THE GENERAL PRACTICE

CONSULTATION

Ewen McPhee

March 2012

Why? Health Rights

Commission 80% of complaints

were due to a failure of doctor to listen to a patient

USA 85% Malpractice claims

Improve satisfaction Increase patient

health outcomes

Video 01.00 – 01.50

Art or ScienceEveryone has their own Style

Often styles adapt

Age

Ethnicity

Time Available

Tiredness

Urgency of presentation

Systematic Approach 15 minutes to

Meet the patientTake a historyExamine the patientOrder testsMake a management

plan The meeting of two

experts

The Framework Preparation Beginning

Build the doctor patient relationshipOpen the discussion

MiddleGather InformationUnderstand the patients perspectiveShare information

EndReach agreement on the problems/plansclosure

Beginning Introductions Establishing Rapport

How? The opening Gambit

Prepared commentary to gain attentionVideo

ListsRead early “anything else”“what is most important today”

Acknowledge running late

Video 02.54 – 03.30

Middle The Patients Agenda

ICE○ Ideas about their

problem○ Concerns of the patient○ Expectations as to how

you might help

“Why are they here ... Why today ...?”

Use open ended Questions

“Is there anything were worried it could be ...?”

Using third person may help “some people often worry that it could be cancer...”

Be prepared to explore psychosocial issues as a large number of GP presentations relate to, Stress, Over tiredness, Financial and Marital Problems.

Video 05.03 – 09.35

The Patient’s story Being available to

listen Eye contact/face

contact Minimal encouragers The sounds of silence Listening actively

Stop what you are doing Content and feelings

need to be received Reflect this back to the

patient

Roadblocks Ordering Warning Moralising Advising Logic Judging

Praising Name calling Analysing Reassuring Questioning Diverting

Video 24.30 – 31.39

Examination An 18 year old woman

presenting to a 45 year old male GP with a mole on her forearm

What is an appropriate examination

How would you negotiate this?

Have you Undressed in your own consulting room?

Video 31.39

Touch Imagine yourself as a patient. You have had

worrying headaches for the last month and you are going back to your GP to receive the results of a CT Scan done this morning.

You are told that there is a mass in the front part of the brain and it looks nasty.

What touch if any would help you in this hypothetical situation

What touch might be intrusive or even abusive.Video 32.57 – 34.5

Middle The Doctors Agenda

Doesn’t always match the patients

Manage presenting problem Manage continuing/chronic

problems○ Past medications and

History Modification of help seeking

behaviour○ Education

Opportunistic health promotion○ BP/Immunisations/

Smoking/Pap/Exercise

Wrapping it up

Reflect and Summarise using patients own words

Explain your thought processes to patientPossible diagnosisInvestigationsTreatment optionsTreatment may be investigations itself

Acceptance SetsVideo 12.50 – 16.20

The Plan

Make a plan not necessarily a diagnosisArrange an appointmentSick certificates

Establish a Safety net (What if I am Wrong?)Make it clear what to do if things change

and / or get worse

Safety Netting You have just seen a 23 year old woman with

vague lower abdominal pain for the last 6 hours with one loos bowel motion and a low grade fever of 37.6C

She is travelling through your area, on business, and is staying in a Hotel tonight moving on at lunchtime tomorrow

Clinically you suspect Gastroenteritis but there are other important possible diagnoses.

What will you say to her?

Housekeeping

What about the doctor?

HALT

Hungry Angry Late Tired