Consulatation 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
Balint - see also also separate webpage here
Michael Balint (1890-1970) was a psycho-analyst from Hungary who emigrated to Britain in the 1930s. After the war he practiced as a psychoanalyst at the famous Tavistock Clinic in London.
Michael Balint began a seminal discussion and support group for family doctors. His work contributed many useful concepts to our understanding of the doctor-patient relationship, including:
• The Apostolic Function
• The Drug 'Doctor'
• The Sick Role
• The Long Consultation
Balint was the first to recognise 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 the consultation
Balint also introduced the concept of the doctor as a drug and likened the relationship of the doctor and patient to a ‘mutual investment bank’, interest growing over time as patient and doctor put more into the relationship
Enid Balint, also a psychoanalyst was Michael's (third) wife. She was his colleague and partner in the work with family doctors
Michael Balint observed in 1957 that a doctor's personality interacts with medical training to produce a unique way of dealing with patients. Doctors tend to avoid examining their own behaviour and so a fixed style develops.
Balint called this the 'Apostolic Function'. This incorporates the doctor's beliefs about how patients ought to behave when ill, how they should behave with doctors and how they should cooperate in their cure.
Balint referred to the drug 'Doctor' to describe the powerful therapeutic effect of doctors as people, that is the effect of the doctor's personality apart from the treatments they prescribe.
Traditionally, the patient adopts the sick role and hands over partial or complete responsibility for his well-being to the doctor. This role allows the patient to drop out of other roles, such as that of breadwinner, and be treated in a dependent, cossetted way. The sick role also requires the patient to seek recovery; otherwise social disapproval and withdrawal of privileges may follow.
Balint promoted the use of the 'long consultation' at a time when the average consultation took six minutes. He gave the patient an hour after surgery to explore the underlying psychosocial causes behind frequent attendances and repeated failures to resolve a problem
A single long session can give insights to the doctor and enough support to the patient to lead to a new rapport and often a resolution of the problem
Beirne
Eric Berne founded a school of psychotherapy based on analysing the transactions between people rather than looking for answers solely within the individual patient.
Berne described how to recognise behaviours ('games') which patients may use to score points off their families, friends and others, including their doctors. Games are behaviours used in a bid to feel better by making someone else feel worse. Recognising a game and not playing it prevents the doctor from being manipulated into accepting responsibility for the results of the patient's own behaviour.
In the game 'Poor Me - Yes, But' the patient presents a problem but always has reasons why proffered solutions are not acceptable. Thus the doctor is proved useless, the point of the game. Some games are deadly as some people will even commit suicide to hurt and 'win'.
Berne also developed a usefully simple model of the ego-states of Freudian psychoanalysis and applied it to the transactions between people. He called these states Parent, Adult and Child. At any given moment we are in one of three states of mind, one based on a rational assessment of our situation, the other two based on memories recorded mostly in early childhood. These states are named Parent, Adult and Child. The Adult is the thinking person, while Parent and Child are replayed memories of what happened to us (mostly at the hands of our parents) and of the feelings we had as a small child.
The two participants in a transaction are therefore each in one of these three states. Consultations conducted between a paternalistic (Parental) doctor and a submissive (Child-like) patient is seldom in the best interests of either but produces no conflict. Conflict will occur however if the patient doesn't accept this position and adopts either an authoritarian role back (Parent) or an unexpectedly questioning (Adult) stance. Best understanding is achieved by Adult to Adult consultations where the two parties respect each others' autonomy.
Thomas Harris followed Berne as head of the school of Transactional Analysis and developed the ideas further.
Books
(1) E Berne, Games People Play, 1964
(2) T Harris, I'm OK, You're OK
Becker and Maiman combined a number of patient beliefs and attitudes into a 'health belief model' which included:
the patient's interest in health matters, which may correlate with personality, class and social group
how vulnerable the patient feels to a particular disease and how severe he feels the threat to be
the patient's estimate of the benefits of treatment versus the costs, risks or inconvenience
the factors that prompt the patient to take action such as developing alarming symptoms, advice from family or friends or reports in the media
The health belief model involves the exploration of the health beliefs of a patient and the interpretation they put upon them.
The health professional then provides information that is personally relevant to the patient, and explores with the patient the possibility of lifestyle changes or treatment.
