Consultation

• Khalil Gibran (1883-1931): 'If you cannot work with love but only with distaste, it is better that you should leave your work and sit at the gate of the temple and take alms from those who work with Joy.'
• "Sir James Spence": 'The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or sick room a person who is ill or believes himself to be ill, seeks the advice of a doctor whom he trust.'
• Consultation


  Central act of medicine
• Consultation


  • Any problem defined in terms of physical, psychological and social components
  • Effective consultation is one that achieves the desired outcome
• Patient


  • Comes to consultation with problems that may have physical, psychological and social dimensions
  • Has own ideas about the nature of the problem, its causes, its importance and possible outcome
  • Has own concerns about the problem and expectation about the medical care that he is about to receive
• Setting of the consultation

  • Can strongly influence the type of communication (appearance and seating arrangement)
  • Compassion, interest and thoroughness are essential components of successful patient care
  • Qualities of concerns, kindness, friendliness and cheerfulness all result in atmosphere of trust and confidence between patient and doctor
• Doctor's roles


  • Problem definition
  • Management
  • Caring
  • Support
  • Prevention
  • Education
• Consultation


  Consists of two distinct parts: The interview in which the doctor seeks to discover why the patient has come to seek help, and the Exposition in which the doctor informs the patient of his conclusion and diagnosis and what treatment and advice he considers the patient needs
• Opening of the consultation

  • Key to putting patients at ease
  • Doctor can communicate this to patient in various ways: Greeting the patient by name, Rising to meet patient, Shaking hand with patient, Indicating where he can sit, Engaging in some preliminary informed chat
• Routine tasks in consultation

  1. Discover the reasons for patient attendance

  2. Define the clinical problems

  3. Address patient problems

  4. Explain the problems to the patient

  5. Make effective use of consultation
• Doctor-centered consultation


  Doctor has authority, patient passive and relying on doctor's judgment
• Patient-centered consultation


  Patient active, doctor encourages patient to report not only symptoms but also their thoughts, feelings about their illness and their expectation of the consultation
• Consultation should be more of a dialogue and meeting between two experts
• Patients are more satisfied when

  • The doctor discovers and deals with patient concern and expectation
  • Communicates warmth
  • Shows interest
  • Concern about the patient
  • Volunteers a lot of information
  • Explains matters to patient in terms that are understood
• Clinician needs to master a broad range of skills

  • Interpersonal skills (questioning, listening, responding, explaining)
  • Reasoning skills (gather appropriate information, interpret and apply in diagnosis and management)
  • Practical skills (perform physical exam and use medical instruments)
• Diagnosis is made by: History (82%), Exam (9%), Investigations (9%)
• Components of consultation competence

  • Interviewing/history taking
  • Physical exam
  • Patient management
  • Problem solving
  • Behavior/relationship with patient
  • Anticipatory care
  • Record keeping
• Medical model


  1. History

  2. Exam (inspection, palpation, percussion and auscultation)

  3. Investigations

  4. Diagnosis

  5. Treatment
• Health belief model


  • People vary in their overall interest in health and their motivation to look after it (health motivation)
  • Patients vary in how likely they think they are to contract an illness (perceived vulnerability)
  • Patients vary in how dire they believe the consequences of contracting a particular illness would be, or of leaving it untreated (perceived seriousness)
  • Patients weigh up the advantage and disadvantage of taking any particular course of action (perceived cost)
  • Beliefs are prompted by cues to action such as TV program, article or visit to the doctor
• Any doctor who wants to influence their patients to look after their health, to comply with advice and to use medical services appropriately need to influence their patients' health beliefs
• Doctor and patient have broadened the scope of consultation through a shift from thinking about patient care in terms of disease and pathology towards thinking in terms of people and their problems
• 50% of all medical advice given is not followed
• Patients comply better if

  • They believe they can control over their health
  • Advice given is consistent with their health beliefs
  • They are more satisfied with the consultation
  • They are involved in the decision
• Pendleton Model


  1. Define the reason for patient attendance

  2. Consider other problems

  3. Choose appropriate action for each problem with the patient

  4. Achieve a shared understanding of the problems with the patient

  5. Involve patient in the management and encourage him to accept appropriate responsibility

  6. Use time and resources appropriately in the consultation and in the long term

  7. Establish or maintain a relationship with the patient which helps to achieve the other tasks
• Stott and Davies Model

  1. Management of presenting problems

  2. Modification of help-seeking behaviors

  3. Management of continuing problems

  4. Opportunistic health promotion
• The Inner Consultation Model by Roger Neighbor

  1. Connecting (establishing rapport with patient)

  2. Summarizing (getting to the point of why the patient has come, discover their ideas, concerns and expectation and summarizing back to patient)

  3. Handing over (doctor and patient agendas are agreed, negotiating, influencing and gift-wrapping)

  4. Safety net (consider possible outcome of the consultation and what doctor might do in each case)

  5. House keeping (am I in good enough shape for a next patient?)
• Dealing with anger


  1. Consider avoiding confrontation

  2. Facilitate discussion

  3. Ventilate feelings

  4. Explore reasons

  5. Refer/investigate
• Dealing with conflict or ethically dubious request

  1. Consider whether to agree or disagree

  2. Discuss with partners

  3. Refer

  4. Defer

  5. Bargain/negotiate

  6. Educate

  7. Counsel
• Dealing with grief


  1. Consider facilitating expression

  2. Help patient understanding of reaction

  3. Educate on what to expect

  4. Identify problems and offers solutions

  5. Inspire hope

  6. Identify positive achievement
• Implications of an event of decision

  • Consider patient, family, care, community, doctor partners, practice and health authority
• Skills involved in Breaking bad news


  1. Preparation (know all facts in advance, who patient wants present, ensure privacy, chair to sit on)

  2. What does the patient know? (is more information wanted?)

  3. Give a warning shot

  4. Allow Denial

  5. Explain (if requested)

  6. Listen to concern

  7. Encourage ventilation of feeling

  8. Summary and plan

  9. Offer availability
• The physicians as a healer

  • They should master those tools and techniques that fall within their own field (e.g. therapeutic agent of healing at physical level, the drug instrument and manual skills)
  • They should master the skills of healing at the mental level (communication, attentive listening, facilitation and the provision of reassurance)
• Management under the following broad headings

  • Reassurance or explanation
  • Advice
  • Prescription
  • Referral
  • Investigation
  • Observation (follow up)
  • Prevention
• Consultation Rating Scale


  • Nature and history of problems adequately defined
  • Etiology of problems defined adequately
  • Patients ideas explored adequately and appropriately
  • Patients concerns explored adequately and appropriately
  • Patients expectations explored adequately and appropriately
  • Effects of problems explored adequately and appropriately
  • Continuing problems considered
  • At risk factors considered
  • Appropriate action chosen for each problem
  • Appropriate shared understanding of problems achieved
  • Patient involved in management adequately and appropriately
  • Appropriate use of time and resources in consultation
  • Use of time and resources in long-term management appropriate
  • Helpful relationship with patient established or maintained