Dr.Hashim Rida Fida

CONSULTATION1. Definition2. Consultation Skill3. Initiating the consultation4. Models of consultation5. Difficult consultations

3Dr.Hashim.Rida.FIDA

DefinitionMost text books describe interviewing as a diagnostic procedure which is a systematic process of data-gathering designed to identify problems and to arrive at a conclusion,leading ultimately to a treatment plan. This is only partly true. To achieve its maximum value, the consultation should be

therapeutics .

5Dr.Hashim.Rida.FIDA

The most important skill of family physician is ability to interview patient effectively as follow ;

1.To provide health care to all patients, regardless of their age, sex, socio-economic standing and disease status.

2.To treat disease and promote healthy lifestyles in individuals and communities.

3.To provide comprehensive, continuous care, bearing in mind the cultural, social, psychological and economic factors that influence health and disease.

4.To provide care either directly or through other members of the team, depending on the needs of

the patient and the resources of the community . 6Dr.Hashim.Rida.FIDA

INITIATING THE CONSULTATIONOBJECTIVES Establishing a supportive

environment Developing an awareness of the

patient’s emotional state Identifying as far as possible all the

problems or issues that the patient has come to discuss

Establishing an agreed agenda or plan for the consultation

Enabling the patient to become part of a collaborative process

SKILLSPreparation• Puts aside last task, attends to self

comfort • Focuses attention and prepares for this

consultationEstablishing initial rapport• Greets patient and obtains patient’s name • Introduces self and clarifies role• Attends to patient’s physical comfort,

demonstrates interest and respect

Identifying the reason(s) for the patient’s attendance

• Opening ended question: identifies the problems or issues that the

patient wishes to address (e.g. “What would you like to discuss today?”)

• Listening to the patient attentively without interrupting or directing patient’s response

Identifying the reason(s) for the patient’s attendance

Checking list of problems or issues that the patient wishes to cover (e.g. “so that’s headaches and tiredness, is there anything else you’d like to discuss today as well?”)

• Agenda setting: negotiates agenda and format of interview taking both patient’s and physician’s needs into account

INFORMATION GIVING, EXPLANATION AND PLANNING

Gauging the correct amount and type of information to give to each individual patient

Providing explanations that the patient can remember and understand

Providing explanations that relate to the patient’s illness framework

INFORMATION GIVING, EXPLANATION AND PLANNINGUsing an interactive approach to

ensure a shared understanding of the problem with the patient

Involving the patient and planning collaboratively to increase the patient’s commitment and adherence to

plans madeContinuing to build a relationship and

provide a supportive environment

Models of consultation1.Bio-medical model (hospital model).

2.Bio-psychosocial model.3.Byrne and long model doctors styles.

4.Balint model .5.Pendelton model

6.Stott an Davis.7.Neighbour model.

18Dr.Hashim.Rida.FIDA

Byrne and long model doctors styles.

Dr.Hashim.Rida.FIDA 19

Patient-centered

Use of patient’s knowledgeAnd experience

Doctor-centered

Use of doctor’s knowledgeAnd skills

Balint modelThe doctor as a drug

Elimination by physical examinationThe child as a presenting complaint

Inappropriate referral

Dr.Hashim.Rida.FIDA 20

Stott and Davis model1.Management of Presenting Problem2.Management of Continuous problem3.Modifiation of help Seeking behavior

4.Opportunistic health promotion

Dr.Hashim.Rida.FIDA 21

Neighbour model1.Connecting (establish a relationship)

2.Summarizing( physical. psycho ad social diagnosis)

3.Handling-over(management of presenting problem)

4.Safety-netting(anticipating care)5.House-keeping(taking care of yourself)

Dr.Hashim.Rida.FIDA 22

Pendleton 7 TasksTo define the real reasons for pt attendanceTo consider other problemsTo choose with the pt. appropriate action for

each problemTo achieve a share understandingTo involve pt. in the managementTo use time & resources effectivelyTo establish & maintain Dr.-pt. relationship

Pendleton 7 TasksTo Explore the Real Reasons for Pt.

AttendanceHistoryNature of the problemEtiologyEffect of the problemIdeasConcernExpectationFears

Pendleton 7 TasksSkills Needed To Explore the Real

Reasons for Pt. AttendanceOpen ended questionsIndirect questionsUse of silenceRecognition of patient’s cuesImmediate response to patient’s cuesConfrontationReflectionProbingSummarization

Pendleton 7 Tasks Practicing Consultation SkillsEstablishing & maintaining Dr- Pt

RelationshipPrior to consultationWelcoming the patientInitiating the interviewShowing interestBalance between intimate relationship &

professional relationshipMaintaining the relationship Showing empathy LegitimationShowing support

Practicing Consultation Skills Ethical ConsiderationsRespecting patient autonomyConfidentialityNon judgmental attitude

Diagnosis in PHCHypothetical Deductive Reasoning Method

Present Complain+ Context of the consultation+ Previous knowledge about the patient.+ Verbal & non verbal cues 3-5 Hypotheses (Dr. clinical + epidemiological knowledge + Dr. experience)Inclusion or exclusion of hypotheses (Dr. conducting verbal examinationor physical examination or selective investigations

Management SkillsNegotiation skillsReassurance skillsHealth EducationCounselingPrescribingInvestigationsReferralFollow upModification of help seeking behaviorUse of medical recordsHouse keeping

Difficult consultation10-20% of daily consultation are difficult. This

difficulties are either due to;1.Difficult patient2.Difficult Doctor

3. Difficult communication between the doctor and patient

Dr.Hashim.Rida.FIDA 35

Difficult ConsultationDifferent Patients Need Different

Consultation SkillsPatient Reluctant to Talk Freely Angry Patient Demanding Patient Talkative Patient Poor Compliance

Difficult ConsultationPatient Reluctant to Talk Freely

Causes : Patient Factors Dr. Factors Circumstances Examples :

The topic Cultural barrier Social class barrier

Dr. authority Time constrains Presence of 3rd party

Difficult ConsultationApproach to Patient Reluctant to Talk

Freely Verbal Communication

Giving reason for the question.Comments on the patient attitudeGeneralization of the problemAsking at the right timeReflectionMirroringConfrontation

Difficult ConsultationApproach to

Patient Reluctant to Talk Freely

Non - verbal Communication. Showing sympathy &

empathyShowing real interestUnhurried mannerTouch for reassuranceUse of physical

examination

Difficult ConsultationAngry Patient

Communication Skills EmpathyLegitimation Non-judgmental

attitudeRespect patient

autonomySupportFlexibility

Difficult ConsultationDemanding

Patient communication Skills Discuss the effect

of the problem in the patient life

Focus on immediate concern

Deal with feelings

Difficult ConsultationDemanding Patient communication Skills

Comment on the process of the interviewNegotiate agenda & goals :

1. Set limit

2. Reinforcement 3. Compromise & Be flexibleFocus on patient as well as his demands &

complaints

Difficult ConsultationTalkative PatientSummarizationPrioritizationUse of touchSympathy &

empathy

Behaviors which brake the relationshipBehaviors which brake the relationshipInterruptionClose ended question

المعاملهالحسنه ال تحتاج

الى امكانيات

Thank You