Lastly the patient is offered follow-up and support.
This model can be summarised as the patient's Ideas, Concerns and Expectations.
There are five main elements of the Health Belief Model:
Health motivation - there is great variation in people's interest in health and the degree to which they are motivated to change it
Perceived vulnerability - with a specific health problem people vary in how likely they think they are to be affected e.g. if a patient thinks that he is at a high risk of a heart attack then he is more likely to follow advice to give up smoking
Perceived seriousness - people vary with respect to their beliefs concerning the consequences of contracting a particular illness and what the effect would be of not treating it
Perceived costs and benefits - patients evaluate the advantages and disadvantages of taking a particular course of action
Cues to action - patients beliefs are prompted or created by a number of stimuli and triggers
The health belief model also introduces another concept - locus of control - an explanation to ourself what is likely to occur with our health. There are three types of human being based on this theory - the internal controller, the external controller, the poweful other.
Internal controller - This type of individual believes that they are fundamentally in charge of their own health, ie their health is largely determined by their own actions.
External controller - This individual has a fatalist approach to their own health, ie they do not have any control of their own health.
Powerful other -The powerful other is the type of patient who believes that you (the doctor) are in charge of their health. They do have a fatalistic view of their own health and do not believe that they are in charge of their own health.
John Heron, a humanistic psychologist, developed a simple but comprehensive model of the six types of intervention a doctor, counsellor or therapist could use with a patient or client:
1. Prescriptive - giving advice or instructions, being critical or directive
2. Informative - imparting new knowledge, instructing or interpreting
3. Confronting - challenging a restrictive attitude or behaviour, giving feedback
4. Cathartic - seeking to release emotion as weeping, laughter, trembling or anger
5. Catalytic - encouraging the patient to explore his own latent thoughts and feelings
6. Supportive - offering comfort and approval, affirming the patient's intrinsic value
Each type of intervention can be looked at separately during training sessions as options throughout the consultation.
Byrne & Long.
Byrne and Long studied over 2000 audio recordings and in 1976 described six phases in the consultation which give it a logical structure.
The model is useful for analysing 'dysfunctional' consultations where the patient may be misunderstood and dissatisfied while the doctor may be frustrated.
Byrne and Long also described a spectrum of consulting styles, one extreme being doctor-centred and the other, patient-centred.
1. The doctor establishes a relationship with the patient
2. The doctor discovers or attempts to discover the reason for the attendance
3. The doctor conducts a verbal and/or physical examination
4. The doctor, the doctor and patient, or the patient (in that order of probability) consider the condition
5. The doctor and occasionally the patient detail further treatment or investigation
6. The consultation is terminated, usually by the doctor
Dysfunctional consultations tended to have less silence and often phase 2 and/or phase 4 were not successfully completed.
In the doctor-centred consulting style, the doctor:
• dominates the consultation
• asks direct, closed questions
• rejects the patient's ideas
• evades the patient's questions
In the patient-centred consulting style, the doctor:
• asks open questions
• actively listens
• challenges and reflects the patients' words and behaviour to allow them to express themselves in their own way
The style can vary within a single consultation, for example open in seeking information but dogmatic over treatment.
Stott and Davis.
Stott and Davis outlined four areas which can be explored each time a patient consults:
1. The identification & management of the presenting problem - The main task of every consultation is to find and treat the reason for the attendance: the nature of the problem, the effect on the patient, the patient's ideas concerns and expectations and an answer to the question, Why now?
2. Modification of the patient's help-seeking behaviour - 'Doctor' means teacher. Teaching the natural history of minor illness and about self-medication is an important part of a long-term strategy for making best use of practice resources. Patients may need to be reminded how to make appropriate use of the practice's appointment system or out-of-hours cover. Every doctor-patient encounter plants the seeds of future patterns of illness behaviour which will affect the over-use (and under-use) of medical services.
3. The management of continuing problems - The GP, as the coordinator of the patients' health care, should consider reviewing any coexisting conditions at each consultation. The doctor's continuing interest in the patient's hypertension, diabetes, epilepsy or asthma is likely to produce better adherence to any management plans.
