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
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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
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One consequence of the traditional model
Source: Fairview Pharmacy, London, 2004 -medicines picked up from an elderly lady’s home
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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).
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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
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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.
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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.
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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)
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Source:Medicine partnership-fromcompliance to concordance
From compliance to concordance
Traditional model Patient centered model
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Source:Medicine partnership-fromcompliance to concordance
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
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Source:Medicine partnership-fromcompliance to concordance
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:
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Opposing Paradigm
Empirical Vs Hermeneutic
Doctor center Vs. Patient center
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Scientific Paradigms:
• The term paradigm is often used to describe the
received beliefs that are taken for granted in ascientific discipline
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• 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
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• 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.
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• 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
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• Neighbour introduces the concepts ofright brain and left brain thinking in the
inner consultation.
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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
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• 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.
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• 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.
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Medical interventions
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Hermeneutic interventions
• Attentive listening• Reflection
• Silence• Empathy vs. sympathy
• Touching• Non doing
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Doctor - centred Vs
Patient centred
• How would you define patient centeredness?
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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
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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
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In Dealing with the patients problem
Answers to problems often come out of no where
Agree---------- Pt centred
Disagree------ Dr centred
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In Dealing with the patients problem
Problem solving is usually by tried and tested
methods
Agree --------Dr centred
Disagree-----Pt centred
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In Dealing with the patients problem
I find that I match most problems with a standard
solution
Agree ----------Dr centred
Disagree-------Pt centred
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In Dealing with the patients problem
The patient’s opinion on problem solving is less
important than the doctors.
Agree------------Dr centred
Disagree------- Pt centred
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In Dealing with the patients problem
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
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In Dealing with the patients problem
Most solutions are unique rather than standard
formulae
Agree------- ----Pt centred
Disagree------- Dr centred
C lt ti d l
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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
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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
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Communication skillsTalking to peopleListening to stories
History takingStructuredFocused
Patient centered
Clinical problemsolving
Effective
ConsultingWith patients
C lt ti T k
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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
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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
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Managing the consultation
• Managing the problems
• Managing the patient• Managing the consultation process
S
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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
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Establishing Rapports
• Beginning the consultation
• Listening• Demonstrating empathy
Challenges/Obstacles to Effective
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Challenges/Obstacles to Effective
Consultation
• Time
• Cost • Culture
• Legal Issues
Danger areas in the consultation
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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.
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• 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..
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