Consultation Models

The Consultation Models

Physical, Psychological and Social (1972)

The RCGP model encourages the doctor to extend his thinking practice beyond the purely organic approach to patients, i.e., to include the patient’s emotional, family, social, and environmental circumstances.

Stott and Davis (1979)

“The exceptional potential in each primary care consultation” suggests that four areas can be systematically explored each time a patient consults.

1. Management of presenting problems
2. Modification of help-seeking behaviors
3. Management of continuing problems
4. Opportunistic health promotion

Byrne and Long (1976)

“Doctors talking to patients”. Six phases which form a logical structure to the consultation:

1. Phase I
   The doctor establishes a relationship with the patient.

2. Phase II
   The doctor either attempts to discover or actually discovers the reason for the patient’s attendance.

3. Phase III
   The doctor conducts a verbal or physical examination or both.

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

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

6. Phase VI
   The consultation is terminated usually by the doctor.

Helman’s ‘Folk Model’ (1981)

Cecil Helman is a Medical Anthropologist, with constantly enlightening insights into the cultural factors in health and illness. He suggests that a patient with a problem comes to a doctor seeking answers to six questions:

1. What has happened?
2. Why has it happened?
3. Why to me?
4. Why now?
5. What would happen if nothing was done about it?
6. What should I do about it or whom should I consult for further help?

Transactional Analysis (1964)

• Many doctors will be familiar with Eric Berne’s model of the human psyche as consisting of three ‘ego-states’ - Parent, Adult, and Child.
• At any given moment each of us is in a state of mind when we think, feel, behave, react, and have attitudes as if we were either a critical or caring Parent, a logical Adult, or a spontaneous or dependent Child.
• Many general practice consultations are conducted between a Parental doctor and a Child-like patient.
• This transaction is not always in the best interests of either party, and a familiarity with TA introduces a welcome flexibility into the doctor’s repertoire which can break out of the repetitious cycles of behavior (‘games’) into which some consultations can degenerate.

Pendleton, Schofield, Tate and Havelock (1984, 2003)

‘The Consultation - An Approach to Learning and Teaching’ describe seven tasks which taken together form comprehensive and coherent aims for any consultation.

1. To define the reason for the patient’s attendance, including:

   • i) the nature and history of the problems
   • ii) their aetiology
   • iii) the patient’s ideas,
   • iv) the effects of the problems

2. To consider other problems:

   • i) continuing problems

3. With the patient, to choose an appropriate action for each problem.

4. To achieve a shared understanding of the problems with the patient.

5. To involve the patient in the management and encourage him to accept appropriate responsibility.

6. To use time and resources appropriately:

   • i) in the consultation
   • ii) in the long term

Neighbour (1987)

Five check points: ‘where shall we make for next and how shall we get there?’

1. Connecting
   Establishing rapport with the patient.

2. Summarizing
   Getting to the point of why the patient has come using eliciting skills to discover their ideas, concerns, expectations and summarizing back to the patient.

3. Handing over
   Doctors’ and patients’ agendas are agreed. Negotiating, influencing, and gift wrapping.

4. Safety netting
   What if?: consider what the doctor might do in each case.

5. Housekeeping
   Am I in good enough shape for the next patient?

Abridged Calgary-Cambridge Guide

Task 1: Initiating the Session

Establishing initial rapport

1. Greets patient and obtains patient’s name
2. Introduces self, role, and nature of interview; obtains consent if necessary

Identifying the reason(s) for the consultation
3. Identifies the patient’s problems or the issues that the patient wishes to address (e.g., “What problems brought you to the hospital?” or “What would you like to discuss today?” or “What questions did you hope to get answered today?”)

Task 2: Gathering Information

• Exploration of patient’s problems
• Discover the biomedical perspective, patient’s perspective, and the background information 4. Uses open and closed questioning technique, moving from open to closed 5. Listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think before answering or go on after pausing 6. Facilitates patient’s responses verbally and non–verbally e.g., use of encouragement, silence, repetition, paraphrasing, interpretation

Task 3: Providing Structure

7. Summarizes at the end of a specific line of enquiry
8. Attends to timing and keeping interview on task

Task 4: Building Relationship

• Using appropriate non-verbal behavior 9. Demonstrates appropriate non–verbal behavior. Eye contact, facial expression, posture, vocal cues e.g., rate, volume, tone

• Developing rapport 10. Uses empathy to communicate understanding and appreciation of the patient’s feelings or predicament; overtly acknowledges patient’s views and feelings

Task 5: Closing the Session

• Forward planning 11. Safety nets, explaining possible unexpected outcomes, what to do if plan is not working, when and how to seek help

• Ensuring appropriate point of closure 12. Final check that patient agrees and is comfortable with plan and asks if any corrections, questions, or other items to discuss.

Task 6: Explanation and Planning

Providing the correct amount and type of information

• 13. Chunks and checks: gives information in manageable chunks, checks for understanding, uses patient’s response as a guide to how to proceed

Aiding accurate recall and understanding

• 14. Organizes explanation: divides into sections, develops a logical sequence

Achieving a shared understanding: incorporating the patient’s perspective

• 15. Provides opportunities and encourages patient to contribute

Planning: shared decision making

• 16. Involves patient by making suggestions and checks if patient accepts plans.