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الثلاثاء، 31 مايو، 2011

MODELS OF THE CONSULTATION


A summary of models that have been proposed over the last 20 years

There have been a number of helpful models of the consultation which have been produced over the last 30 years. Some are task-orientated,  process or outcome-based; some are skills-based, some incorporate a temporal framework, and some are based on the doctor-patient relationship, or the patient’s perspective of illness. Many incorporate more than one of the above.

Models of the consultation give a framework for learning and teaching the consultation; the toolbox is a useful analogy. Models enable the clinician to think where in the consultation they are experiencing the problem, and what they and the patient aiming towards. This is helpful in then identifying the skills that are needed to achieve the desired outcome. A particularly useful general book on Understanding the Consultation by Tim Usherwood (see the book list at the end of this document) describes a number of the models below in more detail, and also includes psychological concepts such as projection, transference and counter-transference.


1.         ‘Physical, Psychological and Social’ (1972)

The RCGP model encourages the doctor to extend his thinking practice beyond the purely organic approach to patients, i.e. to include the patient’s
            emotional, family, social and environmental circumstances.

2.         Stott and Davis ( 1979)

            “The exceptional potential in each primary care consultation” suggests that    four areas can be systematically explored each time a patient consults.

            (a)        Management of presenting problems
            (b)        Modification of help-seeking behaviours
            (c)        Management of continuing problems
            (d)        Opportunistic health promotion

3.         Byrne and Long (1976)

            “Doctors talking to patients”. Six phases which form a logical structure to the            consultation:

            Phase   I           The doctor establishes a relationship with the patient

            Phase  II           The doctor either attempts to discover or actually discovers the                                              reason for the patient’s attendance

            Phase  III         The doctor conducts a verbal or physical examination or both

            Phase  IV         The doctor, or the doctor and the patient , or the patient (in that                                              order of probability) consider the condition

            Phase    V        The doctor, and occasionally the patient, detail further treat-
                                    ment or further investigation

            Phase   VI        The consultation is terminated usually by the doctor.

Byrne and Long’s study also analysed the range of verbal behaviours doctors used when talking to their patients. They described a spectrum ranging from         a heavily doctor-dominated consultation, with any contribution from the patient as good as excluded, to a virtual monologue by the patient untrammelled by any input from the doctor. Between these extremes, they described a graduation of styles from closed information-gathering to non-directive counselling, depending on whether the doctor was more interested in developing his own line of thought or the patient’s.



4.         Six Category Intervention Analysis (1975)

            In the mid-1970’s the humanist Psychologist John Heron developed a simple but      comprehensive model of the array of interventions a doctor (counsellor or
therapist) could use with the patient (client). Within an overall setting of concern       for the patient’s best interests, the doctor’s interventions fall into one of six
            categories:

            (1)        Prescriptive    -  giving advice or instructions, being critical or directive

            (2)        Informative     -  imparting new knowledge, instructing or interpreting

            (3)        Confronting    -  challenging a restrictive attitude or behaviour, giving
                                                   direct feedback within a caring context

            (4)        Cathartic        -  seeking to release emotion in the form of weeping,
                                                    laughter, trembling or anger

            (5)        Catalytic         -   encouraging the patient to discover and explore his own                                             latent thoughts and feelings

            (6)        Supportive      -   offering comfort and approval, affirming the patient’s
                                                    intrinsic value.

            Each category has a clear function within the total consultation.


5.         Helman’s  ‘Folk Model’  (1981)

            Cecil Helman is a Medical Anthropologist, with constantly enlightening insights
            into the cultural factors in health and illness. He suggests that a patient with a
            problem comes to a doctor seeing answers to six questions:

            (1)        What has happened?
            (2)        Why has it happened?
            (3)        Why to me?
            (4)        Why now?
            (5)        What would happen if nothing was done about it?
            (6)        What should I do about it or whom should I consult for further help?

6.         Transactional Analysis  (1964)

            Many doctors will be familiar with Eric Berne’s model of the human psyche as
            consisting of three ‘ego-states’ - Parent, Adult and Child. At any given moment
            each of us is in a state of mind when we think, feel, behave, react and have
            attitudes as if we were either a critical or caring Parent, a logical Adult, or a
            spontaneous or dependent Child. Many general practice consultations are
            conducted between a Parental doctor and a Child-like patient.  This transaction
            is not always in the best interests of either party, and a familiarity with TA
            introduces a welcome flexibility into the doctor’s repertoire which can break
            out of the repetitious cycles of behaviour (‘games’) into which some
            consultations can degenerate.



