Consultation Skills
Byrne&Long / Stott&Davis / Pendleton / Neighbour / PUNs&DENs
In order to pass the MRCGP you will need to be aware of the major theories that comprise the "specialty" component of general practice - Consultation Skills. The list below is presented as an aide-memoire, if you want to pass the exam it is recommended that you read the texts that these theories were originally detailed in.
Doctors Talking to Patients - 1976 - Byrne and Long
Byrne and Long analysed 2000 tape recordings of Doctors and their patients, the book "Doctors talking to patients" was written as a result of this work. In this work they described the structure for the generic consultation in the form of six phases which are outlined below.
They also described the power dynamic that exists within the consultation in the form of a spectrum that ranged from being entirely doctor-centric (with contributions from the patient virtually ignored) to entirely patient-centric.
This was one of the first evidence based analyses of the consultation. Prior to this much of the work was opinion based.
Phase I - Relating to the patient
Before delving into the reasons for attendance an attempt is made to establish a rapport with the patient.
Phase II - Discovering the reason for the patients attendance
An attempt, hopefully but not always succesful, is made to discover the reasons for the patient's attendance.
Phase III - The doctor conducts a verbal or physical examination or both
Depending on the nature of the reason for attendance a verbal or physical examination is made.
Phase IV - Considering the patients condition
The patient's condition is considered, in Byrne and Long's analysis this was most likely to be performed by the doctor alone. It could also be considered by the doctor and the patient, or (least likely) by the patient alone.
Phase V - Detailing further treatment
The doctor outlines what happens next, this could be further investigation and/or treatment. Rarely the patient was found to detail what they expected to happen next.
Phase VI - Terminating the consultation
The doctor or (less likely) the patient ends the consultation.
The exceptional potential in each primary care consultation. 1979 - Stott and Davis
Did you notice something missing from Byrne and Longs model? A role that we take for granted as a component of our life as a GP now is that of health promotion. Stott and Davis described four areas that could be explored during a typical consultation.
Management of presenting problems
Management of continuing problems
Modification of help seeking behaviour
Oppurtunistic health promotion
The Consultation - An Approach to Learning and Teaching. 1984 - Pendleton
In 1984 Pendleton defined seven tasks which lead to a successful consultation. One of the most useful concepts to come out of his work is the that of "Ideas, Concerns and Expectations". A tool for understanding the reasons for the patient's attendance.
Task 1:
Define the reason for the patients attendance including:
- The nature and history of the problem.
- Their aetiology.
- The patient's ideas, concerns and expectations
- The effects of their problems
Task2:
Consider other problems:
- Continuing problems
- At risk factors
Task3:
Choose with the patient an appropriate action for each problem
Task 4:
Achieve a shared understanding with the patient
Task 5:
Involve the patient in the management plan and encourage him to accept appropriate responsibility
Task 6:
Use time and resources appropriately
Task 7:
Establish and maintain a relationship with the patient which helps to achieve the other tasks.
The Inner Consultation - 1987 - Neighbour
Roger Neighbour is a GP who wrote "The Inner Consultation". He has recently been elected president of the Royal College of General Practitioners. His book is one of the key texts you should read whilst on the VTS. His model of the consultation had 5steps which are outlined below.
Connecting
In order to connect with the patient you need to establish rapport and demonstrate empathy. During this stage you alllow the patient to explore their reasons for attending.
Summarising
A frequently heard complaint amongst patients is that they did not feel that their doctor listened to them or failed to understand their reasons for attending. You need to feed back your understanding of their problems in order to demonstrate understanding to the patient and to double check that you have listened and understood completely.
Handing over
A vital part of any management plan is ensuring it is acceptable to the patient. You should use your negotiation skills to agree a management plan and hand over responsibility for areas of that plan to the patient.
Safety Netting
We've all done it, after working through the above steps and bidding farewell to the patient we think ""what if they have y instead of x as I thought?". Cue a sleepless night and a phonecall to the patient in the morning to double check that nothing untoward has been missed. Safety netting is a postscript to the consultation during which you consider alternative diagnoses, particularly the ones which are likely to result in damage to the patient and anxiety to you. You present the patient with the warning signs they should look out for and what to do if they do develop any o f them.
Housekeeping
Consultations by their very nature are stressful. As a profession we are remarkably good at ignoring the signs of stress and allowing it to corrode our personal and professional lives. The inner consultation encourages housekeeping, a moment of reflection between patients when you have the oppurtunity to examine your own feelings about the progress of the consultation.
Puns and Dens - 2000 - Eve
PUNS - Patient Unmet Needs
DENS - Doctors Educational Needs
Dr Richard Eve first described PUNS and DENS as a mechanism by which doctors can identify their educational needs by analysing their activity in consultation.
Identifying a PUN
You will experience the situation where you are not sure of the best course of clinical action, or a patient asks a question about their care you are unable to answer. A PUN.
Finding a DEN
You may deal with this by asking a colleague, bluffing or covering up, or thinking `I must go and look that up'. By identifying the lack of a Doctors skill or knowledge you have found a DEN.
In a busy day it is worthwhile jotting down in your diary the PUN or DEN, in order to reflect upon it and take it further in discussion or reading later. This technique can sometimes show up patterns, and will increase self awareness.
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