CONSULTATION MODELS

1. CONSULTATION MODELS Paula Murphy

2. The Consultation �the occasion when, in the intimacy of the consulting room or sick room, a patient who is ill or who believes himself to be ill seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it� Spence 1960 Cornerstone of general practice

3. The consultation �It happens not infrequently that the relationship between the patient and the doctor is strained, unhappy or even unpleasant. These situations are truly tragic� Balint 1957 Doctor patient relationship fundamental

4. Consultation models To help understand the consultation Increase self awareness & maximise effectiveness Many different models available

5. Consultation models Descriptive � says what has been or can be observed in the consultation eg Byrne & Long, Calgary Normative � say what should happen in a good consultation eg Stott & Davis, Pendleton, Neighbour

6. Byrne & Long,1976 Doctor establishes a relationship with pt Discovering reason for patients attendance Conducting a verbal or physical examination Consideration of patient�s condition Detailing treatment or further investigations Terminating, �parting shot�

7. Stott & Davis Management of presenting problems Modification of health seeking behaviour Management of continuing problems Opportunistic health promotion

8. Rodger Neighbour Connecting Summarising Handing over Safety netting Housekeeping

9. Pendleton Find out why the patient came : history, aetiology, ideas & expectations Consider other problems With the patient chose an appropriate action for each problem Achieve a shared understanding of the problem Involve the patient in Mx & encourage him to accept responsibility

10. Pendleton Involve the patient in Mx & encourage him to accept responsibility Use time and resources appropriately : in the consultation, in the long term Establish & maintain a relationship which helps achieve other tasks

11. Helmans folk model What has happened Why has it happened Why to me Why now What will happen if nothing is done What should I now do about it

12. The consultation Earlier models tended to be more �doctor centred� Newer models �patient centred� Much evidence to suggest that patients are more satisfied & more likely to comply with Rx when allowed to express their concerns & ideas in the consultation

13. Do patients wish to be involved in decision making in the consultation? 410 patients from 5 practices in Lothian Study aimed to determine patients preferences for participation in decision making for different types of problems Structured interview with video clips of acted consultations Pairs of video clips of 5 common scenarios, 1 involved pt in decision making, other involved largely doctor

14. Types of consultations Serious acute Minor acute Chronic Mental health Lifestyle advice

15. Results Patients preference found to be independently predicted by the problem viewed, patients with physical problems preferred a directed approach Patients>60 more likely to prefer a directed approach Social classes 1 & 2 more likely to prefer a shared approach

16. Results Smokers more likely to prefer shared approach No major association in preference found with sex, frequency of attendance or perceived chronic ill health