|Make a provisional diagnosis (Hypothesis)|
|Investigations (Hypothesis testing)|
|Make a definitive diagnosis (Deduction)|
I like this. This is why we went to Med School. This is why we watch House Clancy and St Elsewhere, but it is not the whole picture.
Clearly real life patients particularly in primary care are no so straightforward and often no single disease entity (or entities) is identified. This does not mean attempts to identify and help attenuate their suffering is outside the remit and duties of their physician. Clearly if we restricted ourselves to the purely physical many of us would be out of a job. These models are just frameworks or ways of looking at a problem. But the Medical Model should not be too readily dismissed. A patients Medically Unexplained Symptoms may just be Medically Undiagnosed Symptoms and application of a psychological straight jacket may not always be the best way to go.
Cyriax said “all pain has a cause” treatment should be directed at that cause
Einstein said “you think you are scientists, you call yourselves scientists, you are not scientists”
The point being that Cyriax developed his interest in Orthopaedic Medicine through realising many patients were not getting the proper diagnosis or treatment. His approach is biomedical and echoes Kochs postulates that every illness is caused by a definable agent (Koch’s Postulates) and identification of that agent will allow application of approporiate rational treatment.
|Frasers 7 areas of competence|
|1. Interviewing and history-taking|
|2. Physical examination|
|3. Diagnosis and problem-solving|
|4. Patient management|
|5. Relating to patients|
|6. Anticipatory care|
|Neighbour inner consultation|
|5 stage checklist|
|1 Connecting – establish and maintain rapport|
|2 Summarising – demonstrate to patient you understand why they’ve come|
|3 Handing over – patient accepts agreed management plan|
|4 Safety netting – advise expected outcomes and what to do if otherwise|
|5 Housekeeping – doctor acknowledges / attends to his own feelings|
|Neighbour R (1987) The inner consultation|
|Patient centred model|
|1. Exploring both the disease and the illness experience|
|2. Understanding the whole person|
|3. Finding common round regarding management|
|4. Incorporating prevention and health promotion|
|5. Enhancing the Doctor-Patient relationship|
|Patient centred model Stewart and Levenstein 1984|
|1. Define reasons for the patient’s attendance from their perspective – nature, history, aetiology and effects on their personal and social circumstances; ideas and values about health; their ideas about the problem, its causes and its management; their concerns about the problem and its implications; their expectations for information, involvement and care.|
|2. Consider other problems as appropriate – risk factors, other problems|
|3. Enable patient to choose an action plan for each problem:|
|4. Achieve a shared understanding|
|5. Involve patient in management plan|
|6. Use time and resources appropriately: both in cosultation & longer term|
|7. Establish/maintain a relationship with the patient that helps to achieve the other tasks.|
|Pendleton D, Schofield T, Tate P and Havelock P An Approach to Learning and Teaching 1984(2000)The consultation: an approach to learning and teaching. Oxford University Press, Oxford (2003) The new consultation: developing doctor-patient communication. Oxford University Press, Oxford.|
See also Pendletons Rules for Giving Feedback
|Stott and Davis|
|Areas to be explored during the consultation|
|a Identification & management of presenting problem|
|b Modification of patient’s help-seeking behaviour|
|c Management of continuing problems|
|d Opportunistic health promotion|
Stott NCH and Davis RH (1979) The exceptional potential in each primary care consultation.
Journal of the Royal College of General Praditioners, 29, 201-5.
|Byrne and Long|
|6 phases identified from analysis of 2500 audio-taped consultations of 71 GPs|
|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, the doctor and the patient, or the patient (in that order of probability) consider the condition.|
|5. The doctor and (occasionally) patient agree and detail further treatment or investigation if necessary.|
|6. The consultation is terminated (usually by the doctor).|
|Byrne and Long Doctors Talking to Patients 1976|
Doctor’s consultation styles
based on doctor’s knowledge, domineering, closed questioning rejecting patients ideas and evading patients questions
incorporating the patient’s experience, open questioning, listening challenging and reflecting patients words and behaviour to gain clarity.
Dysfunctional consultations occurred when the doctor failed to discover the reason for the patient’s attendance
(2nd phase) or because the doctor did not tailor his explanation to his patient’s beliefs (4th phase).
these stereotypes may seem somewhat outdated in our more enlightened and more polite times times but recent developments suggest that
– in austere times patient considerations (eg choice) may need to give way to patient need (as defined by the High Priests)
– knowledge and training in caring, courtesy and human decency can sometimes slip
Balint 1957 the doctor the patient and the illness
1) Psychological difficulties may present as physical problems and physical illness has psychological consequences
2) Doctors have feelings and those feelings have a function in the consultation
3) Doctor’s can become more sensitive to the patient through specific training.