4. Opportunistic health promotion - Health promotion can be improved by taking action when the patient attends for other reasons. Vaccination, cervical screening, blood pressure checks and enquiring and advising about smoking or drinking habits can often be done or at least suggested. The doctor should not, however, become overzealous and insensitive to the patient's needs and wants but it is usually possible at least to ask the patient back to see the nurse 'for a checkup' if a gap is spotted.
Cecil Helman, an anthropologist, suggested that a patient with a problem comes to the doctor seeking answers to six questions:
1) What has happened happened? This includes organising the symptoms and signs into a recognisable pattern, and giving it a name or iidentity.
2) Why has it happened? This explains the aetiology or cause of the condition.
3) Why has it happened to me? This tries to relate the illness to aspects of the patient, such as behaviour, diet, body-build, personality or heredity.
4) Why now? This concern the timing of the illness and its mode of onset (sudden or slow)
5) What would happen to me if nothing were done about it? This considers its likely course, outcome, prognosis and dangers.
6) What are its likely effects on other people (family, friends, employers, workmates) if nothing were done about it? This includes loss of income or of employment, or a strain on family relationships.
7)What should I do about it -or to whom should I turn for further help? Strategies for treating the condition, including self-medication, consultation with friends or family, or going to see a doctor.
Pendleton
Pendleton defined seven tasks forming the aims of each consultation. These identify what the doctor needs to achieve and deal with the use of time and resources:
1. To define the reason for the patient’s attendance, including:
a) the nature and history of the problems
b) their aetiology
c) the patient’s ideas concerns and expectations
d) the effects of the problems
2. To consider other problems:
a) continuing problems
b) at-risk factors
3. With the patient, to choose an appropriate action for each problem.
4. To achieve a shared understanding of the problems with the patient.
5. To involve the patien patient in the management and encourage him/her to accept appropriate responsibility.
6. To use time and resources appropriately
1) in the consultation
2) in the long term
7. To establish or maintain a relationship with the patient which helps to achieve the other tasks.
These tasks might be paraphrased as: understand the problem, understand the patient, share the understanding, share decisions and responsibilities and maintain the relationship.
Pendleton Consultation Rating Scale
1) nature and history of problem
2) aetiology of problems
3) patient's ideas
4) patient's concerns
5) patient' expectations
6) effects of problems
7) continuing problems
8) at risk factors
9) for each proble
<----> inappropriate chosen taken
10) for each problem
appropriate shared understanding of the problem achieved
<----> not achieved or inappropriate
11) patient involvement
involved in management adequately and appropriately
12) time and resources in the consultation
13) time and resources in long-term management
14) doctor-patient relationship
Roger Neighbour - The Inner Consultation
Neighbour proposed five checkpoints in the consultation:
1. Connecting: have we got rapport?
2. Summarising: could I demonstrate to the patient that I've sufficiently understood why he's come:
the patient's reason for attending
the patient's ideas and feelings, concerns and expectations are explored and acknowledged adequately
listening and eliciting
the clinical process - assess, diagnose, explain, negotiate and agree
3. Handing over: has the patient accepted the management plan we have agreed?
4. Safety netting: What if...? General practice is the art of managing uncertainty:
predict what could happen if things go well
allow for an unexpected turn of events
plans and contingency plans
5. Housekeeping: Am I in good condition for the next patient? - stress, concentration and equanimity
Fraser (areas of competence)
1. Interviewing and history-taking - To interview and take a history successfully, a GP needs to:
• introduce self to the patient
• put the patient at ease
• listen attentively
• seek clarification of words used by the patient
• phrase questions simply and clearly
• use silence appropriately
• recognise verbal and non-verbal cues
• identify the patient's reasons for consulting
• elicit relevant and specific information from the patient and/or records to help choose from possible diagnoses
• consider physical, psychological and social factors as appropriate
• show a well-organised approach to information-gathering (see 'interviewing skills' esp Calgary-Cambridge guide)
2. Physical examination -The competent GP must be able to:
• examine the patient and elicit relevant and discriminating physical signs correctly and sensitively
• use instruments in a selective, competent and sensitive manner
• use information obtained to confirm or refute working diagnoses
3. Diagnosis and problem-solving - Patient management can be considered under the following broad headings:
4. Patient management
a. Reassurance & explanation -
• the need for reassurance may be the main, often the sole, reason for the patient presenting to the doctor
• inappropriate reassurance is dangerous to the patient and damaging to the doctor's credibility and should be as planned and deliberate as any other medical skill
