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The Oakwood Surgery
Registrar Training Handbook
“Excellence in education”
Important Consultation Models
1957 M Balint
The Doctor, His Patient and The Illness
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:
1964 E Berne
Games People Play
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.
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.
1975 Becker & Maiman
Sociobehavioural Determinants of Compliance
Becker and Maiman combined a number of patient beliefs and attitudes into a 'health belief model' which included:
This model can be summarised as the patient's Ideas, Concerns and Expectations.
1975 J Heron
Six Category Intervention Analysis
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:
Each type of intervention can be looked at separately during training sessions as options throughout the consultation.
1976 Byrne & Long
Doctors Talking to Patients
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.
Dysfunctional consultations tended to have less silence and often phase 2 and/or phase 4 were not successfully completed.
1984 Pendleton et al
(The Consultation )
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.
1987 R 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:
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:
5. Housekeeping: Am I in good condition for the next patient? - stress, concentration and equanimity
1996 Kurtz & Silverman
(The Calgary-Cambridge Observation Guide to The Consultation)
The five tasks of the consultation are:
A. Initiating the session
B. Gathering information
C. Building the relationship
D. Giving information - explaining and planning
E. Closing the session
The expanded framework goes into the five tasks in greater detail.