Transcript Calgary Cambridge model - Northumbria GP Speciality

Using video to explore behavioural
skills in the consultation
The Calgary-Cambridge approach
The MRCGP criteria - tear
them up?
DISCOVER THE REASONS FOR THE PATIENT'S
ATTENDANCE
a. ELICIT AN ACCOUNT OF THE SYMPTOM(S)
(P) PC1: the doctor is seen to encourage the patient's contribution at
appropriate points in the consultation
(M) PC2: the doctor is seen to respond to signals (cues) that lead to a
deeper understanding of the problem
b. OBTAIN RELEVANT ITEMS OF SOCIAL AND OCCUPATIONAL
CIRCUMSTANCES
(P) PC3: the doctor uses appropriate psychological and social
information to place the complaint(s) in context
c. EXPLORE THE PATIENT'S HEALTH UNDERSTANDING
(P) PC4: the doctor explores the patient's health understanding
DEFINE THE CLINICAL PROBLEM(S)
a. OBTAIN ADDITIONAL INFORMATION ABOUT THE
SYMPTOMS, AND OTHER DETAILS OF MEDICAL HISTORY
(P) PC5: the doctor obtains sufficient information to include or
exclude likely relevant significant conditions
b. ASSESS THE PATIENT BY APPROPRIATE PHYSICAL AND
MENTAL EXAMINATION
(P) PC6: the physical/mental examination chosen is likely to confirm
or disprove hypotheses that could reasonably have been formed OR is
designed to address a patient's concern
c. MAKE A WORKING DIAGNOSIS
(P) PC7: the doctor appears to make a clinically appropriate working
diagnosis
EXPLAIN THE PROBLEM(S) TO THE PATIENT
a. SHARE THE FINDINGS WITH THE PATIENT
(P) PC8: the doctor explains the problem or diagnosis in
appropriate language
(M) PC9: the doctor's explanation incorporates some or all
of the patient's health beliefs
b. ENSURE THAT THE EXPLANATION IS
UNDERSTOOD AND ACCEPTED BY THE PATIENT
(M) PC10: the doctor specifically seeks to confirm the
patient's understanding of the diagnosis
ADDRESS THE PATIENT'S PROBLEM(S)
a. CHOOSE AN APPROPRIATE FORM OF
MANAGEMENT
(P) PC11: the management plan (including any prescription)
is appropriate for the working diagnosis, reflecting a good
understanding of modern accepted medical practice
b. INVOLVE THE PATIENT IN THE MANAGEMENT
PLAN
(P) PC12: the patient is given the opportunity to be involved
in significant management decisions
MAKE EFFECTIVE USE OF THE
CONSULTATION
a. MAKE EFFECTIVE USE OF RESOURCES
(M) PC13: in prescribing the doctor takes steps to
enhance concordance, by exploring and responding
to the patient’s understanding of the treatment
(P) PC14: the doctor specifies the conditions and
interval for follow-up or review
The
diseaseillness
model
Evidence to support listening
Beckman and Frankdll (1984)
• Doctors frequently interrupted patients before they had
completed their opening statement — after a mean time of
only 18 seconds!
• Only 23% of patients completed their opening statement
• in only one of 51 interrupted statements was the patient
allowed to complete their opening statement later
• 94% of all interruptions concluded with the doctor obtaining
the floor
• The longer the doctor waited before interruption, the more
complaints were elicited
• Allowing the patient to complete the opening statement led
to a significant reduction in late-arising problems
Evidence to support listening
Beckman and Frankdll (1984)
• Clarifying or closed questions were the most frequent cause of
interruption but any utterance by the doctor that specifically
encouraged the patient to give further information about any one
problem could also cause disruption: this, perhaps surprisingly,
included echoing of the patient’s words
• In 34 our of 51 visits, the doctor interrupted the patient after the initial
concern, apparently assuming that the first complaint was the chief
one
• The serial order in which the patients presented their problems was
not related to their clinical importance
• Most patients who were allowed to complete their opening statement
without interruption took less that 60 seconds and none took longer
the 150 seconds, even when encouraged to continue.
The Calgary-Cambridge approach
• Initiating the Session
– establishing initial rapport
– identifying the reason(s) for the consultation
• Gathering Information
– exploration of problems
– understanding the patient's perspective
– providing structure to the consultation
• Building the Relationship
– developing rapport
– involving the patient
• Explanation and Planning
– providing the correct amount and type of information
– aiding accurate recall and understanding
– achieving a shared understanding: incorporating the patient's
perspective
– planning: shared decision making
• Closing the Session
Initiating the Session
Gathering information
Providing
Structure
Building the
relationship
Physical Examination
Explanation and planning
Closing the Session
Initiating the Session
• preparation
• establishing initial rapport
• identifying the reason(s) for the consultation
Gathering information
Providing
• exploration of the patient’s problems to discover the:
Structure
 biomedical perspective
• making
organisation
overt
Building the
relationship
 the patient’s perspective
 background information - context
•
using
appropriate
non-verbal
behaviour
•
developing
rapport
•
involving
the patient
Physical examination
• attending to
flow
Explanation and planning
• providing the correct amount and type of information
• aiding accurate recall and understanding
• achieving a shared understanding: incorporating the patient’s
illness framework
• planning: shared decision making
Closing the Session
• ensuring appropriate point of closure
• forward planning
So what are your needs?
• Have a look at the Calgary Cambridge
behavioural skills – which do you think you
need to work on most?
• Discuss for a few minutes in pairs then we
will collate on a flipchart
The group process
• Volunteer describes any background information s/he had before the
consultation
• One person volunteers to view the consultation from the patient’s
perspective
• Video is shown as raw material for work – group notes issues and
time on tape
• Volunteer defines what s/he wants to get out of the session (flagging
up good and exploring developmental) onto flipchart then group adds
their agenda too
• Volunteer chooses what agenda item to go with first
– review that portion of the tape
– how could it be done differently?
• Roleplay with patient volunteer, group ideas, further roleplay
(rehearsal)
• Summary of learning points
Good feedback centres on the
fundamental rule of communication
that it is outcome based –
therefore…
•
•
•
•
What were you trying to achieve then,
what were you aiming for,
what did you try to do to get there,
what could you have done differently to
help you get there?
Rules for feedback
• “What I saw was…”
– Descriptive
– Specific
– Non judgmental
• “What I might try is…”
– Owning statements
• Non-judgmental
• Specific
• Directed towards
behaviour rather than
personally
• Checked with the recipient
• Outcome based
• Problem solving In the
form of suggestions rather
than prescriptive
comments
The group process
• Volunteer describes any background information s/he had before the
consultation
• One person volunteers to view the consultation from the patient’s
perspective
• Video is shown as raw material for work – group notes issues and
time on tape
• Volunteer defines what s/he wants to get out of the session (flagging
up good and exploring developmental) onto flipchart then group adds
their agenda too
• Volunteer chooses what agenda item to go with first
– review that portion of the tape
– how could it be done differently?
• Roleplay with patient volunteer, group ideas, further roleplay
(rehearsal)
• Summary of learning points