Consultation Models & Theory

The content of general practice

  1. Clinical practice – health and disease
  2. Clinical practice – human development
  3. Clinical practice – human behaviour
  4. Medicine and society
  5. The practice

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.

The Triaxial Model (1972)

The Royal College of General Practitioners has highlighted the need for doctors to address patient problems in physical, psychological and social terms. The most contemporary thinking about the consultation assumes it must be analysed with respect to these three features.

The effect is to discourage doctors to think purely in organic terms and consider also the patient’s emotional, family, social and environmental circumstances, all of which can have a profound effect on health.

The sociological approach

  • Social factors may influence behaviour in the consultation:
    • different beliefs and norms of behaviour
    • doctor and patient will behave according to the rules of their respective roles
  • Social factors influence many illnesses and are largely responsible for the patient’s decision to seek help
  • Social factors could affect the outcome of consultation or the way it is judged

The anthropological approach

  • Sapiential authority (the right to be heard derived from knowledge)
  • Moral authority
  • Charismatic authority

Helman’s folk model of illness (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:

  • what has happened?
  • why has it happened?
  • why to me?
  • why now?
  • what would happen if nothing were done about it?
  • what should I do about it?

Health belief model

The decision to consult depends upon:

  1. The individual’s general interest in health matters, which may correlate with their personality, social class, ethnic group, etc.
  2. How vulnerable or threatened a patient feels him/herself to be to a particular disease.
  3. The individual’s estimation of the beliefs of treatment weighed against cost, risks and inconvenience.
  4. Trigger factors, such as alarming symptoms, advice from family or friends, messages from the mass media, disruption of work or play.

The transactional analysis approach

Many doctors will be familiar with Eric Beme’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 familiarity with TA introduces 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 human psyche is set to consist of three ego states:

  • the parent – commands directs prohibits controls nurtures
  • the adult – sorts out information and works logically
  • the child – intuition creativity spontaneity enjoyment

At any point, each of us is in a state of mind where we think, feel, behave, react and have attitudes as if we were either 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 interaction is not always in the best interests of either party. Communication may break down when replies do not match the initial offer. Many transactions are predictable and are described as “games”. Transactional Analysis teaches doctors to break out of these repetitious and degenerative cycles of behaviour.

Balint

Much contemporary thinking derives ultimately from Balint and his recognition that patients were more than unbroken machines and the doctor-patient relationship more subtle than was commonly realised. This 1950s approach emphasises the use of transference and counter-transference in diagnosis and treatment and the notion of the doctor as a drug – the most powerful therapeutic tool in the room.

In particular:

  • Doctors have feelings and those feelings have a function in the consultation.
  • Psychological problems are often manifested physically and even physical disease has psychological consequences. The patient cannot be divided into physical and psychological categories – the two always co-exist.

Specific training is needed to change doctors behaviour so that he can become more sensitive to the patient.

Pendleton, Schofield, Tate and Havelock (1984)

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

From observation, seven tasks were detailed which together form comprehensive aims for the consultation:

  1. To define the reason for the patient’s attendance, including
    1. the nature and history of the problems
    2. their aetiology
    3. the patient’s ideas, concerns and expectations
    4. the effects of the problems.
  2. To consider other problems:
    1. continuing problems,
    2. 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/her to accept appropriate responsibility.
  6. To use time and resources appropriately
    1. in the consultation,
    2. in the long term.
  7. To establish and maintain a relationship with the patient which helps to achieve the other tasks.

These have been widely used and taught as appropriate aims for the consultation. They are of particular interest for the purposes of summative assessment since the criteria developed for assessing the video component are derived from this approach.

Neighbour’s model (1987)

Five consultation tasks are defined: ‘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-netting –  ensure a contingency plan has been made for the worst scenario – “What if?”
  5. Housekeeping – clear the mind of the psychological remains of one’s consultation to ensure it has no detrimental effect on the next – “Am I in good enough shape for the next
    patient?”

Intervention analysis

A doctor can use any of six behavioural interventions:

  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 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 or explore his/her own latent thoughts or feelings.
  6. Supportive: offering comfort and survival, affirming the patient’s intrinsic value.

