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The Consultation literature

The Consultation literature. A Chronology. Michael Balint. 1957 A Hungarian psycho-analyst Formed “Balint” groups, where GPs met to discuss their more difficult cases Wrote a seminal book: The Doctor, the patient and their illness”

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The Consultation literature

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  1. The Consultation literature A Chronology

  2. Michael Balint 1957 • A Hungarian psycho-analyst • Formed “Balint” groups, where GPs met to discuss their more difficult cases • Wrote a seminal book: The Doctor, the patient and their illness” • Reading the book suggests the cases were often the ones we now refer to as “Heart sink”

  3. Michael Balint • Problems are never purely physical, psychological or social but a complex mix of all three. • Doctors have a apostolic function, the doctors ideas of what medicine is about,inevitably communicates to the patient

  4. Michael Balint • Entry ticket • Hidden agenda • Doctors have feelings during consultations which may provide useful insights • Articulated the importance of the doctor / patient relationship

  5. Michael Balint • Collusion of anonymity, where patients with physical complaints with psycho-social causes are passed from specialist to specialist with no doctor taking overall responsibility - “somatisation” • The “drug doctor”, the idea that the doctor may be therapeutic, have adverse effects, and invoke dependency

  6. J Spence 1960 The Purpose & Practice of Medicine • Places the consultation at the heart of good practice

  7. The RCGP 1970 The Future General Practitioner, Learning & Teaching • Traditional consultation model: Active / Passive • Hypothetico-deductive model • Physical, psychological & social domains • Holistic Model of the Consultation

  8. John Heron 1975 Six Category Intervention analysis Authoritative (1-3) or Facilitative (4-6) 1 Prescriptive intervention 2 Informative intervention 3 Confronting intervention 4 Cathartic intervention 5 Catalytic intervention 6 Supportive intervention

  9. Eric Berne 1976 Games People Play • American psycho-analyst • Transactional analysis • Parent, Adult, Child roles • The Adult / Adult goal

  10. Byrne and Long 1976 Doctors Talking to patients • Analysis of 2,500 tape recorded consultations • Consulting styles • Doctor centred • Patient centred

  11. Byrne and Long • Sequence of events in a consultation: • Establishing a relationship • Why has the patient come • Verbal and/or physical examination • Considering the condition • Further investigation or treatment • Termination

  12. Stott & Davies 1979 The potential of each primary care consultation • The management of the presenting problem • Modification of help seeking behaviour • Management of continuing problems • Opportunistic health promotion

  13. Pendleton 1984 The consultation, an approach to learning and teaching • 7 tasks the Doctor should attempt in a consultation 1 Define the reasons for the patients attendance 2 Consider other problems

  14. Pendleton 3 With the patient, choose an appropriate solution to each problem 4 Achieve a shared understanding of the problems 5 Involve the patient in the management and encourage the patient to take responsibility 6 Use time and resources appropriately

  15. Pendleton 7 Establish or maintain the doctor patient relationship • Ideas, concerns and expectations • Effects of the problem in its physical, psychological, social, and spiritual consequences

  16. Roger Neighbour 1987 The Inner Consultation • A journey with five checkpoints 1 Connecting 2 Summarising 3 Handing over 4 Safety Netting 5 House Keeping

  17. Roger Neighbour • Rapport building skills • Eliciting skills • Communication skills • Predicting skills • Stress management skills Housekeeping and safety netting are his original contributions

  18. LeSser & Gasp 1991 Problem Based Interviewing Emphasises the detection of psycho-social distress Problem detection skills; • Beginning the interview • Picking up verbal cues • Responding to verbal cues

  19. LeSser & Gasp • Picking up non-verbal cues • Responding to non-verbal cues • Demonstrating empathy • Exploring health beliefs • Controlling the pace of the interview

  20. LeSser & Gasp Problem management skills: • Allowing the patient to ventilate • Negotiating with the patient to initiate change • Problem solving(like directive counselling) • Re-atrributing • Giving information • Special skills(special therapies)

  21. Peter Tate 1994 The Doctors Communication Handbook • The one to read if you haven’t the time for any of the others 1 Discovery the reason for the patients attendance 2 Define the clinical problem 3 Explain the problem to the patient

  22. Peter Tate 4 Explain the problems to the patient 5 Make effective use of the consultation

  23. Silverman et all • 1998 • Builds on the others. • For the first time includes a teaching / training guide • Five check points

  24. And onward

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