7.         Pendleton, Schofield, Tate and Havelock (1984, 2003)

            ‘The Consultation -   An Approach to Learning and Teaching’ describe seven            tasks which taken together form comprehensive and coherent aims for any
            consultation.

            (1)        To define the reason for the patient’s attendance, including:

                        i)          the nature and history of the problems
                        ii)         their aetiology
                        iii)        the patient’s ideas, concerns and expectations
                        iv)        the effects of the problems

            (2)        To consider other problems:

                        i)          continuing problems
                        ii)         at-risk factors

            (3)        With the patient, to choose an appropriate action for each                                      problem

            (4)        To achieve a shared understanding of the problems with the                                               patient

            (5)        To involve the patient in the management and encourage him to                             accept appropriate responsibility

            (6)        To use time and resources appropriately:

                        i)          in the consultation
                        ii)         in the long term

            (7)        To establish or maintain a relationship with the patient which                                 helps to  achieve the other tasks.

The authors’ 2nd edition, “The new consultation” includes recent relevant research material and a wealth of experience accumulated by the authors since their first publication. The first part of the book covers the consultation; the “central act of medicine”, and puts both the perspectives of the doctor and the patient, and the outcomes that both are looking for at the heart of the process of the medical interview. The second half of the book is concerned with learning and teaching effective consulting.

8.         Neighbour (1987)


Five check points: ‘where shall we make for next and how shall we get there?’

            (1)        Connecting        -         establishing rapport with the patient

            (2)        Summarising   -           getting to the point of why the patient has come
                                                            using eliciting skills to discover their ideas,                                                                 concerns, expectations and summarising back to
                                                            the patient.

            (3)        Handing over   -         doctors’ and patients’ agendas are agreed.
                                                            Negotiating, influencing and gift wrapping.

            (4)        Safety net          -         “What if?’: consider what the doctor might do in
                                                            each case.

            (5)        Housekeeping  -          ‘Am I in good enough shape for the next                                                                    patient?’


9.         The Disease - Illness Model  (1984)

McWhinney and his colleagues at the University of Western Ontario have proposed a “transformed clinical method”. Their approach has also been called “patient-centred clinical interviewing” to differentiate it from the more traditional “doctor-centred” method that attempts to interpret the patient’s illness only from the doctor’s perspective of disease and pathology.

The disease-illness model below attempts to provide a practical way of using these ideas in our everyday clinical practice. The doctor has the unique responsibility to elicit two sets of “content” of the patient’s story: the traditional biomedical history, and the patient’s experience of their illness.





 Patient presents problem

Gathering information

Parallel search of two frameworks









Weaving back
and forth between the two frameworks
          Disease framework                                                                                     Illness framework                                                                                         
        The biomedical perspective                                                                     The patient’s perspective                                                                            



        Symptoms                                                                                                     Ideas     
        Signs                                                                                                               Concerns
       Investigations                                                                                               Expectations                                                                                                 Feelings and thoughts
        Underlying pathology                                                                                Feelings and thoughts      
                                                                                                                                 Effects on life
       

        Differential diagnosis                                                                                                Understanding the patient’s
                                                                                                                                 Unique experience of the
                                                                                                                                 illness

                                                                 Integration of the two frameworks
                                                                
                                                                 Explanation and planning
                                                                 Shared understanding and decision-making

        After Levenstien et al in Stewart and Roter (1989) and Stewart et al (1995 & 2003)                                                  



Levenstein JH, Belle Brown J Weston WW et al (1989) Patient-centred clinical interviewing. In Communicating with medical patients (eds M Stewart and D Roter) Sage Publications, Newbury Park, CA.
Stewart M. (2001) Towards a global definition of patient centred care. BMJ.  322(7284):444-5,




10.       The Three Function Approach to the Medical Interview (1989)

            Cohen-Cole and Bird have developed a model of the consultation that has    been adopted by The American Academy on Physician and Patient as their      model for teaching the Medical Interview.

