The consultation team d

Family Physicians

1. THE CONSULTATION A Presentation by Team D Dr Ahmed Yakubu & Dr Kemi Usanga Department of Family Medicine University of Uyo Teaching Hospital Delivered on 30th July, 2021.

2. OUTLINE: Introduction Definition Components of the Consultation Aims of Studying Consultation Consultation Models Communication Skills in Consultation Barriers to Consultation Process Factors that Influence Consultation Conclusion References

3. INTRODUCTION : With modernization there’s an increasing demand for quality assured medical attention. Doctor/patient ratio in Nigeria = 1:2753 translating to 36.6 medical doctors per 100,000 persons. In addition to the foregoing, there’s the added responsibility of formulating a differential diagnosis for each, the need to establish rapport, explore patients ideas, concerns and expectations; finally negotiate a management plan. We face a herculean task with the varying complexities of patients, thus the need to study the ‘consultation’ as a process.

4. INTRODUCTION CONT’D: Evolution: Fairly ‘one-way’ instructional sessions ‘two-way’ stifled interactive sessions Growing patient centered/oriented sessions.

5. INTRODUCTION CONT’D : Research on patient-physician encounter in GOPD is as follows: Patients who do not receive the full benefit of their prescription 50% Consultations with conflicting ideas on what the main presenting problem between patient and doctor. 50% Patient’s complains not elicited by the physician 54% Patients who do not mention all their problems to their family physicians 60% Psychosocial and mental illnesses missed during traditional consultation 66.7% A significant proportion do not recall what happen during the encounter

6. DEFINITION : The Consultation is the occasion, when in the intimacy of the consulting room, clinic or a given safe environment, an ill patient or a person who believes he is ill, seeks the attention or advice of the doctor whom he trusts. OR An interactive session where in a healthy or sick individual/individual who feels unwell seeks explanation and/or cure, or advice from a physician within the confines of an ideal setting.

7. COMPONENTS OF CONSULTATION: a. The patient: The one who assumes the sick role, who must be considered as a biopsychosocial being not neglecting their sense of spirituality. b. The doctor: Compliments the role of the patient, must be objective, emotionally detached from the patient but empathetic. Adhering to the medical ethics. c. The enviroment: The ideal setting, which guarantees privacy and comfort, is well equipped, organized and quiet. d. Interaction (Communication skill)

8. AIM OF STUDYING ‘THE CONSULTATION’: 1. Understand the common models of the consultation that have been proposed and how we can use these models to reflect on previous consultations in order to improve future consultation behaviour. 2. Use the skills typically associated with good doctor/patient communication.

9. AIM OF STUDYING ‘THE CONSULTATION’ CONT’D: 3. Show a holistic approach, and understand that consultations have a clinical , psychological and social component, with the relevance of each component varying from consultation to consultation. 4. Recognise, manage and monitor your personal emotions arising from the consultation. 5. For the purpose of self appraisal and educational development.

10. CONSULTATION MODELS 1. The Physical, Psychological and Social Model This was first developed in 1972. The Model encourages the Doctor to extend his thinking beyond the purely organic approach to patients i. e. to include the patient’s emotional, family, social and environmental circumstances.

11. CONSULTATION MODELS CONT’D

12. CONSULTATION MODELS CONT’D 2. Six Category Analysis: Developed in 1975 by John Heron for doctors, counselors or therapists. The doctor’s interventions fall into one of six categories: Prescriptive – Giving advice or instructions, being critical or directive. Informative – Imparting new knowledge, instructing or interpreting. Confronting – Challenging a restrictive attitude or behaviour , giving direct feed-back within a caring context.

13. CONSULTATION MODELS CONT’D Six Category Analysis Continued: 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.

14. CONSULTATION MODELS CONT’D: 3. Doctors Talking to patient model: It was developed in 1978 by Byrne and Long. It h as six phases which formed a logical structure to the consultation: Phase I – The doctor establishes a relationship with the patient Phase II- The doctor either attempts to or actually discovers the reasons for the patient’s attendance Phase III- The doctor conducts a verbal or physical examination or both.

15. CONSULTATION MODELS CONT’D Doctors Talking to patient model continued: Phase IV- The doctor or the doctor and the patient, or the patient (in this order of probability) consider the condition. Phase V- The doctor and occasionally the patient detail further treatment or investigation. Phase VI- The consultation is usually terminated by the doctor.

