THE CONSULTATION

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THE CONSULTATION

• Louise Beck

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The Consultation in General Practice

• Cornerstone of GP
• Complex interaction
• Numerous models

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• Early models - doctor-centred
• Recent models - patient-centred
• No one correct way!

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Potential Barriers

• lack of time
• language problems
• gender, age, ethnic or social background
• sensitive issues
• hidden or differing agendas
• prior difficult meeting
• lack of trust

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Consultation length

• UK - 7 minutes average
• Increased over last 30 years
• Certain groups have longer consultations

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Consultation length

• Benefits of longer consultations
• increased pt and Dr satisfaction
• improved Dr-pt communication
• increased identification of psychosocial problems
  health promotion
• decreased reconsultation rates
• decreased prescriptions for minor illnesses

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Consultation rate

• 2.5-6 consultations per pt per year
• Various factors affect consultation rate
• new pts
• elderly pts
• social deprivation
• time of year
• increased health promotion

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Consultation rate

• increased list size
• personal lists
• not prescribing for minor ailments

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Consultation models

• Medical organic model
• hx
• examination
• Ix
• Rx
• Follow-up

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Consultation models

• Early 1970s, the RCGP suggested consultations
  should be divided into
• physical aspects
• psychological aspects
• social aspects

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Balint, 1957

• Dr-pt relationship is fundamental
• Key concepts phrases
• the Dr as a drug
• the child as the presenting complaint
• elimination by physical examination
• collusion of anonymity
• the mutual investment company
• the flash

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Byrne Long, 1976

• Phase I - Dr establishes relationship with pt
• Phase II - Dr attempts to discover/actually
  discovers reason for attendance
• Phase III - Dr conducts verbal /- physical
  examination

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• Phase IV - Dr or Dr pt or pt consider the
  condition
• Phase V - Dr details Rx and Ix
• Phase VI - consultation is terminated

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Stott Davis, 1979

• Mx of presenting problems
• Modification of help-seeking behaviour
• Mx of continuing problems
• Opportunistic health promotion

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Helmanns folk model, 1981

• What has happened?
• Why?
• Why me?
• Why now?
• What would happen if nothing were done about it?
• What should I do who should I consult for
  further help?

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Pendleton, Schofield, Tate Havelock, 1984

• Define reason for attendance
• Consider other problems
• Choose appropriate action
• Achieve shared understanding
• Involve the patient in Mx
• Use time and resources appropriately
• Establish maintain relationship

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Neighbour, 1987

• Connecting
• Summarizing
• Handing over
• Safety netting
• Housekeeping

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Tate

• Discover reason for attendance
• Define the clinical problem
• Explain the problem to the patient
• Make effective use of the consultation
• Others- Rosenstock, Becker Maiman, Heron,

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Heartsink patients

• Identified by ODowd in late 1980s
• But have no doubt existed as long as a
  practitioner is willing to listen!

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Heartsink patients

• Characterized by frequent presentation
• Highly complex
• Often multiple problems (some real, others not)
• Problem relates to the GPs perception of
  patients as well as the patients themselves

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Management strategy

• Detailed r/v of notes
• Awareness of your own reaction
• Agreed patient contacts
• Agree agenda within consultation
• Acknowledge that they can be genuinely ill
• Avoid unnecessary Ix referral

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Management strategy

• Consider psychiatric diagnoses
• Planned but careful confrontation