1 Doctor a drug – with positive therapeutic effects – and side effects
2 Flash technique the doctor becomes aware of his feelings in the consultation, and when he interprets this back to the patient, the patient gains some insight into his problems.
3 Collusion of anonymity – professionals avoiding taking ultimate responsibility for the patient
4 Child or other as presenting complaint / entry ticket
5 Elimination by examination
6 Mutual Investment Company
Based on work with groups of doctors meeting regularly to discuss their difficult cases.
Balint model emphasises the contribution of psychological factors to the presenting illness, the importance of treating bodies and minds simultaneously, and the importance of recognising
the doctor’s own feelings.
|Anthropological / folk model|
|Patient wants/needs to know|
|1 What has happened?|
|2 Why has it happened?|
|3 Why me?|
|4 Why now?|
|5 What would happen if nothing were done about it?|
|6 What should I do about it and who should I consult for further help?|
|Helman Anthropological/Folk Model 1981|
|Health belief model ICE|
|Rosenstock Becker and Maiman 1975|
ubiquitous mnemonic/uber-mantra driven deep into the hearts and minds of trainees and nMRCGP candidates.
visible demonstration of an attempt to explore the patients ICE is a sine qua non of success in assessments and overlooking the same is rightly considered to be a bad thing
there is of course a difference between being a genuinely competent and caring practitioner of the art of clinical medicine (tautology?) and a performing seal.
Any apparent skepicism does not reject the fundamental importance of this stuff, but rather a curiosity as to whether the essential and noble aims of medical education are best achieved by a particular contemporary approach
|ICE version 2 for OSCES and everyday practice (Pastest and others)|
|This should also be always at the top of one’s mindset, until it becomes and remains reflexive|
Berne Transactional Analysis Games People Play 1964
Human psyche consists of three ego states:
parent — commands and controls nurtures
adult — logical, processing
child — intuitive, creativitve, spontaneous , pleasure-seeking
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 a parent (critical or caring), a logical adult or a child (spontaneous or dependent)
|Heron Six Category Analysis|
|Heron Six Category Interventional Analysis 1975|
|Calgary Cambridge / Kurtz Silverman|
|A. Initiating the session|
|B. Gathering information|
|C. Building the relationship|
|D. Giving information explaining and planning|
|E. Closing the session|
Patient presents with problem — Clinician gathers data
Then 2 parallel/simultaneous pathways
ICE Feelings Thoughts Affects
Disease Framework Symptoms Signs Investigations Underlying Pathology Differential Diagnosis
To be integrated into Explaination and planning in terms patient can understand
|RCGP triaxial model (1972)|
|Extend thinking beyond organic
Consider Emotional, Family, Social and Environmental factors
Developed from studying illness behaviour in different cultures. A healing ritual consists of:
giving the problem a name (diagnosis)
performing a therapeutic ritual (management)
renaming the problem as cured or improved (cure)
Patients believe healers. Society has invested the healers with authority (called Aesculapean authority) which derives from:
the doctors’ greater knowledge or expertise sapiential authority
the doctors’ desire or motivation to do good moral authority
the doctors’ desire to see the practice of medicine as something of a mystery charismatic authority
Communication with patients from other cultures: the place of explanatory models Bhui and Bhugra 2004 rcpsych.org
|Boeckz needs model|
MRCGP Video Criteria
Doctor encourages patient’s contribution.
Dr. responds to cues
Dr. elicits appropriate details to place complaint in social & psycho-logical context
Dr. explores patient’s health understanding Merit
Dr. obtains sufficient information for no serious condition to be missed.
Dr. chooses an appropriate examination.
Dr. makes clinically appropriate working diagnosis.
Dr. explains diagnosis.
Dr. uses appropriate language.
Dr. takes account of patient’s belief Merit.
Dr. confirms patient’s understanding Merit.
Dr. uses appropriate management plan.
Dr. shares management options.
Dr. uses appropriate prescribing behaviour.
Scope for telephone consultations
Providing the results of investigations
Request for sick notes or claim forms
Triage of emergency appointment requests
Triage of home visit requests
Health promotion e.g. promoting immunisation, cervical smear, smoking cessation services etc
Income generation – obtaining QOF data e.g. smoking status
Effective healthcare delivery e.g. follow up of depressed patients, managing diabetes etc
Advantages of telephone consultations
Convenience for patients e.g. no time off work, no transport issues and no child care issues.