16. CONSULTATION MODELS CONT’D 4. The Exceptional Potential in Each Primary Care Consultation Model – First developed by Stott and Davies in 1979. It suggests four areas which can be systematically explored, each time a patient consults to include: Management of presenting problems Modification of help seeking behaviour Management of continuing problems Opportunistic health promotion

17. CONSULTATION MODELS CONT’D OBJECTIVES of The Exceptional Potential in Each Primary Care Consultation Model: To provide a theoretical base from which a practitioner can develop the full potential in any primary care consultation. To highlight some unique features of good primary care To provide a simple and valid structure in training and practice. To o allow the philosophy, principles, and research achievements in comprehensive care to be discussed within a simple patient-centered framework,

18. CONSULTATION MODELS CONT’D 5. Hellman’s Folk Model: Developed by Cecil Hellman (a medical anthropologist) in 1981. He opined that a patient with a problem comes to the doctor seeking answers to six questions:- What has happened? Why has it happened? Why to me? Why now ? What would happen if nothing was done about it. What should i do about it and who should I consult for further help?

19. CONSULTATION MODELS CONT’D 6. Neighbour Model: Developed in 1987, with five main points Connecting – Establishing a rapport with patient. Summarizing – Getting to what concern brought him to you, using skills to discover their ideas, concerns, expectations and summarizing the points for the patient.

20. CONSULTATION MODELS CONT’D Neighbour Model Continued: Handing over- Following negotiations the doctor and patient’s agenda are agreed upon. Safety-netting: what if? – Consider your proposed actions for each case. Housekeeping – Reassess yourself to see if you are in good enough shape for the next patient .

21. CONSULTATION MODELS CONT’D 7. The Three Functions Approach: Developed by Cohen-Cole and Bird. 1989 It has three major components: Gathering data to understand the patient’s problem Developing Rapport Education and motivation

22. CONSULTATION MODELS CONT’D 8. The Calgary-Cambridge Approach: D eveloped by Suzanne Kurtz and Jonathan Silverman in 1998. The structure of the consultation proposed is as follows: Initiating the session Gathering information Building the relationship

23. CONSULTATION MODELS CONT’D The Calgary-Cambridge Approach Continued: 4. Explanation and planning 5. Close the Session

24. CONSULTATION MODELS CONT’D 9. THE TRADITIONAL MODEL: Presenting complaints History of presenting complaints Past medical history Drug history Social and family history Review of systems Examination

25. CONSULTATION MODELS CONT’D Traditional Model cont’d: Biological diagnosis Investigation Treatment and follow up In the traditional model areas of challenges may include responding to cues, exploring a patient’s health understanding and developing a shared management plan with the patient.

26. CONSULTATION MODELS CONT’D 10. The Patient-centered Model: This Model was developed in 1995 by McWhiney and colleagues at University of Western Ontario. Components of PCCM: 1. Exploring the disease and the illness experience 2. Understanding the whole person 3. Finding common ground regarding management

27. CONSULTATION MODELS CONT’D Components of PCCM cont’d: 4. Incorporating prevention and health promotion 5. E nhancing the doctor-patient relationship 6. ‘Being realistic’ about personal limitations and resources.

28. BENEFITS OF THE PATIENT CENTERED CONSULTATION: 1. Many studies have shown that adherence and patient satisfaction both increase when patients are given information by their doctors about their management. 2. Patient- centred consultation reduces costs. It is less expensive, for instance, to promote adherence than to hospitalize people for not taking their drugs as prescribed. 3. Patient- centred consultation maximizes time. It certainly reduces the number of visits by the patient.

29. BENEFITS OF THE PATIENT CENTERED CONSULTATION CONT’D: 4. The diagnosis is more likely to be accurate and management of the condition is better tailored to meet patients needs. 5. Less resources are used because only the needful are involved. 6. Reduces litigation because it meets patients’ satisfaction. 7. Doctor’s satisfaction is also improved.

30. PCCM Assessment : In using this patient- centred approach a 3-stage assessment is advocated: Assess the clinical Component Identifying disease: Understanding the illness experience (FIFE) Assess the contextual component:

31. COMMUNICATION SKILLS IN CONSULTATION For acquaintance and familliarization with skills in communication during consultation the acronym P. R. A. C. T. I. C. A. L. may be come in handy: P - Prior to the consultation review the patient’s folder. Pull your attention span together and concentrate on what is coming. Switch off your phone if possible.

