Consultations and Written Skills

What are consultation models? Models we can use to help structure our consultations, and helps with shared decision making They make sure we • establish rapport • explore ideas, concerns and expectations • negotiate a management plan • are in line with the framework • make use of limited resources • manage our own emotions, agendas and uncertainty • Clinical knowledge • Communication • Strategy for managing the consultation What makes an effective consultation? • Recognising the patients' needs and expectations • Involving the patient in decision making Each consultation is a moment of exceptional potential that gives us the opportunity to promote healthy living and provide treatments Effective consultations maintain and improve our job satisfaction, and prevent What is the importance of using an effec- burn-out from dysfunctional consultative consultation model? tions They also lead to higher levels of patient satisfaction and improved concordance with treatment, improved health outcomes and better symptom relief, due to the higher quality patient-clinician communication. 1 / 14 What is ICE? Ideas, concerns and expectations • Ideas- explore patients views about their conditions nature, cause of progression • Concerns- address the patients fears and anxieties surrounding the situation, including seriousness of the issue, possible implications for the future or unpleasant feelings and emotions • Expectations- shared agenda to ensure that the consultation addresses the patient's expectations, and this can be done through therapeutic options (prescribing a medication), advice or referral • It over-simplifies the complex interaction that is the clinician-patient consultation • They teach behaviours rather than attiWhat are disadvantages of using consul- tudes, values and beliefs tation models? • They should not be followed rigidly, but should be adapted to one's innate consulting skills and personality traits, allowing our natural warmth and empathy to show through • Unstructured • Runs out of time What are the main reasons for a consul- • Failure to develop a shared managetation to fail? ment plan with the patient • Failure to recognise the real issues in the consultation Steps to follow during the consultation 1. Presenting complaint 2. History of presenting complaint 3. Past medical history What is the medical/ traditional model? 4. Examination 5. Social history (usually low emphasis) 6. Drug history 7. Differential diagnosis- Working diag2 / 14 nosis 8. Investigations 9. Treatment • It sorts the main problem out What are advantages of the traditional • It is structured medical model? • It is medically comprehensive (covers a range of topics) • It doesn't advise on what to do in an incident where the clinician cannot come up with a diagnosis • It disregards the patient and clinician as people • It is not an effective use of time as it covers areas which may have little relevance What are disadvantages of the traditional • It disregards the psychosocial conmedical model? text, and it doesn't involve responding to patient cues- traditionally, doctors were more likely to ignore patient cues as they wanted to feel in control of the consultation, and were fearful of exploring a patients feelings in case this took them down an unfamiliar path, or lengthened the consultation What is the Balint model? • Michael Balint introduced the psychological component of the consultation • The Balint model acknowledges that both the clinician and the patient have feelings that they bring to the consultation and these impact on the consultation • It encourages the clinician to think about the encounters with patients that leave them drained, puzzled or stuck What are advantages of Balint? • Helps to understand the relationships between the patient and the clinician, which increases effectiveness of the consultation 3 / 14 What are disadvantages of Balint? • Doesn't help us provide structure to our consultations and doesn't give us a useful, practical framework that we can use to accomplish tasks in the consultation What is the Byrne-Long model? It can be condensed into a six-stage process: 1. The clinician forms rapport with the patient 2. The clinician tries to elucidate the reasons for the patient having attended the surgery 3. The clinician performs an examination 4. The clinician (perhaps with, perhaps without) the patient considers the problem 5. The clinician (perhaps with, perhaps without) the patient makes a plan 6. The consultation ends, usually by the clinician finishing it What are advantages of Byrne-Long model? • Provided a logical structure, and introduces concept of introducing and finishing the consultation • Introduces the idea of involving the patient when considering the problem • Quite a clinician-centred model, as What are disadvantages of Byrne-Long there is little collaboration with the patient model? and no mention of shared management plans What is the Pendleton model? It describes seven tasks that the clinician and patient must accomplish in the consultation 1. Establish reasons for attending 2. Consider whether there are other problems 3. The clinician and patient must choose an appropriate management plan for each of the problems 4. Work together to achieve a shared un4 / 14 derstanding of each problem 5. The clinician should involve the patient in the management plan, and encourage the patient to adopt a degree of responsibility for each problem 6. Use time and resources efficiently 7. The clinician should use the consultation to develop