CONSULTATION SKILLS

Dr. Ekram A Jalali

INITIATING THE CONSULTATION

OBJECTIVES 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

SKILLS

Preparation• 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 PLANNING

Using 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 made Continuing to build a relationship and

provide a supportive environment

Pendleton 7 Tasks To define the real reasons for pt attendance To consider other problems To choose with the pt. appropriate action for

each problem To achieve a share understanding To involve pt. in the management To use time & resources effectively To establish & maintain Dr.-pt. relationship

Pendleton 7 Tasks To Explore the Real Reasons for Pt.

Attendance History Nature of the problem Etiology Effect of the problem Ideas Concern Expectation Fears

Pendleton 7 Tasks Skills Needed To Explore the Real

Reasons for Pt. Attendance Open ended questions Indirect questions Use of silence Recognition of patient’s cues Immediate response to patient’s cues Confrontation Reflection Probing Summarization

Pendleton 7 Tasks Practicing Consultation Skills Establishing & maintaining Dr- Pt

Relationship Prior to consultation Welcoming the patient Initiating the interview Showing interest Balance between intimate relationship &

professional relationship Maintaining the relationship Showing empathy Legitimation Showing support

Practicing Consultation Skills Ethical Considerations

Respecting patient autonomy Confidentiality Non judgmental attitude

Diagnosis in PHC

Pattern of recognition Hypothetical deductive reasoning

method Using clinical epidemiology Living with uncertainty 50% No diagnosis

Diagnosis in PHC Hypothetical 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 examination or physical examination or selective investigations

Management Skills Negotiation skills Reassurance skills Health Education Counseling Prescribing Investigations Referral Follow up Modification of help seeking behavior Use of medical records House keeping

Difficult Consultation

Different Patients Need Different Consultation Skills Patient Reluctant to Talk Freely Angry Patient Demanding Patient Talkative Patient Poor Compliance

Difficult Consultation Patient 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 Consultation Approach to Patient Reluctant to

Talk Freely Verbal Communication

Giving reason for the question. Comments on the patient attitude Generalization of the problem Asking at the right time Reflection Mirroring Confrontation

Difficult Consultation Approach to

Patient Reluctant to Talk Freely

Non - verbal Communication.

Showing sympathy & empathy

Showing real interest Unhurried manner Touch for reassurance Use of physical

examination

Difficult Consultation Angry Patient

Communication Skills Empathy Legitimation Non-judgmental

attitude Respect patient

autonomy Support Flexibility

Difficult Consultation Demanding

Patient communication Skills Discuss the effect

of the problem in the patient life

Focus on immediate concern

Deal with feelings

Difficult Consultation

Demanding Patient communication Skills Comment on the process of the

interview Negotiate agenda & goals :

1. Set limit 2. Reinforcement

3. Compromise & Be flexible Focus on patient as well as his

demands & complaints

Difficult Consultation

Talkative Patient Summarization Prioritization Use of touch Sympathy &

empathy

Behaviors which brake the relationship Interruption Close ended question

Thank You