Consultation Skills

Dr. Tawfeeq Naseeb

Assistant Professor
Family Medicine
 Learning objectives

By the end of this session, you will be able

to understand and define the following
objectives:
 Criteria for successful
consultation
 Common types of consultation models
 The clinical significance of these
models
 Application of these models in
clinical practice
 Introduction

 The consultation is the central

task of a medical practice
 Consultation skills form the
basis of good patient care
Time is usually short
 Introduction

 Consultation models enable the

doctors to identify:
Where are the difficulties in
consultation
Patient’s aims
 Introduction

Consultation models helps the doctor

to maintain control in the consultation
 What is a
Consultation
The Consultation Process

Patient’s Doctor’s
needs knowledge
& &
expectations experience

The consultation
What are Consulting Skills?

Clinical Communication
skills skills

Consulting skills
What is the purpose of any consultation?

So – we need to know
consultation skills
To bring & communicate effectively
our relevant with our patients
knowledge,
skills and So – we have to
experience know our medicine
to the service
of the patient
So – we have to be
patient-centred
 What is necessary for
a successful consultation?
• Relevant clinical knowledge and
skills
• A general strategy for managing the
consultation
• Specific skills, particularly:
• finding out what the problem really is?
• getting the patient adhere to a
management plan
• Process awareness: recognising,
and dealing with, what’s going in
you and the patient
 Consultation Models

The consultation is at the

heart of family medicine

What’s a Model?

Is an example that
deserves to be imitated
for a successful
consultation
 So Why are Models so Important?

• Patients don’t function simply as

machines
• They have feelings too

• Doctors don’t function simply as

machines
• They have feelings too
Consultation Models

• Weiner 1948
• Maslow 1954
• Balint 1957
• Berne 1967
• Byrne&Long 1976
• Scott&Davis 1979
• Helman 1984
• Pedelton 1984
• Neighbour 1987
• Fraser 1994
• Cambridge 1996
Classical Medical Model
 A-Scott and Davis (Task Oriented)
“In each primary care consultation” there
are four areas which can be explored
(a) Management of presenting problems
(b) Modification of help-seeking
behaviours
(c) Management of continuing problems
(d) Opportunistic health promotion
 B-Pendleton Model
• ‘The Consultation’ -
An Approach to Learning and
Teaching
• This model describe seven
tasks which when taken
together form comprehensive
and coherent aims for any
consultation
 Pendleton

(1) To define the reason for the

patient’s attendance, including:
i) The nature and history of the
problems
ii) Their aetiology
iii) Patient’s ideas, concerns and
expectations
iv) The effects of the problems on
patient’s social life
 Pendleton

(2) To consider other problems:

i) Continuing problems
ii) Risk factors
(3) With the patient, to choose an
appropriate action for each
problem
(4) To achieve a shared
understanding of the problems
with the patient
 Pendleton
(5) To involve the patient in the
management and encourage him
to accept responsibility
(6) To use time and resources
appropriately:
i) in the consultation
ii) in the long term
(7) To establish or maintain a
relationship with the patient which
helps to achieve the other tasks.
 C-Berne (Behaviour Oriented)

Human psyche model. It consists 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, and
react as if we were either:
A critical or caring Parent
A logical Adult
A dependent Child
The Doctor as a Parent

“If I’ve told you

once I told you
1,000 times,
stop smoking!!”
Patient controlled consultation
Patient as a Parent

“You’re paid to
do what I tell
you!!”
 Behaviour Oriented

Doctor Patient

Parent Parent

Adult Adult

Child
Child
Behaviour Oriented

Doctor Patient

Parent Parent

Adult Adult

Child Child
 D-Byrne and Long
Six phases form a logical structure to
the consultation:
Phase I: The doctor establishes a
relationship with the patient
Phase II: The doctor either attempts
to discover or actually discovers the
reason for the patient’s attendance
Phase III: The doctor conducts a
verbal or physical examination or both
 Byrne and Long
Phase IV: The doctor, or the doctor
and the patient , or the patient (in that
order of probability) consider the
condition
Phase V: The doctor, and
occasionally the patient, detail further
treatment or further investigation
Phase VI: The consultation is
terminated usually by the doctor
E-Neighbour’s ‘Inner Consultation’ model
‘the consultation as a journey with FIVE
checkpoints’
Checkpoint 1– Connecting
(establishing rapport)
• Greeting the patient
• Opening the interview
• Body language, gestures
• Matching patient’s language or posture
• Conveying friendliness
 Checkpoint 2 - Summarising
• Elicit patient’s story, symptoms, ideas,
concerns & expectations, stated and
unstated agenda
• Offer the patient a summary of what
you’ve understood to be the problem
• See whether patient accepts your
summary
• If not, continue to elicit, then offer a
further summary
 Checkpoint 3 - Hand-over
• Agreeing a management plan, and
checking that the patient accepts it
• Sharing decision-making & responsibility
Negotiating
• Explaining in terms patient can
understand
• Tailoring action to patient’s perception of
the problem
• Checking for understanding & agreement
 Checkpoint 4 - Safety-netting
• Thinking ahead to plan for the
unexpected
• Acknowledging uncertainty and risk
• Ask yourself three questions (and know
the answers!):
• If I’m right, what do I expect to happen?

• How will we know if I’m wrong?

• What would we do then?

