidden problems Expectations

Patient’s agenda

Doctor’s agenda Sharing understanding

Presenting problems

Patient centered Doctor centered

A power-shift model of styles of consultation

Secondary problems Perceived problems Perceived effects

Analysing Further questioning Clarifying Interpreting Verifying

Information gathering Fact collecting


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Communication Skills - Video

Introduction Patient cues

Opening Gambit Rapport Open Qs

Management A mutual decision made

Goals established Process clear Patient/Doctor roles clear

Negotiation process

Context

Person

Disease

Illness

Symptoms Signs Investigations

Stage of life Personality Accupation Aspirations

Family context Culture Finances

Feelings Ideas Functions Expectations

Patient Centred Clinical Method


East DeaneryTHE GP CURRICULUM

You can only remember three things…..

3 core domains

3 other domains

3 bits you need to apply the domains


East Deanery1. Primary care management

To provide quality care – access good clinical care – organised and evidence basedgood communicationTo act in -diagnosis and managementcoordinate PHCTrefer – secondary care / voluntary services / familybe an advocate


East Deanery2. Person centred care

Patients want -

a competent doctor

an active role

to be listened to

a caring doctor

We want -

to be effective

Why has this patient with this problem come to see me today?What does this problem mean to this patient?


East Deanery3. Specific problem solving skills

Tolerate uncertainty vs reduce uncertaintyExplore probability vs explore possibilityMarginalise danger vs marginalise error

You need - knowledge of natural history of illnessrange of skillsstepwise plan of actionuse time – both urgent and at leisurelikelihood information


East DeaneryA comprehensive approach Coping with multiple complaintsDealing with co-morbidityBalancing treatment / symptom relief / preventionWorking the system

Community orientation Public healthJusticePrioritisation / resource allocation / rationing

A holistic approach Triple diagnosisHealth beliefs Cultural and existential


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3 “essential features” that will impact on your ability to apply the competencies

Contextual The working environmentThe practice demographyPressures you are underHome and personal circumstances

Attitudinal Belief and valuesRegulatory frameworkLegal frameworkEthical principals

Scientific KnowledgeBasic understanding of medical scienceEvidence based medicineAbility to critically analyse information


East DeaneryAgendas

Doctors agenda

To make a diagnosisTo initiate managementTo practice safelyTo get through our surgeries efficiently

Patients agenda

To find out what has happenedTo be able to fit this into their personal circumstances (knowledge & beliefs)To understand and agree what needs done


East DeaneryWhat do patients want?

Clear information

Mutually agreed goals

An active role

Positive empathy and support

Sensitivity and support

Involvement

Explanations


East DeaneryWhat are the benefits?

Patient satisfaction

Compliance

Better health outcomes


East Deanery

Doctors

agenda

Patients

Agenda

Effective

Consulting

What are we trying to achieve?

MERGING AGENDAS

Documents

General Practice ST1 – GP Placement Introduction