            (1)        Gathering data to understand the patient’s problems

            (2)        Developing rapport and responding to patient’s emotion

            (3)        Patient education and motivation


            Functions                                            Skills

            1.         Gathering data             a)         Open-ended questions
                                                                        b)         Open to closed cone
                                                                        c)         Facilitation
                                                                        d)         Checking
                                                                        e)         Survey of problems
                                                                        f)         Negotiate priorities
                                                                        g)         Clarification and direction
                                                                        h)         Summarising
                                                                        i)          Elicit patient’s expectations
                                                                        j)          Elicit patient’s ideas about
                                                                                    aetiology
                                                                        k)         Elicit impact of illness on                                                                                            patient’s quality of life


            2          Developing rapport                  a)         Reflection
                                                                        b)         Legitimation
                                                                        c)         Support
                                                                        d)         Partnership
                                                                        e)         Respect

            3          Education and motivation        a)         Education about illness
                                                                        b)         Negotiation and maintenance of a                                                                               treatment plan
                                                                        c)         Motivation of non-adherent                                                                                         patients


In 2000 the authors published a second edition, where they altered the order of the three functions of effective interviewing, putting “Building the relationship” in front of “Assessing the patient’s problems”,  and “Managing the patient’s problems”.

The authors have included three excellent chapters on :
  • Understanding the patient’s emotional response
§         Managing communication challenges
  • Higher order skills
The section on overcoming cultural and language barriers and troubling personality styles and somatisation are particularly helpful.

11.       The Calgary-Cambridge Approach to Communication Skills Teaching
                                                                                                                        (1996)

            Suzanne Kurtz & Jonathan Silverman have developed a model of the            consultation, encapsulated within a practical teaching tool, the Calgary      Cambridge Observation Guides. The guide is continuing to evolve and now   includes Structuring the consultation. The Guides define the content of a communication skills curriculum by delineating and structuring the skills that have been shown by research and theory to aid doctor-patient communication. The guides also make accessible a concise and accessible summary for facilitators and learners alike which can be used as an aide-     memoire during teaching sessions

            The following is the structure of the consultation proposed by the guides:

            (1)        Initiating the Session
                        a)         preparation
                        b)         establishing initial rapport
                        c)         identifying the reason(s) for the consultation

            (2)        Gathering Information

                        exploration of of the patient’s problems to discover the:
                        a)         biomedical perspective
                        b)         the patient’s perspective
c)         background information - context

            (3)        Building the Relationship

                        a)         using appropriate non-verbal behaviour
                        b)         developing rapport
                        c)         involving the patient

            (4)        Providing structure

                        a) making organisation overt
                        b) attending to flow

            (5)        Explanation and Planning

                        a)         providing the correct amount and type of information
                        b)         aiding accurate recall and understanding
                        c)         achieving a shared understanding: incorporating the patient’s                                                 perspective
                        d)         planning: shared decision making

            (6)        Closing the Session

                        a) ensuring appropriate point of closure
                        b) forward planning


12.       Comprehensive Clinical Method/Calgary-Cambridge Guide Mark 2.  (2002)
This method combines the traditional method of taking a clinical history including the functional enquiry, past medical history, social and family history, together with the drug history, with the Calgary-Cambridge Guide.  It places the Disease-Illness model at the centre of gathering information. It combines process with content in a logical schema; it is comprehensive and applicable to all medical interviews with patients, whatever the context.
Below is an example of the skills required to elicit the disease, the illness and the background content when gathering information.







Gathering Information



process skills for exploration of the patient’s problems  
                   (the bio-medical perspective and the patient’s perspective)

  • patient’s narrative
  • question style: open to closed cone
  • attentive listening
  • facilitative response
  • picking up cues
  • clarification
  • time-framing
  • internal summary
  • appropriate use of language
  • additional skills for understanding patient’s perspective


                                                                content to be discovered:


 the bio-medical perspective                                                                             the patient’s perspective
           (disease)                                                                                      (illness)

sequence of events                                                                                                     ideas and concerns
symptom analysis                                                                                                                       expectations
relevant functional enquiry                                                                                     effects
                                                                                                                                       feelings and thoughts



essential background information

past medical history
drug and allergy history
social history
family history
functional enquiry




13.  BARD 2002 Ed Warren (2002)
The BARD model attempts to consider the totality of the relationship between a GP and a patient and the roles that are being enacted. The personality of the doctor will have considerable influence on the doctor-patient encounter, as will the doctor’s previous experience of the patient. The model attempts to include how the doctor’s personality can be used to best effect, and looks specifically at the doctor and patient roles in the medical encounter. It aims to “encompass everything that happens during a consultation” and encourage reflection. It is important that GPs play to their strengths, and use their role and personality and behaviour positively for the benefit of the patient.