The social-psychological approach

  • doctor’s personality
  • patient’s personality
  • patient’s beliefs
  • verbal behaviour
  • non-verbal behaviour

Problem-based interviewing

Giving the patient some of the control for process and outcome.

The tasks of a GP within the consultation

(Dykhuis)

  1. Primary assessor
  2. General physician
  3. Personal doctor Family doctor
  4. Community doctor

Target behaviour in the consultation

(Irwin & Bamber: 1984)

1 ( ) The beginning

2 ( ) Body posture

3 ( ) Eye contact

4 (IV) Attentive listening

5 (IV) Use of facilitation

6 (I) Use of confrontation

7 (I) Use of silence

8 (IV) Style of questions

9 Absence of jargon

10(I) Appropriateness of interrupting patient

11(IV) Keeping patient to relevant matters

12(IV) Picking up verbal cues

13(I) Picking up non-verbal cues

14(V) Ability to clarify

15( I) Covering of psychological aspects

16( I) Covering of personal aspects

17( I) Covering of social aspects

18(IV) Presence of empathy

19(V) Quality of exposition

The primary care consultation 1976

In 1976 Byrne and Long analysed more than 2000 consultations and identified six logical phases to a consultation. They also stressed that this logical structure rarely appears in reality – sadly, a point that has tended to go unnoticed in communication skills teaching.

  1. The doctor establishes a relationship with the patient.
  2. The doctor attempts to discover or actually discovers the reasons for the patient’s attendance.
  3. The doctor conducts a verbal or physical examination or both.
  4. The doctor and/or patient consider the condition.
  5. The doctor and patient agree and detail further treatment or investigation if necessary.
  6. The consultation is terminated (usually by the doctor).

Dysfunctional consultations usually fell down in phase 2 and/or 4.

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.

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
  1. Open-ended question
  2. Open to closed cone
  3. Facilitation
  4. Checking
  5. Survey of problems
  6. Negotiate priorities
  7. Clarification and direction
  8. Summarising
  9. Elicit patient’s expectations
  10. Elicit patient’s ideas about aetiology
  11. Elicit impact of illness on patient’s quality of life
2 Developing rapport
  1.  Reflection
  2. Legitimation
  3. Support
  4. Partnership
  5. Respect
3 Education and motivation
  1. Education about illness
  2. Negotiation and maintenance of a treatment plan
  3. Motivation of non-adherent
    patients

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 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
    • establishing initial rapport
    • identifying the reason(s) for the consultation
  2. Gathering Information
    • exploration of problems
    • understanding the patient’s perspective
    • providing structure to the consultation
  3. Building the Relationship
    • developing rapport
    • involving the patient
  4. Explanation and Planning
    • providing the correct amount and type of information
    • aiding accurate recall and understanding
    • achieving a shared understanding: incorporating the patient’s perspective
    • planning: shared decision making
  5. Closing the Session

The Cambridge-Calgary method of giving feedback

Teaching styles

  • The authoritarian style: “Tell and Sell” – standard “teachers” teaching.
  • The Socratic style: Teaching by question and answer.
  • The heuristic style: “Find out for yourself”. Encourages learning by doing and demands free interchange between trainer and trainee.
  • The counselling style: Aims to help the trainee understand the interactions taking place between himself and the material being learned. Teacher must not be authoritarian. Equivalent to a counselling style in the consultation.
  • The neo-Socratic style

Remember Pendleton’s rules for the consultation!

References

  1. Working Party of the Royal College of General Practitioners (1972)
  2. Stott NCH & Davis RH(1979)
    The Exceptional Potential in each Primary Care Consultation:
    J R Coil. Gen. Pract. vol 29 pp 201-5
  3. Byrne PS & Long BEL(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 Coil. Gen. Pract. vol 31 pp 548-62
  6. Stewart Ian, Jones Vann
    T A Today: A New Introduction to Transactional Analysis Lifespace Publishing 1991
  7. Pendelton D, Schofield T, Tate P & Havelock P (1984) The Consultation: An Approach to Learning and Teaching:
    Oxford: OUP
  8. Neighbour R
    The Inner Consultation (1987) N/ITO Press; Lancaster
  9. Stewart M et al
    Patient-Centred Medicine
    Sage 1995
  10. Cohen-Cole, S
    The Medical Interview, The Three Function Approach Mosby-Year Book (1991)
  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
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