Transcript The General Practice Consultation

How do you teach the General
Practice Consultation?
Dr Ian McKelvey
I underestimated two things when
I opted to become a GP…
1. GP Receptionists
2. The Value of the Consultation
Consultation Models.
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Calgary Cambridge
Pendleton et al– The Consultation
Neighbour – The Inner Consultation
Stott and Davies – The exceptional potential of each
primary care consultation
Byrne and Long – 6 phases
Helman’s ‘folk model’
McWhinney’s disease Illness Model
Counselling Model
The RCGP’s COT
McKelvey – The Consultation Hill.
….they are all interchangeable and
pretty much say the same thing!
In theory there is no difference between
theory and practice; in practice there is.
Initiating the Session
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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
 the patient’s perspective
 background information - context
• making
organisation
overt
Building the
relationship
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using
appropriate
non-verbal
behaviour
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developing
rapport
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involving
the patient
Physical examination
• attending to
flow
Explanation and planning
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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
Roger Neighbour
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Connecting
2.
Summarising...physical, psychological, social.
3.
Handing Over …influencing, negotiating, giftwrapping, ‘my friend John’….
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Safety-netting....?OK
Housekeeping.. Am I in good shape for the next
patient?
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Pendleton et al
Define reason for attendance
nature and history of problems
Aetiology
Ideas, Concerns, Expectations
Effects of problems
Consider other problems
Continuing problems
At risk factors
With patient, choose appropriate action
for each problem
Achieve shared understanding of
problem/s
Involve patient in management and
encourage him to accept appropriate
responsibility
Use resources appropriately
In the consultation
In the long term
Establish and maintain a relationship with
the patient that helps achieve the other
tasks
McWhinney’s disease-illness model
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Patient presents at a particular time
when have reached either their
‘limit of symptom tolerance’ or
‘limit of anxiety’
useful to move focus to patient agenda
( hospital doctor to GP)
McWhinney
On and
on
Patient
Parallel
Understanding
of patients
experience
Medical
Parallel
HF
Helman’s Folk Model
Patient comes to a doctor seeking answers to 8
questions….
1. What has happened?
2. Why has it happened?
3. Why to me?
4. Why now?
5. What would happen if nothing were done about it?
6. What should I do about it or whom should I consult for
further help?
7. What can you (the doctor) do about it?
8. How can I stop it happening again?
Stott and Davies.
The Exceptional Potential in each primary care consultation
• Management of
presenting problems
• Management
of continuing
problems
• Modification of
help-seeking
behaviours
• Opportunistic
Health Promotion
Counselling Model
• Ultimate patient centred approach
• ‘Allow patient to explore in their own way and at own
pace the origins, implications and solutions to their
problem’
• Doctor must have ability to keep own opinions and
suggestions to themselves
• Use techniques such as reflecting, interpreting and
judicious use of silence in order to bring the patient to an
insight which is his own and nobody else’s
• PERHAPS NOT IDEAL TO EMBRACE PRIOR TO CSA
• i.e. BOLLOCKS
Neighbour’s Consultation Model
4. Safety
netting
5. House
keeping
3. Handing Over
2. Summarising
1. Connecting
The centipede was happy, quite,
Until a toad in fun
Said, “Pray, which leg goes after which?”
This worked his mind to such a pitch
He lay distracted in a ditch
Considering how to run.
1. Connecting
• Rapport
• Gambits & Curtain Raisers
• Minimal cues – verbal and nonverbal
• What is said & not said
• Representational systems-V,A & K
• Eye movements
• 3 cardinal mental thought processes
Speech censoring
Internal Speech
Acceptance Set
Rapport
• The ‘sine qua non’ of effective communication
• Two people being mutually responsive to each others
signals
• Not the same as liking someone
• Dr owes it to the patient
• A process, not a state. Something you do, like tuning a
radio
• Reading the physical signs of someones mental state
• Can be practiced by developing greater sensory
awareness of the minimal cues by which people signal
their thoughts and feelings.
• Minimal cues….?
Minimal Cues - the physical signs
of mental illness
• Verbal – what’s said and not said
• Non-verbal Auditory
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Visual
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Kinaesthetic
• Imagine being invisible at a party….
Pedicates - Visual(V) Auditory (A)
Kinaesthetic (K)
I see what you mean (V)
I hear what you are saying say (A)
I grasp what it is you are going through (K)
The future looks bleak. My life’s a mess (V)
We’re not in tune with each other any more. We
just row and clash. (A)
I don’t know where to turn. I feel stuck in a rut. (K)
Eye movement Accessing Cues
Visual constructed
Visual remembered
Auditory remembered
Auditory
constructed
Kinaesthetic
Auditory internal
dialogue
2. Summarising
•What information do we need?
I, C, E.
Feelings
Effects of symptoms, treatment etc
•When should you elicit that information?
•What signals can the patient give to suggest that
more information could be elicited?
•How should we elicit the information?
3.Handing Over
•Negotiating
Give the patient options
•Influencing
in my opinion…
Use questions instead of statements
Reframing
Shepherding –
value laden phrases, eg admission or not
presuppositions
eg tea or coffee
pre-empting
my friend John…
•Gift Wrapping
Chunk & Check
How to give instructions – rule of 3.
