Home

C-C
guide

 Handouts

 One to One

Course
plans

Specific
issues

Assessment  Reading

MODELS OF THE CONSULTATION  -A summary Download

Physical, Psychological and Social Stott and Davis Byrne and Long 
Six Category Intervention Analysis  Helman’s  ‘Folk Model’ Transactional Analysis  
Pendleton, Schofield, Tate and Havelock Neighbour  The Disease - Illness Model 
Three Function Approach Calgary-Cambridge Approach Comprehensive clinical method (CC2)
REFERENCES 

1.            Physical, Psychological and Social’ (1972)  
T
he 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)                         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 

            (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)       Back to top

             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 Back to top

            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) Back to top

             ‘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. 

8.            Neighbour (1987)  Back to top

            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) Back to top

 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

 

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

            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

 11.       The Calgary-Cambridge Approach to Communication Skills Teaching  Back to top                   
(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) establishing initial rapport
b) identifying the reason(s) for the consultation

(2) Gathering Information

a) exploration of problems
b) understanding the patient’s perspective
c) providing structure to the consultation

(3) Building the Relationship

a) developing rapport
b) involving the patient

(4) Providing structure to the interview
a) summary
b) signposting
c) sequencing
d) timing

(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

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.


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 Update 5.9.02
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 Back to top
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 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.

  1. 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.

REFERENCES Back to top


1 Working Party of the Royal College of General Practitioners ( 1972)

2 Stott N C H & Davis R H ( 1979)
The Exceptional Potential in each Primary Care Consultation:
J R Coll. Gen. Pract. vol 29 pp 201-5

3 Byrne P S & Long B E L (1976)
Doctors talking to Patients: London HMSO

4 Heron J (1975)
A Six Category Intervention Analysis: Human Potential Research
Project, University of Surrey

5 Helman C G (1981)
Disease versus Illness in General Practice
J R Coll. Gen. Pract. vol 31 pp 548-62

6 Stewart Ian, Jones Vann (1991)
T A Today: A New Introduction to Transactional Analysis
Lifespace Publishing

7 Pendelton D, Schofield T, Tate P & Havelock P (1984)
The Consultation: An Approach to Learning and Teaching:
Oxford: OUP

8 Neighbour R (1987)
The Inner Consultation
MTO Press; Lancaster

9 Stewart M et al (1995)
Patient Centred Medicine
Sage Publications

10 Cohen-Cole, S (1991)
The Medical Interview, The Three Function Approach
Mosby-Year Book
Cohen-Cole S, Bird J. (2000) 2nd edition Mosby Inc.

11 Kurtz S & Silverman J (1996)
The Calgary-Cambridge Observation Guides: an aid to defining the
curriculum and organising the teaching in Communication Training
Programmes.
Med Education 30, 83-9

Silverman J, Kurtz S and Draper J, (1998)
Skills for Communicating with Patients
Radcliffe Medical Press, (2nd edition in preparation)

12 Kurtz S, Silverman J, Benson J, Draper J. (2003)
Marrying Content and Process in Clinical Method Teaching; Enhancing the Calgary-Cambridge Guides Academic Medicine volume 78 no. 8 pp 802-809 (see also www.SkillsCascade.com)

13. Warren E. (2002)
An introduction to BARD: a new consultation model
Update 5.9.02 152-154

14. Balint M. (1986)
The Doctor, the Patient and the Illness
Edinburgh: Churchill Livingstone

15. Launer J. (2002)
Narrative-based primary Care: a practical guide. Radcliffe Medical Press Abingdon Oxford


Other useful texts
Usherwood T (1999)
Understanding the consultation: evidence, theory and practice
OUP Buckingham Philadelphia

 

Skillscascade @2000-2003. All content is copyright by original owners.