• reassurance is unlikely to be effective without an appropriate degree of explanation, as well as adequate history-taking and examination. The doctor needs to explore the patient's understanding and fears concerning the symptoms, especially such potentially sinister symptoms and signs as chest pain, headache or a lump
• reassurance requires trust and this depends on good communication. The doctor has to take into account differences in patients' intelligence and education, medical experience, ethnic background, social class and personality
• reassurance also carries more weight if there is a strong bond between doctor and patient. This comes from continuity of care, which may make it easier for the patient to accept the doctor's judgment
b . Advice and counselling
• a holistic approach, continuity of care and the RCGP triad of physical, psychological and social aspects of problems apply as much to advice-giving as to diagnosis
• advice must be realistically adapted to the patient's circumstances, lifestyle and personality
• the doctor may be required to assume a more formal counselling role to help patients work through their probems or come to terms with their circumstances
• counselling helps patients to identify their problems and to carry out their own solutions by giving insight and identifying possible courses of action
• counselling implies that the patient recognises the need to modify his/her behaviour
• some patients realise that they are not physically or or mentally ill but are having difficulty adapting to or coping with problems in their everyday life. They may be aware of the cause of their distress and come for comfort and support, mostly given by listening and empathising
• physical symptoms may need to be related to work, relationships or other areas of life.
• doctors differ greatly in how much formal counselling they do. Most refer on to various types of counsellor
c. Prescribing
d. Referral
As with hospital referrals, doctors vary enormously in their rates of investigation. GP's are however very discriminating and achieve a high proportion of abnormal results.
If there is much doubt about the diagnosis after taking the history and examining the patient, it is unlikely that investigations will help. Routine tests without a clear clinical indication are of little value. Investigations should aim to answer specific clinical questions when there is doubt as to diagnosis or management.
In general practice routine investigations are even more inappropriate than in hospital, since most patients suffer from non-life-threatening, self-limiting conditions.
e. Investigation
f. Observation & follow-up
g. Prevention
5. Relating to patients
6. Anticipatory care
7. Record-keeping
Six Category Intervention Analysis (1975)
In the mid- 1970's the humanist Psychologist John Heron developed a simple but comprehensive model of the array of interventions a doctor (counsellor or therapist) could use with the patient (client). Within an overall setting of concern for the patient's best interests, the doctor's interventions fall into one of six
categories:
1.Prescriptive - giving advice or instructions, being critical or directive
2.Informative - imparting new knowledge, instructing or interpreting
3.Confronting - challenging a restrictive attitude or behaviour, giving direct feedback within a caring context
4.Cathartic - seeking to release emotion in the form of weeping,
laughter, trembling or anger
5.Catalytic - encouraging the patient to discover and explore his own
latent thoughts and feelings
6.Supportive - offering comfort and approval, affirming the patient's intrinsic value.
Each category has a clear function within the total consultation.
The Triaxial Model (1972)
The Royal College of General Practitioners has highlighted the need for doctors to address patient problems in physical, psychological and social terms. The most contemporary thinking about the consultation assumes it must be analysed with respect to these three features.
The effect is to discourage doctors to think purely in organic terms and consider also the patient’s emotional, family, social and environmental circumstances, all of which can have a profound effect on health.
The sociological approach
•Social factors may influence behaviour in consultation: ◦different beliefs and norms of behaviour
◦doctor and patient will behave according to the rules of their
respective roles
•Social factors influence many illnesses and be largely responsible for the patient's decision to seek help
•Social factors could affect outcome of consultation or the way it is judged
The anthropological approach
•Sapiential authority (the right to be heard derived from knowledge)
•Moral authority
•Charismatic authority
Helman's folk model of illness (1981):
Cecil Helman is a Medical Anthropologist, with constantly enlightening insights into the cultural factors in health and illness. He suggests that a patient with a problem comes to a doctor seeing answers to six questions:
•what has happened?
•why has it happened?
•why to me?
•why now?
•what would happen if nothing were done about it?
•what should I do about it?
Health belief model
The decision to consult depends upon:
1.The individual’s general interest in health matters, which may correlate with their personality, social class, ethnic group, etc.
2.How vulnerable or threatened a patient feels him/herself to be to a particular disease.
