Dr Ashraf Ahmed - Consultation Skills

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Consultation Skills

Qatar Primary Health Care 2008“The Foundation of Health and Wellbeing”

1-4 November 2008

Dr. Ashraf AhmedABFM - 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…I took it for six days…then I thoughtwell I’m a bit tired so the next day I

halved it. That’s experience.(hypertension patient)

Basically I don’t want to be dependent onthese tablets…I’ve been taking tablets wellbasically for thirteen years I’ve been taking

these tablets (epilepsy patient)

I’m doing fine as I am, thanks. I’ve had nodire effects … I think the treatment of

hypertension is fashionable just now…itseasy for doctors…take a pill and come

back(hypertension patient)

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 alldisease areas

%Patients notcomplying per

disease area

35

40 40

55

80

A rthritis Epilep sy Hyp ertension Diab etes A sthma

Source: Whitney HAK, Jr. et al. (Editors). Medication compliance: a healthcare problem. Annals of Pharmacotherapy 1993; 27 (9. Suppl).



Source:Medicine partnersip-fromcompliance to concordance

…but non-compliance with prescribed medicines is a

major problem

50% of

medicines for

chronicconditions

are not taken

asprescribed

Ill-health andreduced quality

of lifeReduced lifeexpectancyAvoidable

healthcare costEconomic loss tosociety

Consequences



Observational studies point to significant opportunity to better informpatients during the average prescribing consultation

Discussion in itiated by doctor %

•Instructions for use •87

•54

Communication

•Intended benefits

•Patient’s opinionabout medication

•Possible side-effects

•Almost half ofconsultations fail to explainbenefits of medication

•22

•15

•5•Patient’s ability tofollow treatment plan

•Side-effects explained inevery 5th consultation only

•Small minority ofconsultations elicit patient’sview or surface obstacles tocompliance

Source: Makoul G, Arntson P, Schofield T. (1995) Health promotion in primary care: physician-patientcommunication and decision making about prescription medications. Soc Sci Med ; 41 (9): 1241-1254.



But analyses of doctor-patient communications suggest that these beliefs and view

are often not explored in prescribing consultationsPerceived and actual frequency %

•Provide instructions

for taking themedication

•62

•87

•40

•31

Communication

•49

•34

•Discuss side-

effects of themedication

•Discuss patient’sability to follow

treatment plan

•Find out whatpatient thinks about

treatment plan

•49

•8

GP Estimate

Observed

•Doctorsunderestimatethe degree towhich they

‘instruct’

•Doctorsoverestimate thedegree to which

they consult andelicit theirpatient’s views

Source: Makoul G, Arntson P, Schofield T. (1995) Health promotion in primary care: physician-patientcommunication 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 partof the NHS plan

‘Patients are not passive recipients ofprescribing decisions. They have theirown 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)

‘Too many patients feel talked at ratherthan listened to. This has to change… Tobring this about, patients must have moresay in their own treatment’

(NHS Plan)

‘Prescribing and medicine taking will

increasingly be seen by patients andprofessionals alike as a partnership

between them… to give patients moreof a say in and greater commitment to

their treatment’

(Pharmacy in the Future )

‘In a patient-centred healthcare servicepatients must be involved, wherever possiblein decisions about their treatment andcare.’

(Kennedy Report)

Source: NHS, DoH

‘Older people & their carers need to

be more involved in decisions abouttreatment and to receive more

information than they currently doabout the benefits and risks of

treatment’(Older People NSF)



Source:Medicine partnership-fromcompliance to concordance

From compliance to concordance

Traditional model Patient centered model




Professionals need shared decision making skills

T o b e t a k e n a s

d i r e c t e d

T o b e t a k e n a s

a g r e e d

Key elements oftraining:

-Understanding patientperspectives-Trying it out throughrole play / scenarios

-Team working




Changing Professional Behaviour Changing Professional Behaviour

Shaping Policy Shaping Policy

Enabling Patients to be Partners Enabling Patients to be Partners

Services to Support Concordance Services to Support Concordance

Knowledge Management Knowledge Management

Medicines Partnership has five work streams

to implement concordanceA clarification / recasting is proposed:



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 ascientific discipline



• Empirical: the verification of hypotheses byrecourse to data accessible by the five

senses. This is logical left brain activity,very much the doctor centered scientificapproach. 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 ofunderstanding whereby the doctorexperiences in an empathic flash what thepatient is going through.