Convenience for doctors e.g. tends to be a shorter consultation and so provides better time management.
May reduce practice costs e.g. more doctor time available for other patients or income generating roles.
Can overcome the issue of a lack of consultations rooms
Can improve medical access for the disabled
Disadvantages of telephone consultations
No nonverbal cues – missed hidden agendas or fears
No examination findings
Deafness, accents or language can be a big barrier to communication
Reduced opportunity for health promotion e.g. BP, BMI etc
No opportunity for near patient testing e.g. pregnancy test or urine dip test
Issues of confidentiality – who are you talking to and who may overhear?
Speak to the patient if possible not a third party.
Speak slowly and clearly.
Demonstrate approachability and helpfulness
Try and maintain a calm and confident manner
Elucidating the reason for patient contact & their expectations.
Ask clear discriminating questions
Use your active listening skills
Elicit their concerns
Use the verbal cues the patient provides
Assess and respond to emotional issues
Remember the value of reflecting & summarising.
Identifying capable carers
Translating diagnosis into lay terms
Demonstrating how diagnosis links to symptoms
Predicting the course of an illness or the outcome
Checking understanding and agreement
Reaching an agreed plan (including negotiation/assertive skills in arranging appropriate place of assessment)
Educating the patient on use of out of hours services
Putting in place an appropriate safetynet
Ensuring adequate and accurate information is recorded
Avoiding overcommitment of patient’s own GP, or lack of appropriate followup
NB Remember to clearly document all your telephone consultations.
Telemedicine & Facetime consultations
Get the Story, Get the Picture, and make Shared Decisions.
Caller’s have expectations ….. what they want …. generally:
to know who they are speaking to
to get a timely response
empathy and recognition of their anxiety ….. recognition of their concerns
empowerment to deal with …..to know what they can do about, their problem
to know what to do if things change / get worse
Once you have the story ………
obtain enough clinical information to make clinical decisions
be prepared to negotiate your suggestions
collaborate with the caller on the best course(s) of action
Differences between telephone and face-to-face consultations
lack of visual clues / signs need for clear verbal communication
explicit communication rather than relying on implicit visual cues / clues
specific difficulties with deafness, language problems
confidentiality uncertainties at both ends
communication often via third party
improved access for those with mobility difficulties or those who are highly mobile!
improved time efficiency for both parties
Output of triage : “Disposal” or “Call Disposition”
You need to be aware of your options and your resources.
Ambulance (arranged by you for them)
A&E (own transport, if less urgent)
Home Visit (… and specify urgency)
OOH Treatment Centre (own or OOH patient transport if available?)
Various Community based service options (Int.Care, Mental Health Crisis Team etc)
“Referred” to pharmacist … for OTC Rx
Advice (+/ prescription faxed to pharmacy)
& consider your safety net & consider : should they see own GP ?
Pitfalls in telephone consultation; where things go “wrong”
Not reading the Call Handler (CH) script and considering your options
Bad openings, “yawn, hi it’s the emergency doctor here”
Interrupting the patients story / narrative
Objecting to the patients statements
Not finding out why they have called (their concerns and/or their beliefs)
Committing too early to your one and only chosen option
Showing clear lack of confidence
Thinking aloud, giving too much away, and lacking focus
Thinking too far ahead … putting their own GP in an awkward situation. When recommending patient sees their own GP, generating specific expectations especially of investigation or referral can cause problems. Could you avoid a clash of expectations by leaving more room for their own GP to assess and manage? Use a generic follow up statement e.g. “I think your own GP would be happy enough to see you, assess you and help you out”.
Commenting on other clinicians performance, “bad mouthing” fellow professionals generates complaints. Don’t get caught up commenting to patients about other clinicians apparent negative behaviours; it generates and fuels complaints. If another clinician’s behaviour gives serious cause for serious concern there are routes for referring that concern.
Making them hang up on you out of frustration.
Retriaging – rarely, if time delay, can be appropriate, otherwise a recipe for confusion and complaint. Speak to the clinician who did the triage.
Telephone Consultation Etiquette : what makes a useful consultation?
Identify yourself CLEARLY by name and the organisation you work for.
Identify who you are talking to: name and one identifier, use a valid excuse if you are not comfortable with this e,g “….. can I just check I have the correct record”, “and can I just confirm your date of birth…..?
Apologise if there is delay in response (diffuses the caller)
Early decision dilemma – you may be able to infer from the CHs message that the case appears to be an ALTC. Act on this decisively and swiftly. Only if there is resistance to your recommendation would you need to assess further
Open early with an empathic / empathetic tone “I’m led to believe that your are concerned about your child ……Jade/ Kylie etc
Project your verbal image with a smile (empathetically tuned for the recently bereaved!)
