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.

• 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.

Providing

Structure

Initiating the Session

preparation

establishing initial rapport

identifying the reason(s) for the consultation

providing the correct amount and type of information

aiding accurate recall and understanding

achieving a shared understanding: incorporating the patient’sillness framework

planning: shared decision making

Closing the Session

Building therelationship

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Gathering information

Physical examination

Explanation and planning

making organisation overt

attending to flow

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

biomedical perspective the patient’s perspective

background information - context

• ensuring appropriate point of closure• forward planning

using appropriate non-verbal behaviour

developing rapport

involving the patient

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Roger Neighbour

1. Connecting

2. Summarising...physical, psychological, social.

3. Handing Over …influencing, negotiating, gift-wrapping, ‘my friend John’….

4. Safety-netting....?OK

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

Pendleton et al1. Define reason for attendance• nature and history of problems• Aetiology• Ideas, Concerns, Expectations• Effects of problems2. Consider other problems• Continuing problems• At risk factors3. With patient, choose appropriate action

for each problem4. Achieve shared understanding of

problem/s5. Involve patient in management and

encourage him to accept appropriate responsibility

6. Use resources appropriately• In the consultation• In the long term7 Establish and maintain a relationship with

the patient that helps achieve the other tasks

McWhinney’s disease-illness model

• 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)

Patient Parallel

Medical Parallel

McWhinney

Understanding of patients experience

HF

On and on

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

• Opportunistic Health Promotion

• Modification of help-seeking behaviours

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

1. Connecting

2. Summarising

3. Handing Over4. Safetynetting

5. Housekeeping

The centipede was happy, quite,Until a toad in funSaid, “Pray, which leg goes after which?”This worked his mind to such a pitchHe lay distracted in a ditchConsidering how to run.

1. Connecting

• Rapport• Gambits & Curtain Raisers• Minimal cues – verbal and non-

verbal• What is said & not said• Representational systems-V,A & K• Eye movements• 3 cardinal mental thought processes

Speech censoringInternal SpeechAcceptance 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

• Visual

• 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 rememberedVisual constructed

Auditory rememberedAuditory constructed

KinaestheticAuditory internal dialogue

2. Summarising

•What information do we need?I, C, E.FeelingsEffects 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

•NegotiatingGive the patient options

•Influencingin my opinion…Use questions instead of statementsReframingShepherding –

value laden phrases, eg admission or not

presuppositions eg tea or coffee

pre-empting my friend John…

•Gift WrappingChunk & CheckHow 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 scenarioInstructions to patientF/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

• 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

• Each case is marked on 3 domains

• data gathering, examination and clinical assessment skills

• Clinical management skills• Interpersonal skills

• All domains have equal weighting• Do not spend 8 minutes on history and

examination…you will fail this station

Shared Summit

Preparation

AscentDescent

Reflection

The Consultation Hill.

“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• 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

• 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

• Reflection • Legitimation • Support • Partnership • Respect

• Education about illness • Negotiation and maintenance of a treatment plan• Motivation of non-adherent patients

• Neighbours 9 rules of thumb of ‘How to give

instructions’