MODELS OF THE CONSULTATION

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.

3. Byrne and Long (1976) Back to top
“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 treatment 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) Back to top
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

(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.

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:

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.

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

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

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

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

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.

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. View powerpoint slide of model

Patient presents problem

Gathering information

Parallel search of two frameworks

Disease framework Illness framework

Doctor’s agenda Patient’s agenda

Symptoms Ideas

Signs Concerns

Investigations Expectations

Underlying pathology Feelings

Thoughts

Effects

Differential diagnosis Understanding the patient’s unique

experience of illness

Integration of the two frameworks

Explanation and planning:

shared understanding and decision making

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.