VTS HALF DAY RELEASE
DAY ON THE CONSULTATION Sample course
Preparation; read chapter 3 in “Skills for communicating with patients”
Possibly GP reg to present some of the evidence that there are problems in this part of the consultation and the evidence that supports the use of certain skills which improve outcome.
Registrars to bring tapes; one in which the doctor was pretty sure why the patient came but the doctor still didn’t understand the problem
1st session 1.30 - 3.pm
Quick introductions, round of names
· protected time to look at the consultation; the core of what we do as general practitioners and kindle enthusiasm
· concentrate on the information gathering part of the consultation; look at the structure and skills of this section and in particular focus on how we take an accurate clinical history and weave in the patient’s framework, as well as problem solve all at the same time; a tall order in around 5-7minutes!
· have fun and enjoy ourselves
Summarise the importance of:
1. a model and framework in order work out :
2. a basic framework of any consultation; a beginning, middle and an end
3. basic C/C guide
So last term we spent some time on the beginning of the consultation.
The objectives, preparation, discovering why the patient has attended, developing rapport and setting the agenda for the interview, and the skills which we need to use in order to achieve these objectives:
Show overhead and refer to guide back to top
We also mentioned the all important disease-illness model (Show overhead)
This time we are going to focus on gathering information, both from the disease and illness perspectives and look at how we hypothesise and problem solve as we go along. Most studies have shown that in clinical encounters the history contributes between 60-80% of the data to make the diagnosis. So it’s really important to find effective ways of managing this part of the consultation; the way most of us were taught at medical school is not appropriate in the 10 minute GP consultation; we need a focused approach. There’s no one way, we all will use a different style and hopefully vary it to suit an individual patient, but there is a structure and some defined skills which will help.
It’s not easy to do this well; watching summative assessment tapes it’s a common problem for the registrar not to be clear about the clinical history:
for eg a clear account of the patient’s dizziness, headaches, nor for instance, how seriously depressed the patient is.
Very uncommon to see a registrar elicit the patient’s perspective.
The bonus for getting this part of the consultation including the patient’s framework right are enormous; not only will you be more likely to get the diagnosis right and build the relationship with the patient, but also you are in a splendid position to start to explain, give information and plan, and you are much more likely to a joint management plan which will be acceptable to the patient. (Cf. getting the beginning of the consultation right in order to proceed smoothly to gathering information.)
EXERCISE 1 Pairs exercise
Think of a patient in the last few weeks in which the consultation didn’t go smoothly - one which you were uneasy about -
5 mins each way, focus on the section of information gathering;
· what bits of information did you discover?
· what else would you have liked to discover - what was missing
tell your partner about it
feedback information that the doctors would have liked to obtain from each pair and summarise the problems on a flip chart
Discuss the problems
This is a very good exercise and gets everyone thinking not only about what was difficult in gathering information from both the doctor’s point of view as well as the illness perspective of the patient, but also encouraged registrars to talk about what “blocked” them from taking a good history;
eg being tired or anxious about something else, little knowledge about the clinical problem, not switching off from the patient you have just seen, not having the skills to “delve” further when the patient gives a negative answer to enquiries re concerns or thoughts.
It also gets the group “going” and is another exercise which encourages doctors to story tell and talk about what they enjoy best - their encounters with patients.
It can lead the facilitators nicely to give some evidence that there are problems in this part of the consultation and allows the registrars to feel that they were not alone;
also to talk about how doctors hypothesise, fit symptoms into patterns, and bring “windows” down for enquiring further into symptomatology eg questions for heart failure or unscheduled vaginal bleeding.
Put in here the evidence that there are problems in this part of the consultation
EXERCISE 2 Fours or fives with a flip chart 10 mins
focus on a particular patient, and think about it from both the doctor’s and patient’s points of view.
· what are we trying to achieve in this part of the consultation?
· what are the skills which will help us to achieve these objectives?
Mill around the charts and then compare with the framework and skills of the C/Cguides or ask each group to present their frameworks.
?present on or two pieces of research evidence here to support the use of say open/closed questions, the facilitative response.
EXERCISE Roleplay 30 mins back to top
Choose one of the scenarios which regs have experienced recently and already talked about. Just do the gathering info part. Work out the objectives first.
One person be the patient, one the doctor; could be reverse roleplay
remind the regs to write down what they see, also feedback rules as for ALOBA
Leader to summarise which skills were effective and how they fit into the structure of the consultation, checking back to the guides.
The leader to stop the roleplay if appropriate and look at where the registrar is with problem solving, “what are you thinking this might be now?”. “is there anything you still need to know either from the disease point of view, or the patient’s illness framework?”
The leader can also can encourage the doctor to work out which “window” of direct questions to ask for example about SOB (both disease and illness ) and when it’s best to signpost to the patient that you need to ask certain questions in order to clarify the problem.
Hopefully we should start to cover;
Exploration of problems
· open/closed/directed questions, definition and when to use
· facilitative response
· internal summary
Understanding the patient’s perspective and when and how to elicit
· ideas and concerns
· thoughts and feelings effects on life
Providing structure to the consultation
3.0 - 3.30 pm tea
3.30 - 4.30 Second session two small groups using videos, concentrating on gathering information
If you are lucky, you will get a tape where you can focus on information gathering.
4.30pm join in the large group
Round of one thing learned about information gathering - something to take away.
Summarise the CC guides on information gathering and the benefits of doing this effectively before giving information/negotiating a plan.
next session 24th November; we hope to use a simulated patient this time. Please bring scenarios
Could do TATT, joint pains eg
It is important to label at some point how useful keeping open is at the beginning of gathering information when you feel shaky about your knowledge or experience base about the problem the patient has brought. General practice is full of uncertainty; finding out the patient’s thought concerns and expectations can really help with defining the problem when you are at sea!
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