• Balint was the first to recognize that the

symptom offered by the patient might notbe the real reason for their attendance andthat the emotions triggered in the doctorcould have a powerful effect on the courseof the consultation



• Neighbour introduces the concepts ofright brain and left brain thinking in the

inner consultation.



LEFT RIGHT

• LOGICAL• REALISTIC

• RATIONAL• HARD• ANALYTICAL• DOGMATIC

• SYSTEMATIC• TIDY• CAUTIOUS• PLANNER

• OBJECTIVE• FACTUAL• DISCIPLINED• ORGANIZED

• DETAILED

• INTUITIVE• EMOTIONAL

• OPENMINDED• APPROXIMATING• EXPERIMENTING• IMPETOUS

• SOFT• IMAGINITIVE• FLEXIBLE• SUBJECTIVE

• SPONTANEOUS• HUMOROUS• UNTIDY• LIBERAL

• PLAYFUL• RISK-TAKER



• Mcwhinney, Nighbour, Balint and others

have suggested that we learn to developthis form of intersubjective enquiry. Itseems likely that in this are lies the art ofgeneral practice.



• The point here is that we all have right

brains and do use them. We tend to givemore conscious importance to the logicalanalysis of the left brain yet many of usare secretly governed by the right brain.



Medical interventions



Hermeneutic interventions

• Attentive listening• Reflection

• Silence• Empathy vs. sympathy

• Touching• Non doing





Doctor - centred Vs

Patient centred

• How would you define patient centeredness?



most solutions are unique rather

than standard formulae

Only when the patient accepts theplan do we move on

The patient’s opinion on problemsolving is less important than the

doctors.

I find that I match most problemswith a standard solution

Problem solving is usually by triedand tested methods

Answers to problems often come outof no where

This area of the consultation isprimarily concerned with the doctorsprofessional skills

DR OR PTCENTRED

DISAGREEAGREEIn Dealing with the patientsproblem



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




Answers to problems often come out of no where

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

Disagree------ Dr centred




Problem solving is usually by tried and tested

methods

Agree --------Dr centred

Disagree-----Pt centred




I find that I match most problems with a standard

solution

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

Disagree-------Pt centred




The patient’s opinion on problem solving is less

important than the doctors.

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

Disagree------- Pt centred




Only when the patient accepts the plan do we

move on

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

Disagree----- Dr centered

I D li i h h i bl




Most solutions are unique rather than standard

formulae

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

Disagree------- Dr centred

C lt ti d l



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 EachPrimary 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 methodTherapeutic

Communication RapportElicit

Negotiation

Interpersonal Overcoming fear of intimacy

relationship Developing positive regards for patients



Communication skillsTalking to peopleListening to stories

History takingStructuredFocused

Patient centered

Clinical problemsolving

Effective

ConsultingWith patients

C lt ti T k



Consultation Tasks

Find outNature-History

Cause of problems

Find outNature-History

Cause of problems

Find out the Patient’s

IDEAS

CONCERNSEXPECTATIONS

FEELINGD

Find out the Patient’sIDEAS

CONCERNSEXPECTATIONS

FEELINGD

Discuss optionsNegotiate

Reach agreement

Discuss optionsNegotiate

Reach agreement

Prioritize problemsPrioritize problems

ExplainSummarize

Check Understanding

ExplainSummarize

Check Understanding

Establishrapport

Establishrapport

Why patient-centered



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, bloodsugar

• Pain control, e.g. after surgery• Patient satisfaction



Managing the consultation

• Managing the problems

• Managing the patient• Managing the consultation process

S



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

E bli hi R



Establishing Rapports

• Beginning the consultation

• Listening• Demonstrating empathy

Challenges/Obstacles to Effective



Challenges/Obstacles to Effective

Consultation

• Time

• Cost • Culture

• Legal Issues

Danger areas in the consultation



Danger areas in the consultation

• psychological diagnoses - everyone fears being accused of having animaginary illness

• age - fit, healthy 60-year-olds resent implications that ailments such asosteoarthritis 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 areasto discuss

• aggression - reacting aggressively to aggression is inappropriate - it isoften caused by fear, previous bad experience with doctors or anxietythat the condition will not be taken seriously. It can also be caused byguilt or by ignorance of other ways to respond.



• Developing one's consultation skills takes

time, practice and much self criticism andself awareness.

• Making video recording of consultations isa very potent tool to examine them indetail later..



Documents

Dr Ashraf Ahmed - Consultation Skills