Start with an open question: How can we help you? What’s been happening with What’s the situation with ….. What can we do for
you….. (addresses the expectation issue without committing yourself)
Use active listening. Make yourself interested. Concentrate on their words not your ideas.
Use grunts, mmm’s, ahaa’s and empathetic ahhh’s as appropriate
Pick up on cues, the use of “strong” words; reflect these back with a question
Use open questions : “How, What, Where, When, Which
Use “Why” carefully or avoid it.
Allow the caller to voice their concerns; & Acknowledge their concerns
Enhance by clarifying and summarising
Do clearly define the patients reason for calling.
Why have they called at this time ? By asking “what’s changed”
Assessing children : “please describe to me, what little …… is doing now?”
If it becomes clear that the call will not be ended with advice, and needs face to face assessment whether in hospital of the Primary Care OOH centre, then move on to “floating” (suggesting) appropriate action.
What do they expect? Be careful with the timing of this one. A good open empathetic telephone consultation may modify expectations.
The inappropriate home visit demander may be inspired by your concern and reassurance and be empowered in knowing what to do. Expectations will often be revealed in the narrative. Directly asking about expectations early could lead you off directly into an awkward negotiation before assessment has taken place.
Introduce closed questions with statement of purpose. Focus on relevant clinical specifics, seeking +ve & ve responses to system oriented clinical questions. Remember closed questions don’t always get accurate responses.
Do ask about recent contact with their (own) GP, ongoing medical conditions & current medication to get a fuller picture.
Once you have gathered enough information to act, suggest clinically appropriate management.
Get agreement on your recommended outcome
Instructions: K.I.S.S. ….. Keep it short and simple
Check caller knows what’s happening!
How are they going to get to A&E / PCC? Directions to PCC (bring their medications!)
Chose a closing safety net statement : 2 messages maximum.
specific reasons to call back, based upon one or two specific additional symptoms, or symptoms changing in severity, or taking longer than an expected timeframe for recovery.
Good safety nets are short and simple BUT specific, AND suggest action to take.
Specific safetynetting gives the patient more control & empowerment to cope with their problem.
Sound empathetic, not overanxious “they” end the call. Use Persuasive style
Collaboration use “We” to mean “you & I” …. & not “our organisation”
Put aside you personal feelings …. Concentrate on the issue to be resolved.
If the other party has a different point of view, do not view this is as a challenge. “We have a problem that we need to talk about to find a solution that is works for both of us”.
Recognise and work on the conflict of ideas .. not on the conflict between the two of you.
Be determined to reach an agreement not secure a personal victory.
Look at your objectives from their point of viewpoint. You require their involvement.
Sell your point “sunny side up” (i.e. the positive bits for them)
Listen …. Say the right things in the right way at the right time; know when not to speak ….. listen carefully.
Be wary of compulsive talking, a symptom of lack of confidence – especially interrupting the other person whenever they say something potentially “objectionable” (e.g. scientific fallacy).
Do not give your argument away too quickly – leaves you no space to change the way you put forward your case.
Do allow the other person to complete what they have to say …. You need to know what they are thinking.
“Float” suggestions rather than commit. “there are various thing we could do, suppose I were to suggest …, what do you think? Had you thought…?
Recognising that “demand” usually comes from their anxiety arising out of uncertainty.
Be wary of offering face to face consultation before you “get the story & the picture”
may not be what is needed by either of you
may not be what the caller / parent wants
does not give them more control, it makes them more anxious.
You want to know what can be done to help them best.
What to do about the parents that “inappropriately” demand a home visit?
Performance review of calls suggests that it is commonplace for doctors to “put their foot in it” by not assessing on the phone and then offering face to face consultation as an only solution when one really isn’t needed.
What concerns would they have about travel? Dispel myths. The “unreasonable” demand rarely arises if you have been empathetic to their concerns, your advice has been confident, clear and simple to understand. They should now know what to do and
how to cope. More access to the covert, more chance of shared outcome. Assess first ….. do not ask for expectations directly and engage in negotiation without “the facts”. Then you can influence and persuade.
Consider slightly manipulative escalations, e.g. “We both want the best for your child. We have better facilities and diagnostic equipment here at the PCC to assess your child”.
Consider a “Wince” e.g. “Oh. Oh really. Pause. Most parents do bring their kids down to our PCC. This allows us to prioritise home visits for the infirm elderly and terminally ill; you would be able to be seen more quickly at the PCC”.
