Consultation Skills

Qatar Primary Health Care 2008

“The Foundation of Health and Wellbeing”
1-4 November 2008

Dr. Ashraf Ahmed

ABFM - MRCGP(UK) - MRCGP (int)- Dip(PCR)
Dip. Quality Health Administration
 Qualitative research in the UK shows a similar pattern

Quotes from non-complying patients

… you’ve upped it to fifty mgs or whatever
Basically I don’t want to be dependent on …I took it for six days…then I thought
these tablets…I’ve been taking tablets well well I’m a bit tired so the next day I
basically for thirteen years I’ve been taking halved it. That’s experience.
these tablets (epilepsy patient) (hypertension patient)

Patient

I’m doing fine as I am, thanks. I’ve had no

dire effects … I think the treatment of
hypertension is fashionable just now…its
easy for doctors…take a pill and come
back
(hypertension patient)

Source: Dowell J, Jones A, Snadden D., Exploring medication use to seek concordance with ‘non-adherent’
patients: a qualitative study. British Journal of General Practice. 2002
One consequence of the traditional model

Source: Fairview Pharmacy, London, 2004 -

medicines picked up from an elderly lady’s home
Non-compliance affects virtually all
disease areas

%Patients not 80
complying per
disease area
55

40 40
35

Arthritis Epilepsy Hypertension Diabetes Asthma

Source: Whitney HAK, Jr. et al. (Editors). Medication compliance: a healthcare problem. Annals of Pharmacotherapy 1993; 27 (9. Suppl).
…but non-compliance with prescribed medicines is a
major problem
Consequences

50% of Ill-health and

medicines for reduced quality
of life
chronic
Reduced life
conditions expectancy
are not taken Avoidable
as healthcare cost
prescribed Economic loss to
society

Source:Medicine partnersip-from
compliance to concordance
 Observational studies point to significant opportunity to better inform
patients during the average prescribing consultation

Communication Discussion initiated by doctor %

•Instructions for use •87

•Almost half of
consultations fail to explain
•Intended benefits •54 benefits of medication

•22
•Side-effects explained in
•Possible side-effects every 5th consultation only

•Patient’s opinion •15

about medication •Small minority of
consultations elicit patient’s
•Patient’s ability to •5 view or surface obstacles to
follow treatment plan compliance

Source: Makoul G, Arntson P, Schofield T. (1995) Health promotion in primary care: physician-patient
communication and decision making about prescription medications. Soc Sci Med ; 41 (9): 1241-1254.
But analyses of doctor-patient communications suggest that these beliefs and views

are often not explored in prescribing consultations

GP Estimate
Communication Perceived and actual frequency %
Observed

•62 •Doctors
•Provide instructions underestimate
for taking the the degree to
medication •87 which they
‘instruct’
•40
•Discuss side-
effects of the
medication •31

•Doctors
•Find out what •49 overestimate the
patient thinks about degree to which
treatment plan •34 they consult and
elicit their
patient’s views
•49
•Discuss patient’s
ability to follow
treatment plan •8

Source: Makoul G, Arntson P, Schofield T. (1995) Health promotion in primary care: physician-patient
communication and decision making about prescription medications. Soc Sci Med ; 41 (9): 1241-1254.
 Policy makers in the UK acknowledge the need to implement concordance as a key part
of the NHS plan
‘Prescribing and medicine taking will
increasingly be seen by patients and
professionals alike as a partnership
between them… to give patients more
of a say in and greater commitment to
their treatment’
(Pharmacy in the Future)
‘Too many patients feel talked at rather
than listened to. This has to change… To
bring this about, patients must have more
say in their own treatment’
(NHS Plan)
Source: NHS, DoH
‘Patients are not passive recipients of
prescribing decisions. They have their
own beliefs about medicines, how they
work and how they are best used.
Moreover, medicines taking has to fit
within their normal daily lives’
(Pharmacy in the Future)
‘Older people & their carers need to
be more involved in decisions about
treatment and to receive more
information than they currently do
about the benefits and risks of
treatment’
(Older People NSF)
‘In a patient-centred healthcare service
patients must be involved, wherever possible
in decisions about their treatment and
care.’
(Kennedy Report)
From compliance to concordance
Traditional model Patient centered model

