Consultation Skills

1
Consultation Skills

• Gathering information

2
Two Consultations

• How do the consultations differ?
• Why?
• What makes one more effective than the other?

3
Session Aims To Consider

• What do we want to achieve ?
• What information should we seek?
• What skills are needed?
• The Disease-illness Model and supporting
  evidence.
• Opportunities to analyse and rehearse skills by
  looking at your consultations

4
Calgary-Cambridge Framework

• Providing Structure Building the Relationship
• 1. Initiating the session
• 2. Gathering information
• 3. Physical Examination
• 4. Explanation and planning
• 5. Closing the session

5
Gathering Information the goals

• Info is accurate, complete, mutually understood.
• Patients feel listened to and their views valued.
• Collaborative relationship developed
• Structure enables efficiency, patient
  understanding and involvement

6
Gathering information

• Content WHAT?
• Process HOW?

7
Think of a patient in the last few weeks in which
the consultation didnt go smoothly - one which
you were uneasy about.

• What bits of information did you discover?
• What else would you have liked to discover - what
  was missing?
• (In pairs, 5mins each way,
  feedback)

8
Traditional History e.g. McLeod

• Strengths
• scientific method
• detached objectivity
• systematic
• comprehensive account of features of disease

9
Traditional History

• Weaknesses
• ?
• ?
• ?
• Lets review the evidence . . .

10
Byrne and Long (1976)

• UK GPs pursued a doctor-centred approach which
  discouraged patients from telling their story or
  voicing their concerns.
• Cf Rogers and Todd (2000) who showed that
  oncologists ignored cues about pain unless it was
  amenable to specialist cancer treatment.)

11
2. Platt and McMath (1979)

• USA hospital doctors used a high control
  (doctor-centred) style. Focussing prematurely
  on medical problems
• inhibited patients ability to voice concerns,
• limited hypothesis-generation and
• resulted in inaccurate assessment of problems.

12
3. Tuckett et al (1985)

• Few UK GPs elicited ideas and concerns
• Eliciting patients beliefs aids their
  information understanding and recall.

13
4. Kleinman et al (1978)

• Discordance in health beliefs between doctor and
  patient adversely affects satisfaction,
  adherence, management and outcome.

14
4. Kuhl (2002)

• Disregarding patients concerns may
  inadvertently cause iatrogenic suffering
• when patients bear the burden of a doctors
  own unresolved psychological and emotional issues
  about death, suffering, pain and relationship.

15
What do you think?
16
Transforming the Clinical Method

• Patient-centred clinical interviewing
• McWhinney (1989) Stewart et al (1995, 2003).
• Both doctor and patients agenda considered e.g.
  disease-illness model

17
The Disease-illness Model(after Levenstein et al
(1989) and Stewart et al (2003))

• Illness Framework
• (Patients Experience)
• Ideas
• Concerns
• Expectations
• Feelings and thoughts
• Effects on life
• Understanding the patients unique experience of
  illness

• Disease Framework
• (Biomedical Perspective)
• Symptoms
• Signs
• Investigations
• Underlying Pathology
• Differential Diagnosis

18
Advantages of Disease-Illness Model

• Supporting, understanding and building
  relationship.
• Patients perspective aids diagnosis and
  efficiency. (Stewart 1997)
• Traditional disease model does not explain
  everything. (Blacklock 1977)
• Groundwork for explanation and planning. (Tuckett
  et al 1985)

19
What Evidence supports the use of a
Disease-Illness Model?

• Stewart et al. (1997) patient-centredness
  resulted in fewer follow-ups, investigations and
  referrals.
• Blacklock (1977) 50 chest pain unproven after
  6m.
• Tuckett et al (1985) problems arise when
  doctors explanations do not answer patients
  concerns.

20
Contents Summary

• Biomedical
• Perspective
• Background Information

• Patients Perspective

21
So . . . How do we get there?
22
Process Skillsfor gathering information

• Exploration of patients problems
• -patients narrative
• -questioning techniques
• -listening
• -facilitative response
• -cues
• -clarification
• -time-framing
• -internal summary
• -language

• Additional Skills
• -active exploration of ICE and effect on
  patients life
• -encourage expression of feelings

23
Open-to-closed Questions

• Examples open, specific but open, closed
• The Open-to closed cone (Goldberg 1983)
• Open broad perspective
• Closed specific, detailed
• Advantages
• More complete story
• Allows doctor time
• Enables effective diagnostic reasoning- more info
  and time to develop hypotheses which are then
  tested.
• Illness aspects disclosed.
• Establishes pattern for patient contribution.

24
Evidence?

• Roter and Hall (1987) Amount of info elicited
  was related to appropriate open/closed qus. More
  relevant info with open qus.
• Goldberg et al (1983) Diagnostic accuracy
  related to open-to-closed questioning.

25
Direct questions about ICE

• What do you think might be happening?
• Have you any ideas about it yourself? Any
  theories?
• What are you concerned it might be?
• Is there anything specific that you were
  concerned about?
• What were you hoping we might be able to do for
  this?
• What do you think might be the best plan of
  action?
• How do you think we should tackle this?
• Others?

26
Picking up cues verbal and non-verbal

• repetition
• checking out verbal and non-verbal cues
• e.g. you mentioned that . . . or I sense
  you are not happy about . . .

27
Exploring both disease and illness perspectives

• Sequence of events
• Further analysis of each symptom
• Further exploration of patients perspective
• Discover background information
• How about a run-though together?
• Volunteer patient?

28
1. Sequence of Events

• patients narrative, open questions listening,
  facilitating
• more directed open questions
• clarify and time-frame
• respond to cues
• summarise and signpost

29
Exploring both disease and illness perspectives

• 2. Further analysis of each symptom
• open then closed questions,
• signpost
• 3. Further exploration of patients perspective
• open questions
• acknowledge patients view and feelings,
• signpost
• 4. Discover background information
• increasingly directed and closed questions

30
Take-home Points

• It is essential to discover the patients
  perspective - this should be actively sought-out.
• Accurate, efficient information-gathering
  requires use of open questions and listening
  techniques.
• The requisite skills can be improved with
  practice . . .

31
So, thats the theory . . !
32
After the Break . . .

• 2 groups videos looking at gathering
  information.
• Especially helpful to look at difficult
  consultations and work out alternative approaches.

33
(No Transcript)