3.The individual’s estimation of the beliefs of treatment weighed against cost, risks and inconvenience.
4.Trigger factors, such as alarming symptoms, advice from family or friends, messages from the mass media, disruption of work or play.
The transactional analysis approach
Many doctors will be familiar with Eric Beme's model of the human psyche as consisting of three 'ego-states' - Parent, Adult and Child. At any given moment each of us is in a state of mind when we think, feel, behave, react and have attitudes as if we were either a critical or caring Parent, a logical Adult, or a spontaneous or dependent Child. Many general practice consultations are conducted between a Parental doctor and a Child-like patient. This transaction is not always in the best interests of either party, and a familiarity with TA introduces a welcome flexibility into the doctor's repertoire which can break out of the repetitious cycles of behaviour ('games') into which some consultations can degenerate.
The human psyche is set to consist of three ego states:
•the parent - commands directs prohibits controls nurtures
•the adult - sorts out information and works logically
•the child - intuition creativity spontaneity enjoyment
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 either Critical or Caring Parent, a Logical Adult or a Spontaneous or Dependent Child. Many general practice consultations are conducted between a Parental doctor and a Child-like patient. This interaction is not always in the best interests of either party. Communication may break down when replies do not match the initial offer. Many transactions are predictable and are described as "games". Transactional Analysis teaches doctors to break out of these repetitious and degenerative cycles of behaviour.
Balint
Much contemporary thinking derives ultimately from Balint and his recognition that patients were more than unbroken machines and the doctor-patient relationship more subtle than was commonly realised. This 1950s approach emphasises the use of transference and counter-transference in diagnosis and treatment and the notion of the doctor as a drug - the most powerful therapeutic tool in the room.
In particular:
•Doctors have feelings and those feelings have a function in the consultation.
•Psychological problems are often manifested physically and even physical disease has psychological consequences. The patient cannot be divided into physical and psychological categories - the two always co-exist.
Specific training is needed to change doctors behaviour so that he can become more sensitive to the patient.
Pendleton, Schofield, Tate and Havelock (1984)
'The Consultation - An Approach to Learning and Teaching' describe seven tasks which taken together form comprehensive and coherent aims for any consultation.
From observation, seven tasks were detailed which together form comprehensive aims for the consultation:
1.To define the reason for the patient’s attendance, including i.the nature and history of the problems
ii.their aetiology
iii.the patient’s ideas, concerns and expectations
iv.the effects of the problems.
2.To consider other problems: i.continuing problems,
ii.at-risk factors.
3.With the patient, to choose an appropriate action for each problem.
4.To achieve a shared understanding of the problems with the patient.
5.To involve the patient in the management and encourage him/her to accept appropriate responsibility.
6.To use time and resources appropriately i.in the consultation,
ii.in the long term.
7.To establish and maintain a relationship with the patient which helps to achieve the other tasks.
These have been widely used and taught as appropriate aims for the consultation. They are of particular interest for the purposes of summative assessment since the criteria developed for assessing the video component are derived from this approach.
Neighbour’s model (1987)
Five consultation tasks are defined: 'where shall we make for next and how shall we get there?'
1.Connecting - establishing rapport with the patient
2.Summarising - getting to the point of why the patient has come using eliciting skills to discover their ideas, concerns, expectations and summarising back to the patient.
3.Handing over - doctors' and patients' agendas are agreed. Negotiating, influencing and gift wrapping.
4.Safety-netting - ensure a contingency plan has been made for the worst scenario - "What if?"
5.Housekeeping - clear the mind of the psychological remains of one’s consultation to ensure it has no detrimental effect on the next - "Am I in good enough shape for the next
patient?"
Intervention analysis
A doctor can use any of six behavioural interventions:
1.Prescriptive: giving advice or instructions, being critical or directive.
2.Informative: imparting new knowledge, instructing or interpreting.
3.Confronting: challenging a restrictive attitude or behaviour, giving feedback within a caring context.
4.Cathartic: seeking to release emotion in the form of weeping, laughter, trembling or anger.
5.Catalytic: encouraging the patient to discover or explore his/her own latent thoughts or feelings.
6.Supportive: offering comfort and survival, affirming the patient’s intrinsic value.
