The “why” of consulting?

1. The “why” of consulting?

2. Exercise • Why are good consultation skills important? • In small groups: • What consultation skills were learnt & how: • (a) As a GP trainee • (b) Since qualifying as a GP • Share thoughts and feedback key findings

3. Friday 25, January 2013 Man, 60, who was in debt was found drowned in Avon ‘She said in the 12 months leading up to his death he had visited the doctor “quite frequently” and was coming home and telling her he was “quite poorly”, although the doctor said they had struggled to find anything wrong with him.’

4. Risk of Negligence Claim History of unprofessional behaviour medical school Male doctors Narrative about a doctor Not working in country of primary medical qualification Volume of practice / work load 1% doctors cause 25% of claims Risk of 2nd claim 20%, 3rd 25%. 4th 40%

5. Interventions Communication teaching Managing difficult patients Mastering shared decision making “The risk of a complaint starts before the patient enters the room.”

6. 1957 Michael Balint • Psychological basis of medical complaints • Doctor as a Drug • Empathy • Listening skills

7. 1976 Byrne and Long • Doctor centred V • Patient centred

8. Goldberg and Huxley (1980) GP behaviour related to ability to detect psychological illness Making eye contact early in consultation Clarifying presenting complaints Sensitive to verbal and non-verbal cues

9. Consultation Models

11. Do longer consultations improve management of psychological problems? • Literature review • 27 papers • No RCTs • Poor design • Generally interested or self-selecting GPs. • Consultations with psychological content take longer! • Due to consultation style or time effect??? • Time a major barrier to treating depression. • Some evidence: • Increasing consultation time improves accurate psychological diagnosis

12. Somatisation • Teaching junior doctors to manage patients who somatise: is it possible in an afternoon? Medical Education 2007: 41 : 995–1001 • 22 GP trainees • Video-taped assessment with role players somatised depression • Training in one VTS afternoon • Repeat assessment 1 month later • Pre-training overall score 1.4, Post-training 2.2 (P=0.002) • Negotiating style Pre 8/22 GPRs, Post 16/22 (P=0.02) • Empathy score pre: 2.3, post 3.0 (P=0.03)

13. Depression RCTs Poor evidence base in primary care especially at lower thresholds Poor fit of guidelines to primary care Continuum of normal to illness, and threshold for diagnosis varies GPs doubt effectiveness of guidelines in face of social problems and co-morbidity. EBM treatment not always meets patients needs or unavailable or in state of flux. MH issues often treated “simply” with usual GP care

14. Consultation Skills Grown out of psychotherapy Evidence base weak for improved outcome but… Lack of agreement on outcome & method. Reduce risk of complaint -> satisfied patients Current teaching possiblyselects“psychotherapy friendly” doctors. We can teach behavioural change (how to pass CSA) Need understanding and meaning (why) Probably the best training to detect psychological issues

16. "Education is not the filling of a pail, but the lighting of a fire.”~William Butler Yeats

17. Neighbour Listen (Active listen) Summarise (aloud) (Do the clinical bit) Think aloud Share management

18. Maslow’s Hierarchy of Needs

19. Maslow’s Hierarchy of Needs

22. Mindfulness • Taking notice….of mind , body and surroundings • Neuroscience basis, neural connections, NICE • Physical Health (smoking, drinking) • Mental Health 5-a-day: CLANG • Connection – family, friends • Learning – capable, confident, social contact • Active – exercise has antidepressant effects • Take Notice - outside and inside • Give – more important than receiving, even a kind word

23. 5-a-day – Which direction are you looking? Mental illness Mental health Mental healthy Flourishing issue: stress, worry Well Being

24. Solution Detective • Focussing on solutions an not the problems • When was the last time things were better? • What was happening? Why? • Do more of what works. • Think of alternatives if not working, not more! • E.g. CSA, AKT, antidepressants • Magic wand question.

25. Motivational Counselling

26. BATHE Technique B - Background: What is going on in your life? A - Affect: How do you feel about that? T - Trouble: What troubles you about that? H - Handling: How are you handling that? E - Empathy: That must be very difficult for you “Allows the practitioner to hand the problem back to the patient, while still showing them understanding, all in a standard consultation”

27. Balint Groups • From trainee to GP. • Benefits • Skills development • Reflective practice • Being a doctor • MRCGP • Balint trainers • Psychotherapy input

28. A model for Education

29. A model for Education Balint Group

30. Gifts Sickness brought me this 
Thought, in that scale of his: 
Why should I be dismayed 
Though flame had burned the whole 
World, as it were a coal, 
Now I have seen it weighed 
Against a soul?

31. Thank you! Dr Martin Wilkinson Director GP Education Health Education West Midlands martin.wilkinson@wm.hee.nhs.uk