and promote a lasting relationship • It is more patient-centred and specifiWhat are advantages of the Pendleton cally encourages the clinician to involve model? the patient in the management plan • The number of tasks to complete is overwhelming and hard to fit into a small amount of time • The model requires exploring multiple What are disadvantages of the Pendleother problems too which takes time and ton model? the patient may be frustrated by a clinician who spends time discussing problems they may not believe to be relevant eg social problems What is the Neighbour model? A five-stage model 1. Connecting- the clinician establishes report with the patient and endeavours to see things from the patients point of view 2. Summarising- an opportunity for the clinician to summarise why the patient has come to see them. If the summary is inaccurate, patients have the opportunity to make amendments 3. Handover- the clinician and patient formulate a management plan together. This involves giving patients options, checking their understanding and transferring responsibility for some aspects of the management plan back to the patient 4. Safety-netting- a contingency plan is formed, which covers the patient and the 5 / 14 clinician if the clinician has got the diagnosis wrong or if something unprecedented happens 5. House-keeping- this allows clinicians to acknowledge and deal with any emotions arising from the consultation before they see the next patient, to prevent this having any adverse effect on the next consultation • The model is more achievable, structured and easy to recall • It is patient-centred whilst also attending to the clinician's feelings • It empowers the patient by ensuring the What are advantages of the Neighbour clinician hands back a degree of responmodel? sibility for some aspects of the management plan • It is the first model that recognises the importance of safety netting and being a healthy clinician (house-keeping) • There is limited time available for the consultation so the model may not be practical in practice • The 'connecting' part of the model What are disadvantages of the Neigh- should not just be at the start of the bour model? consultation, and rapport should be built throughout • There is no advice on how to end a consultation, which is valuable especially as there is limited time available • A five-stage model, incorporating the physical, psychological and social aspects of the consultation What is the Calgary-Cambridge model? • In addition to the five stages, there are two threads that run throughout the consultation- 'building the relationship' and 'providing structure' 6 / 14 What is 'building the relationship'? Rapport building, which involves demonstrating empathy and sensitivity and using the patient notes in a way that does not interfere with the consultation, and pharmacists are encouraged to share their thoughts by thinking out-loud and accepting the legitimacy of the patients view and feelings What is 'providing structure'? Ensuring the consultation flows well, and that the pharmacist and patient are clear about what will happen during it eg saying to the patient you need to ask them a few more questions before you examine them What are the five stages in the Calgary-Cambridge model? 1. Initiating the session- establishing rapport with the patient and finding out why the patient has attended. Generate an agenda incorporating the needs of both the patient and the clinician 2. Gathering information- the clinician develops a structure of the consultation, and explores the problem using open and closed questions, picking up on cues, and establishing the patients ideas, concerns and expectations 3. Physical examination 4. Explanation and planning- the information is provided in chunks rather than in great detail at the end of the consultation, and the clinician checks the patients understanding throughout 5. Close the session- the clinician summarises the information and ensures that the agreed plan is clear to both parties 7 / 14 How should the clinician pick up on cues? • Repeat verbal cues back to the patient to show you have heard it and are responding to it, and it also gives the patient the opportunity to elaborate, and can provide you with more information about their health beliefs eg "a bit frightened?" • Explore verbal cues in more detail by asking questions about it eg "are you worried that the pains you are having are angina?" • Describe the non-verbal cues to the patient to show you have picked up on it and are responding to it. They could also be a sign that better explanation is needed to renegotiation of the management plan eg "you do not look too happy at that suggestion" What are advantages of the Calgary-Cambridge model? • It is very patient-centred • It is comprehensive as it covers both disease (clinician) and illness (patient) frameworks • It is applicable to all pharmacist consultations in different areas eg community, hospital, GP • It is practical and gives us tasks to complete • It is triaxial as it incorporates physical, psychological and social factors • It focuses on responding to patient cues which can help us use our time more effectively • It is the only model that is evidence based 8 / 14 What are disadvantages of the Calgary-Cambridge model? • It involves 71 micro-skills which is very difficult to incorporate simultaneously, making it more challenging to learn • Some patients may not like it and would prefer a more paternalistic approach where the decisions are made for them by the clinician • It is a model written for face-to-face consultations however 1/4 of consultations in British primary care are now done by telephone, and the lack of face-to-face contact makes it difficult to detect cues (there are still cues to detect in the phone eg silence, hesitation, and not responding to these cues can impact rapport-building) What is the Hellman folk model? A model that suggests every patient comes to the clinician wanting the answers to six key questions 1. What has happened? 