The social-psychological approach
•doctor's personality
•patient's personality
•patient's beliefs
•verbal behaviour
•non-verbal behaviour
Problem-based interviewing
Giving the patient some of the control for process and outcome.
The tasks of a GP within the consultation
(Dykhuis)
1.Primary assessor
2.General physician
3.Personal doctor Family doctor
4.Community doctor
Target behaviour in the consultation
(Irwin & Bamber: 1984)
1 ( ) The beginning
2 ( ) Body posture
3 ( ) Eye contact
4 (IV) Attentive listening
5 (IV) Use of facilitation
6 (I) Use of confrontation
7 (I) Use of silence
8 (IV) Style of questions
9 Absence of jargon
10(I) Appropriateness of interrupting patient
11(IV) Keeping patient to relevant matters
12(IV) Picking up verbal cues
13(I) Picking up non-verbal cues
14(V) Ability to clarify
15( I) Covering of psychological aspects
16( I) Covering of personal aspects
17( I) Covering of social aspects
18(IV) Presence of empathy
19(V) Quality of exposition
The primary care consultation 1976
In 1976 Byrne and Long analysed more than 2000 consultations and identified six logical phases to a consultation. They also stressed that this logical structure rarely appears in reality - sadly, a point that has tended to go unnoticed in communication skills teaching.
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 and/or patient consider the condition.
5.The doctor and patient agree and detail further treatment or investigation if necessary.
6.The consultation is terminated (usually by the doctor).
Dysfunctional consultations usually fell down in phase 2 and/or 4.
Byrne and Long's study also analysed the range of verbal behaviours doctors used when talking to their patients. They described a spectrum ranging from a heavily doctor-dominated consultation, with any contribution from the patient as good as excluded, to a virtual monologue by the patient untrammelled by any input from the doctor. Between these extremes, they described a graduation of styles from closed information-gathering to non-directive counselling, depending on whether the doctor was more interested in developing his own line of thought or the patient's.
The Three Function Approach to the Medical Interview (1989)
Cohen-Cole and Bird have developed a model of the consultation that has been adopted by The American Academy on Physician and Patient as their model for teaching the Medical Interview.
1.Gathering data to understand the patient's problems
2. Developing rapport and responding to patient's emotion
3.Patient education and motivation
Functions Skills
1. Gathering data a.Open-ended question
b.Open to closed cone
c.Facilitation
d.Checking
e.Survey of problems
f.Negotiate priorities
g.Clarification and direction
h.Summarising
i.Elicit patient's expectations
j.Elicit patient's ideas about aetiology
k.Elicit impact of illness on patient's quality of life
2 Developing rapport a. Reflection
b.Legitimation
c.Support
d.Partnership
e.Respect
3 Education and motivation a.Education about illness
b.Negotiation and maintenance of a treatment plan
c.Motivation of non-adherent
patients
The Calgary-Cambridge approach to communication skills teaching (1996)
Suzanne Kurtz & Jonathan Silverman have developed a model of the consultation, encapsulated within a practical teaching tool, the Calgary Cambridge Observation Guides. The Guides define the content of a communication skills curriculum by delineating and structuring the skills that have been shown by research and theory to aid doctor-patient communication. The guides also make accessible a concise and accessible summary for facilitators and learners alike which can be used as an aide memoire during teaching sessions
The following is the structure of the consultation proposed by the guides:
1.Initiating the Session ◦establishing initial rapport
◦identifying the reason(s) for the consultation
2.Gathering Information ◦exploration of problems
◦understanding the patient's perspective
◦providing structure to the consultation
3.Building the Relationship ◦developing rapport
◦involving the patient
4.Explanation and Planning ◦providing the correct amount and type of information
◦aiding accurate recall and understanding
◦achieving a shared understanding: incorporating the patient's perspective
◦planning: shared decision making
5.Closing the Session
The Cambridge-Calgary method of giving feedback
Teaching styles
•The authoritarian style: "Tell and sell" - standard "teachers" teaching.
•The socratic style: Teaching by question and answer.
•The heuristic style: "Find out for yourself". Encourages learning by doing and demands free interchange between trainer and trainee.
•The counselling style: Aims to help the trainee understand the interactions taking place between himself and the material being learned. Teacher must not be authoritarian. Equivalent to a counselling style in the consultation.
•The neo-socratic style