Source:Medicine partnership-from
compliance to concordance
Professionals need shared decision making skills

To be To be
taken as taken as
directed agreed

Key elements of
training:
-Understanding patient
perspectives
-Trying it out through
role play / scenarios
-Team working
Source:Medicine partnership-from
compliance to concordance
 Medicines Partnership has five work streams
to implement concordance
A clarification / recasting is proposed:

ChangingProfessional
Changing ProfessionalBehaviour
Behaviour

ShapingPolicy
Shaping Policy

EnablingPatients
Enabling Patientsto
tobe
bePartners
Partners

Servicesto
Services toSupport
SupportConcordance
Concordance

KnowledgeManagement
Knowledge Management

Source:Medicine partnership-from
compliance to concordance
 Opposing Paradigm

Empirical Vs Hermeneutic
Doctor center Vs. Patient center
 Scientific Paradigms:

• The term paradigm is often used to describe the

received beliefs that are taken for granted in a
scientific discipline
• Empirical: the verification of hypotheses by
recourse to data accessible by the five
senses. This is logical left brain activity,
very much the doctor centered scientific
approach. This is also known as positivism
• Hermeneutic: the art of interpretation or
phenomenological enquiry.

• This is an intersubjective approach,

leading to what Balint called the flash of
understanding whereby the doctor
experiences in an empathic flash what the
patient is going through.
• Balint was the first to recognize that the
symptom offered by the patient might not
be the real reason for their attendance and
that the emotions triggered in the doctor
could have a powerful effect on the course
of the consultation
• Neighbour introduces the concepts of
right brain and left brain thinking in the
inner consultation.
 LEFT RIGHT
• LOGICAL • INTUITIVE
• REALISTIC • EMOTIONAL
• RATIONAL • OPENMINDED
• HARD • APPROXIMATING
• ANALYTICAL • EXPERIMENTING
• DOGMATIC • IMPETOUS
• SYSTEMATIC • SOFT
• TIDY • IMAGINITIVE
• CAUTIOUS • FLEXIBLE
• PLANNER • SUBJECTIVE
• OBJECTIVE • SPONTANEOUS
• FACTUAL • HUMOROUS
• DISCIPLINED • UNTIDY
• ORGANIZED • LIBERAL
• DETAILED • PLAYFUL
• RISK-TAKER
• Mcwhinney, Nighbour, Balint and others
have suggested that we learn to develop
this form of intersubjective enquiry. It
seems likely that in this are lies the art of
general practice.
• The point here is that we all have right
brains and do use them. We tend to give
more conscious importance to the logical
analysis of the left brain yet many of us
are secretly governed by the right brain.
Medical interventions
Hermeneutic interventions

• Attentive listening
• Reflection
• Silence
• Empathy vs. sympathy
• Touching
• Non doing
Empirical interventions

• Reassurance
• Advices: explaining, clarifying, interpreting,
analyzing, opinion giving
• Cognitive refraining
• Prescriptions, referrals etc.
 Doctor - centred
Vs
Patient centred

• How would you define patient

centeredness?
In Dealing with the patients AGREE DISAGREE DR OR PT
problem CENTRED

This area of the consultation is

primarily concerned with the doctors
professional skills
Answers to problems often come out
of no where
Problem solving is usually by tried
and tested methods

I find that I match most problems

with a standard solution

The patient’s opinion on problem

solving is less important than the
doctors.
Only when the patient accepts the
plan do we move on

most solutions are unique rather

than standard formulae
 In Dealing with the patients problem

This area of the consultation is primarily concerned

with the doctors professional skills

Agree--------Dr centred
Disagree----Patient centred
 In Dealing with the patients problem

Answers to problems often come out of no where

Agree---------- Pt centred
Disagree------ Dr centred
 In Dealing with the patients problem

Problem solving is usually by tried and tested

methods

Agree --------Dr centred

Disagree-----Pt centred
 In Dealing with the patients problem

I find that I match most problems with a standard

solution

Agree ----------Dr centred

Disagree-------Pt centred
 In Dealing with the patients problem

The patient’s opinion on problem solving is less

important than the doctors.