 Checkpoint 5 - House-keeping
• Taking care of your own well-being
‘The consultation is not over till you’re
ready for the next one’
• Identifying any left-over feelings or needs
after the patient leaves
• Doing what you need to do, e.g.
• Stretch and relax.
• Have a cup of coffee
• Talk to someone
• Release feelings
Neighbour’s ‘Inner Consultation’ model:
‘the consultation as a journey with 5 checkpoints’
Take care of your own
physical & mental wellbeing

5 - HOUSE-KEEPING Establish working

rapport with the patient

1 - CONNECT
Check, by offering a
summary, that you’ve
understood what the
2 - SUMMARISE patient has come for

Make sure the patient is

3 - HAND-OVER happy with the agreed
management plan

4 - SAFETY-NET Anticipate the

unexpected and make
a contingency plan
F-The Three Function Approach to the
Consultation / Skill Oriented
• Cohen-Cole have developed a model
of the consultation that is called Skill
Oriented Consultation
(1) Gathering data to understand
the patient’s problems
(2)Developing rapport and
responding to patient’s emotion
(3)Patient education & motivation
 The Three Function Approach
to the Medical Interview

Functions Skills
1. Gathering data a) Open-ended questions
b) Open to closed cone
c) Facilitation
d) Checking
e) Survey of problems
f) Negotiate priorities
g) Clarification and direction
 The Three Function Approach
to the Medical Interview

Functions Skills
1. Gathering data h) Summarising
i) Elicit patient’s expectations
j) Elicit patient’s ideas about
aetiology
k) Elicit impact of illness on
patient’s quality of life
 The Three Function Approach
to the Medical Interview

Functions Skills
2. Developing • Reflection
rapport • Support
• Partnership
• Respect
 The Three Function Approach
to the Medical Interview

Functions Skills
3. Education and • Education about illness
motivation • Negotiation and
maintenance of a
treatment plan
• Motivation of non-
adherent patients
 G-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
 The Calgary-Cambridge Approach
• 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

• preparation
• establishing initial rapport
• identifying the reason(s) for the consultation

Gathering information

Providing • exploration of the patient’s problems to discover the: Building the

Structure  biomedical perspective  the patient’s perspective relationship

• making  background information - context • using

organisation appropriate
overt non-verbal
Physical examination
behaviour
• attending to
flow • developing
rapport
Explanation and planning
• involving
• providing the correct amount and type of information
the patient
• 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
 H-The Disease - Illness Model
McWhinney has proposed a
“transformed clinical method”
His approach has also been
called “patient-centred clinical
interviewing” to differentiate it
from the more traditional
“doctor-centred” method that
attempts to interpret the patient’s
illness only from the doctor’s
perspective of disease and
pathology
 Patient-Centered Approach

What is it?
Means treating patients as
partners, involving them in
planning their health care and
encouraging them to take
responsibility for their own
health
 Patient-Centered Care also means
 Respecting patient’s values,
beliefs, preferences
 Customizing care to the
individual patient
 Providing patient education
 Patient-Centered Care also means
 Coordinating and integrating
care
 Expert management of
symptoms
 Provision of emotional
support to patients
 Accommodation of patient’s
supporters
Components of Patient-Centered Care

1. Exploring both disease and the patients'

illness experience
2. Understanding the whole person
3. Finding common ground
4. Incorporating prevention and health
promotion
5. Enhancing the patient-doctor relationship.
6. Being realistic
 Differences between Doctor Centered
and Patient Centered Consultation
     

Parameters Doctor Centered Patient Centered

 
Task Doctors agenda: Patient's agenda:
  What is the What is the
Diagnosis? Problem?

Exploring signs
and symptoms of Exploring patient's
the disease ideas, concerns &
process. expectations & how
do the problems
affect the patient? 
 Differences between Doctor Centered
and Patient Centered Consultation

 Parameters Doctor Centered Patient Centered

  Prescription Psychotherapy
Interventions Interpretation Counselling
  Evaluation Support
     
Techniques Closed questions Open questions
 
     
Time Controlling time Allowing time to
  by the doctor explore unknown
aspects of the
problems
Differences between Doctor Centered
and Patient Centered Consultation

 Parameters Doctor Patient Centered

Centered
     
Control Authoritarian, Discussing
  recommending options with the
or suggesting patient, which
management patient may or may
decisions. not take up
Deciding for the Decisions with the
patient patient
 
 Doctor Centered and
Patient Centered Consultation

The patient-centered model is

valuable in several ways. It defines
what doctors do when they are
functioning well in helping their
patients
The Doctor-centered in contrast, is
more concerned with the doctor's
need to organize the process of
the consultation, trying to confirm
the diagnosis with carefully
chosen specific questions
 Doctor Centered and
Patient Centered Consultation

Patient-centered care expands

on the disease-oriented model
by incorporating:
* Patient’s experience of
illness
* The psychosocial context,
and Shared decision making
 Disease Illness Model
The process of healing depends
on knowing the patient as a
person, in addition to accurately
diagnosing their disease
A model of clinical practice will
need to integrate the
conventional understanding of
disease with each patient's
unique experience of illness
 Patient presents with a complain

Parallel Search of Two Frameworks

Disease Illness

History Patient’s ideas

Physical examination Expectations
Investigations Fears
Differential diagnosis Impact on function

Integrated understanding & shred management

 Summary
Consultation models help us to
decide what to do in the
consultation and how to do it
There are so many models –
confusing or adding richness?
The aim is to develop your own
style
Keep your model simple.
And…make sure you can do
something with it
You may wish to use different
models for different situations
 Summary
Measure the correct amount
and type of information to
give to each individual
patient
Provide explanation that the
patient can remember and
understand
Use an interactive approach
to ensure a shared
understanding of the problem
 Summary
Involve the patient in the
planning. This will increase
patient’s commitment and
adherence to plans made
Continue to build relationship
with your patients and provide
supportive attitude
Treat your patients the way
you would like to be treated
 Thanks for
listening

Any Questions?