4. Safety Netting
•“General Practice is the Art of Managing Uncertainty”
•If I am right, what do I expect to happen?
Worst case scenario
Instructions to patient
F/U - What if patient doesn’t come back?
•How will I know if I am wrong?
•What will I do then?
What to say to the patient
5. House Keeping
•Long term
•In between Patients
•During Consultations
CSA and nMRCGP
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13 cases
Own room
10 minutes each. 2 minutes between each case
A practical assessment of consulting skills
Expensive £1,260 a throw.
Examiner sits in the corner
Break in the middle after 7 patients of 15 mins
No marks will be gained after 10 mins when buzzer
sounds
• No 1-2 minute warning buzzer
• “shows poor time management” is a reason they can fail
you at any station…..and they will
CSA
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Each case is marked on 3 domains
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data gathering, examination and clinical
assessment skills
Clinical management skills
Interpersonal skills
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All domains have equal weighting
Do not spend 8 minutes on history and
examination…you will fail this station
The Consultation Hill.
Shared Summit
Ascent
Preparation
Descent
Reflection
“seek first to understand, then be understood”
Preparation
• System preparation
patient access, phone, booking systems, reception staff, waiting room,
toilets, IT system, forms, equipments, consultation room, PILs, telephone
interruption policy.
• Personal preparation
Be rested, mentally and physically. If late, don’t rush. Offload ‘baggage’.
Identify personal prejudices and stresses and leave outside the clinical
encounter
Ascent
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Reason for attendance/ information gathering
ICEs
Why here, why now?
Preferred representational system? (VAK)
Acceptance set?
Rapport
History and Examination
Largely patient led
Dr – listening, facilitating, encouraging, interpreting, clarifying,
empathising (actively)
• End by ‘summarising’ to reach shared summit. (beware of reaching
the wrong summit if Dr and patient don’t share same understanding
of patients reasons for attending)
• Dr should by the end have established a ‘working diagnosis’ and
formulated an action plan.
Shared Summit
• Pause, take in the air, enjoy the view of a shared
understanding. ( pause, slow intake of breath, reflective look, shift in body
posture, change of tone, rate, volume of speech)
• Can be identified and acknowledged
• May be most exposed here, so Dr must be
preparing for a safe descent down a devised
route which is now more Dr led.
• Route planned so can negotiate and ‘hand over’
using information gained on the ascent
• Need to get here in 7-8 minutes for the CSA!
Descent
• Tailored explanation of the problem and a solution
offered, incorporating and using patients already
established health beliefs and understanding, which can
be sensitively modified if appropriate.
• Management plan proposed and seek approval from the
patient (acceptance set)
• Confirm patients understanding and define their
responsibility and involvement in the process. This will
increase compliance
• What if it goes wrong? Acknowledge this and plan
another assault on the consultation hill?
• Foothills include ‘safety netting’
Reflection
• Always something to be learnt from any
clinical encounter
• PUNs and DENs (Eve ; discovering learning needs in GP)
• It’s a lifetime of learning….!
My last word, ….honest
• You need to reflect upon how your work affects your
physical, mental, spiritual and emotional state ….
• ….as healthy doctors are more likely to provide good
medical care.
• Kit fit, let the journey be safe for both you and patient,
enjoy the challenge of the consultation hill and strive to
make the next trip more successful.
• ‘In general practice the consultation is a journey, not a
destination’….Roger Neighbour
So how do you teach all
this….?
•Joint surgeries
•Video analysis
•Role Play
•Has to be experiential…
•Trainee has to identify the area to work on and feel it important enough to improve/work on.
Can use SET-GO (what I Saw, what Else did you see, what do you Think,,clarify Goal, any
Offers how to get there.
•Do it in bite sized chunks – Work on one task per week
Ideas
‘Tell me about what you think is causing it.’
‘What do you think might be happening?’
‘Have you any ideas about it yourself?’
‘Do you have any clues; any theories?’
‘You’ve obviously given this some thought, it would help me to know what you were
thinking it might be’.
Concerns
‘What are you concerned that it might be?’
‘Is there anything particular or specific that you were concerned about?’
‘What was the worst thing you were thinking it might be?’
‘In your darkest moments ...‘
Expectations
‘What were you hoping we might be able to do for this?’
‘What do you think might be the best plan of action?’
‘How might I best help you with this?’
‘You’ve obviously given this some thought, what were you thinking would be the
best way of tackling this?’
Effects on Life
…..the 50p game.
The Three Function Approach to the Medical Interview (1989)
Cohen-Cole and Bird have developed a model of the consultation that
has been adopted by The American Academy on Physician and Patient
as their model for teaching the Medical Interview.
• Gathering data to understand
the patient's problems
• Developing rapport
• Education and motivation
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Open-ended question
Open to closed cone
Facilitation
Checking
Survey of problems
Negotiate priorities
Clarification and direction
Summarising
Elicit patient's expectations
Elicit patient's ideas about aetiology
Elicit impact of illness on patient's quality of life
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Reflection
Legitimation
Support
Partnership
Respect
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Education about illness
Negotiation and maintenance of a treatment plan
Motivation of non-adherent patients
Neighbours 9 rules of thumb of ‘How to give