32. COMMUNICATION SKILLS IN CONSULTATION CONT’D R – Relationship . Greet the patient. Offer him/her a seat. Politely introduce yourself. Make a proper opening statement with a question, such as: ‘How can I help you?’ This is a good question if the client does not look ill, but: ‘What illness brought you to the hospital? ‘- is a better question for an ill-looking patient.

33. COMMUNICATION SKILLS IN CONSULTATION CONT’D A – Anxieties . Address the patient’s fears. Use open ended questions. Ask about his ideas of the illness, his concern, the feelings that the illness has evoked and his expectations. Watch for non-verbal clues. C – Common language should be used . Clarify the patients statements. Summarize what you think he has said. A summary tells the patient that you have been listening and it demonstrates your interest.

34. COMMUNICATION SKILLS IN CONSULTATION CONT’D T – Translating . Use simple words to communicate your findings along with the diagnosis to the patient. I – Interaction . In formulating a management plan, explain everything in simple language to your patient. Give the information in small bits, checking for his understanding, aiming for a shared understanding of the problem.

35. COMMUNICATION SKILLS IN CONSULTATION CONT’D C- Convert insight into action . Discuss the implementation of your management plan and how it will be achieved. A – Agreement . Check to make sure that you and the patient are in agreement about his clinical assessment and overall management plan

36. COMMUNICATION SKILLS IN CONSULTATION CONT’D L – Leave . End of consultation. With the patient out of the room, reflect on the consultation. If anything was missed, it may still be possible to gather the loose ends now and plan to make good at the review/check-up visit.

37. BARRIERS TO CONSULTATION PROCESS Barriers could be: Physical, Psychological or social and they need to be recognized and overcome. They include: Physical Barriers: Deafness Intoxication Aphasia Dementia Delirium

38. BARRIERS TO CONSULTATION PROCESS CONT’D Psychological Barriers: Depression Anxiety Psychosis Paranoia Personality disorders

39. BARRIERS TO CONSULTATION PROCESS CONT’D Social Barriers: Language/Interpreter Illiteracy Cultural barriers Immigration status Legal problems.

40. FACTORS THAT INFLUENCE THE CONSULTATION: Recording the consultation can be an impediment if care is not taken. Sometimes the urge to finish quickly may present while prescription is being written and so adversely influence the consultation. Age – Younger persons are more likely to expect a relationship of mutual participation than elderly ones.

41. FACTORS THAT INFLUENCE THE CONSULTATION CONT’D: Gender – Women are more likely to take more time at the consultation than men while doctors are more likely to discuss more with men. Education – Patients with high social and educational background tend to participate more in the consultation. Duration of illness – A patient’s desire to participate in the consultation increases in the course of an illness as they gain more knowledge and understanding of the illness.

42. FACTORS THAT INFLUENCE THE CONSULTATION CONT’D: Finance – Consultations on fee for service basis tend to take more time than where doctors are government paid. Patients presenting with medically unexplained symptoms (MUS), tend not to be satisfied with their consultation. The physicians appearance (dressing)

43. CONCLUSION: Consultation models provide a potential structure for the complex interactions that occur between patients and doctors. They help doctors process the vast amount of information that is conveyed to them during the consultation. They help Family physicians communicate more effectively with their patients, which in turn can improve their job satisfaction, patient satisfaction and patient outcomes.

44. CONCLUSION: They can help FPs to understand where their consultations are going wrong, and may help them find ways to correct this problem. There will never be a model that covers every eventuality in the exceptional and unique world of primary care. If consultation models are used, they should not be followed rigidly, but adapted to one’s innate consulting skills and personality traits, allowing our natural warmth and empathy to show through.

45. What is the role of referral in the consultation process ?

46. REFERENCES Okokon, I. B. The Consultation in Primary Care. A Presentation at the 2014 Revision Course in Family Medicine. Denness, C. What are Consultation Models for? SAGE Journals. 2013. Available from www.journals.sagepub.com Accessed on 28/07/2021. Mehay, R. Ram’s top tips for the CSA-part one. 2012. Available from www.bradfordvts.co.uk/mrcgp/csa. accessed on 28/7/2021.

47. THANK YOU FOR LISTENING