The four proposed avenues for analysis are:
Behaviour
Aims
Room
Dialogue


Behaviour
A doctor has many alternatives in how they present to a patient, and these choices will reflect the needs of the patient and the personality of the GP. It includes non-verbal and verbal skills as well as confidence, “lightness of touch”, and behaviours which feel “just right”. The key is for the doctor to choose the most appropriate behaviour with each patient in front of them

Aims
It is important for the aims of a consultation to be clear in order to help the doctor and the patient to head in the right direction. However not all the aims will necessarily need to be achieved in one consultation, and priorities have to be clarified.

Room
The consultation will be affected by the environment in which the doctor works, as well as for example, where the doctor sits, or whether a side room is used for the examination.

Dialogue
How you talk to the patient is crucial. Tone of voice, what you say, language, the ability to confront or challenge needs thought. How can you be sure that both you and the patient are talking the same language?



14. Balint 1986
Michael Balint and his wife Enid, who were both psychoanalysts, started to research the GP/patient relationship in the 1950s, and over many years ran case-discussion seminars with GPs to look at their difficulties with patients. The groups’ experiences formed the basis for a very important contribution to the general practice literature; The doctor, the patient and the illness. In exploring the doctor-patient relationship in depth, Balint helped generations of doctors to understand the importance of transference and counter-transference, and how the doctor himself is often the treatment or drug. Balint groups are still popular, and are usually run on psychodynamic lines and often one of the group leaders is a psychotherapist. Balint’s tenet was that doctors decide what is allowable for discussion from the patient’s offer of problems, and that doctors impose constraints on what is acceptable to explore in the consultation, often unconsciously.  This selective neglect or avoidance is often related to something in the doctors life which is threatening. For example a doctor may not wish to explore alcoholism in a patient if he or she either drinks to excess themselves, or someone close to the doctor has an alcohol problem. It the patient is also reluctant to discuss the issue then this can lead to collusion.

Balint groups commonly begin with “has anyone a case today?” A doctor then tells the story of a patient who is bothering him and the group will help the doctor to identify and explore the blocks which are constraining exploration and management of the patient’s problem.

15. Narrative-based Medicine
Launer J (2002)
Narrative studies explore the way people tell stories. The modernist approach had been to be attentive to these stories and the particular approach described in this book is a specific one, developed by a team of teachers at the Tavistock Clinic in London. In primary care we have an option not only to reflect on these stories, we can respond to and even challenge them. Thus the post-modern and more radical view would be that a clinical interaction is one in which two parties bring their own individual contexts and preferences, to create what is a unique and developing conversation. For example, in the context of the consultation between a patient and the GP, there is often no “ultimate truth” to the answer to the question “why has the patient attended”, or what the patient is hoping for from the doctor, because in an attempt to explore these important questions, even more important questions and ideas will emerge.

Skills which help the patient to understand better what is happening to them not only include the basic skills of listening, and empathising. Question style is crucial; appropriately timed questions asked with respect and in the spirit of caring about the eventual outcome for the patient can be used with great effect in contexts where the clinician is trying to help the patient look at a problem from a different point of view, and encourage behaviour change. They might be compared with to Socratic questioning, and form the basis of narrative-based interviewing and originally come from family systems therapy.
The six key concepts are:
  • conversations
  • curiosity
  • circularity
  • contexts
  • co-creation
  • caution

Some examples:
“When you get home, what do you think your husband might say when you tell him what we have been talking about?”
“Who in the family thinks you are depressed as well as your husband?”
“If we can’t get to the bottom of your problem, what do you think you might do next?”

Constructing a genogram with the patient is a good example of one of the other techniques used in narrative-based medicine.

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