Agree------------Dr centred
Disagree------- Pt centred
 In Dealing with the patients problem

Only when the patient accepts the plan do we

move on

Agree--------- Pt centred
Disagree----- Dr centered
 In Dealing with the patients problem

Most solutions are unique rather than standard

formulae

Agree------- ----Pt centred

Disagree------- Dr centred
 Consultation models
• 1957 M Balint - The Doctor, His Patient and The Illness
• 1964 E Berne - Games People Play
• 1975 Becker & Maiman - Sociobehavioural Determinants
of Compliance ...
• 1975 J Heron - Six Category Intervention Analysis
• 1976 Byrne & Long - Doctors Talking to Patients
• 1977 RCGP definition- Physical, psychological & social ...
• 1979 Stott & Davis - The Exceptional Potential in Each
Primary Care Consultation
• 1981 C Helman - Disease vs Illness in Gen Practice
• 1984 Pendleton et al - The Consultation
• 1987 R Neighbour - The Inner Consultation
• 1987 R C Fraser -Clinical Method: A Gen Pract.approach
• 1996 Kurtz & Silverman The Calgary-Cambridge
Observation Guide to The Consultation
Knowledge E.g. Facts about ‘compliance’ etc
What is on patient’s agenda?

Skills Medical Clinical Reasoning

Clinical method
Therapeutic

Communication Rapport
Elicit
Negotiation

Interpersonal Overcoming fear of intimacy

relationship Developing positive regards for patients
 Communication skills
Talking to people
Listening to stories

History taking
Structured Effective
Focused Consulting
Patient centered With patients

Clinical problem
solving
 Consultation Tasks
Explain
Explain
Summarize
Summarize
Check
CheckUnderstanding
Understanding

Find
Findout
out
Nature-History
Nature-History Prioritize
Prioritizeproblems
problems
Cause
Causeofofproblems
problems Establish
Establish
rapport
rapport

Find
Findout
outthe
thePatient’s
Patient’s
IDEAS Discuss
Discussoptions
options
IDEAS
CONCERNS
CONCERNS
Negotiate
Negotiate
EXPECTATIONS
EXPECTATIONS Reach
Reachagreement
agreement
FEELINGD
FEELINGD
 Why patient-centered
Consulting?
• Because it can improve:
• Emotional health, e.g. anxiety, distress
• Symptom, e.g. headache, dizziness
• Function, e.g. in cancer, diabetes
• Physiological measures, e.g. Bp, blood
sugar
• Pain control, e.g. after surgery
• Patient satisfaction
 Managing the consultation

• Managing the problems

• Managing the patient
• Managing the consultation process
Three Sources of Information

• What the patient tells the doctor

• What the doctor sees and hears
( including non-verbal and vocal cues)
• How the doctor feels
 Establishing Rapports

• Beginning the consultation

• Listening
• Demonstrating empathy
Challenges/Obstacles to Effective
Consultation

• Time
• Cost
• Culture
• Legal Issues
 Danger areas in the consultation
• psychological diagnoses - everyone fears being accused of having an
imaginary illness

• age - fit, healthy 60-year-olds resent implications that ailments such as

osteoarthritis are due to old age

• insecurity - an insecure patient may misinterpret the doctor's remarks

as criticism and feel further undermined

• taboos - for example, sex or contraception may be unacceptable areas

to discuss

• aggression - reacting aggressively to aggression is inappropriate - it is

often caused by fear, previous bad experience with doctors or anxiety
that the condition will not be taken seriously. It can also be caused by
guilt or by ignorance of other ways to respond.
• Developing one's consultation skills takes
time, practice and much self criticism and
self awareness.
• Making video recording of consultations is
a very potent tool to examine them in
detail later..