If you are still stuck, shrug off your emotions, you have not failed, it does happen. Bottom line be wary of choosing your battles.
© Rob Pearson 2007
Prebooked Telephone Consultations
Useful way of providing an alternative point of access for patients – more convenient for both patients and the practice.
1. Trial the system first using just one GP, for a short time period and test the change! What effect did the test have? Did the telephone consultations save time? Were patients satisfied with the service? Think about how telephone consultations could be “rolled out” across the practice.
2. Use a simple protocol for all team members to follow when offering telephone consultations. Some practices have found it useful to provide different “scripts” for reception staff, nurses and GPs to follow when offering telephone consultations to patients. I may be useful to train receptionists to develop their confidence in using the script.
3. Advertise the service. You can inform patients of a “new” telephone service through the Practice Leaflet, Handouts left onReception and given out in consultations, Posters in reception or articles in Newsletters. It may be worth “relaunching” a telephone consultation service as a ‘new’ and ‘tailor made’ service for patients.
4. Telephone consultations are not appropriate for all types of consultations. You may wish to start with requests for home visits and same day appointments. Other types of consultations which could be offered include: Condition Reviews, Medication Reviews, Advice, Medical Certificates, Results, Follow Ups or administration.
5. Double check you have the correct telephone number and ring on time. Telephone numbers can be taken at the time the telephone appointment is made so that people can be called on mobile phones or at work when appropriate. Alternatively patients can be asked to call the practice at a set time.
6. Ensure confidentiality; confirm whom you are speaking to, don’t leave messages on answer machines.
7. Record the consultation in the clinical records.
8. Both patient and clinician should feel comfortable about the telephone consultation. You may find it useful to monitor the number of telephone appointments that result in a face to face consultation.
Pat Hart, Marple Cottage Surgery, Stockport
often thrown in at the end of a consultation and not always at a convenient moment
an exhaustive history is not expected but safety-netting is essential and should help to protect the patient and the dr involved
when a patient mentions a medical problem to you you have a duty to deal with it but not necessarily there and then – a short note will obviate the need to rely on ones own recollection which is often hazardous
courts have to resolve a conflict of evidence and may prefer the recollection of a patient for whom this is a unique experience to that of a doctor or whom this was one in a series of consultations
the courts make no allowances for the circumstancs of the consultation eg where the surgery was very busy or if the patient doorstepped you in the car park
|Clinical Entry Checklist|
|Encounterdetails||DateLocation/type of encounterAuthor/Clinician
Avoid abbreviations. Legible. Understandable
|Historyrecorded|| PC+ve points-ve points
|Examinationrecorded||+ve findings-ve findingsVital signs + other parameters
|Managementrecorded|| PlanOptions discussedRisk benefits discussed
Advice and info given to patient
Agreed/disagreed actions for patient
|MPS||Your practice Vol 6 Issue 1 2012 p11|
GP Gatekeeper controlling access to secondary care
Historical 1800’s Apothecaries vs Physicians / Surgeons
Doctor’s protecting their own interests
Exceptions A & E perceived emergency
STDs public health
Weaknesses GP monopoly is it fair?
Other countries survive with direct access to secondary care
(But many are trying to develop a GP gatekeeper)
Europe Holland and Norway same as UK
Variation in performance of gatekeeper
Strengths Protect patients from over investigation and over treatment
One person maintains whole picture approach to patient
Gatekeeper rations according to need
GP can target care more specifically
Variation at least 20 fold 1 to 20 per 100 consultations
Commonest rate is about 7 per 100 consultations (or about 1 in 14 patients)
Strict definition very difficult new or re-referrals
selection bias who does the smear referrals
who has an “old list”
who sees the diabetics etc
Would you like to be a high or low referrer? Which is good, which bad?
No correlation between rate and age / sex of doctor
use of investigations
Increased knowledge in a field often increases referrals knowledge better, internal referrals
Consultants judge fewer than 5% of referrals as unnecessary
Reasons for Referral
Positive Diagnosis access to specialist’s experience dermatology
Investigation GP access restricted MRI / CT etc
Treatment especially surgical
Opinion Several treatment options, which is best eg glue ear
Negative Patient pressure
Several people have an interest in a good quality referral letter
GP Good summary point for future reference
Patient Summary of their relevant past and present history
Avoiding repetition of investigations
Consultant Reason for referral
Current position / findings
Medication / allergies
Relevant background whole patient approach
Admin. Patient’s details including new NHS number!
Layout Headed paper, not illegible scribble on loo paper
Clearly state at beginning reason for referral
belongs more elsewhere – QOF, quality , Uk primary care