2. Why has it happened? 3. Why has it happened to me? 4. Why has it happened now? 5. What should I do about it? 6. What will happen if I do nothing about it? Failure to address these questions may cause mismatch between the clinician's and patient's agendas It doesn't provide structure to our conWhat are disadvantages of the Hellman sultations or help us complete all of the folk model? tasks demanded of us in the short space of time 9 / 14 What is the WWHAM model? W- Who is the medicine for? It may not be for the customer W- What are the symptoms? H- How long have you had the symptoms? Many minor ailments clear up within a few days A- Action taken so far? Have they tried any medicine or treatment without success M- Medication taken so far? Do they take any prescribed medicines/ OTC medicines/ herbal remedies, as some can interact with each other • Performance competency 1: Encourages the patient's contribution (initiating the session, building the relationship) • Performance competency 2: Responds to cues (building rapport, gathering information) • Performance competency 3: Places complaint in appropriate psychosocial contexts (gathering information, building the relationship) • Performance competency 4: patient's health understanding Explores (gathering information) • Performance competency 5: Includes or excludes likely relevant significant condition (sharing this, if appropriate, will also provide structure to the consultation and may form part of explanation and planning) • Performance competency 6: Appropriate physical or mental state examination (gathering information) • Performance competency 7: Makes an appropriate working diagnosis (and 10 / 14 sharing this, which will form part of explanation and planning and also provides structure to the consultation) • Performance competency 8: Explains the problem in appropriate language (explanation and planning, building the relationship) • Performance competency 9: Seeks to confirm the patient's understanding (explanation and planning, building the relationship) • Performance competency 10: Develops What are the performance competencies an appropriate management plan (explain the COT criteria? nation and planning) • Performance competency 11: The patient is given the chance to be involved in significant management decisions (explanation and planning, building the relationship) • Performance competency 12: The doctor makes effective use of resources • Performance competency 13: the conditions and interval for follow-up are specified (closing the session, providing structure and building the relationship) • Pharmacists are required to write prescriptions, fill out medical records, and prepare reports • It is important that these are written well because it is needed to provide info and advice to patients and other healthcare Why are written communication skills im- professionals about medications portant? • It enables us healthcare professionals to coordinate patient care (continuity of care) and ensure that patients receive the most appropriate treatment. • It allows for audit and quality monitoring • Poor written communication can cause delays or miscommunication, and im11 / 14 pacts decision making which can affect patient safety - eg unclear instructions and improper punctuation in a prescription can cause dose to be misinterpreted • If it isn't written down, it didn't happen!!! Hence, always write down what happens with the date and time after every consultation/ interaction/ conversation What are patient clinical records? • Information about a patient and their journey • It involves history, examination, diagnosis and plan • Pharmacists should always gain consent from the patient to access and use their records • If recording info in a patient record, the pharmacist should, after gaining consent, inform the patient of what info is being recorded and why • Patients can now access their health record via the NHS app so records need to be written well to provide motivation to the patient to participate in monitoring and treatment, reduces the need for face to face consultations, and increases person autonomy/control of their own care • It is important to keep records to account for and justify professional decision making (and the source of information accessed to make that decision) if there was an investigation or a claim of negligence • Also, if a healthcare professional fails to access all relevant records and the patient subsequently comes to harm, the healthcare professional would be negligent. 12 / 14 What is SOAP? An acronym to remember what to include in a patient record S- Subjective information- the patients presenting history - PC, HPC, PMH, DH, AH, SH, FH O-Objective information- the observations, physical examinations, investigations and diagnostic tests made A- Asssessment- assessment or diagnosis of the patient P-Plan- treatment and follow up plan agreed with the patient/carer - any further investigations required, any medicines prescribed, any follow-up or referrals made, red flags, safety netting, time frame for symptoms to improve Five Cs 1. Clarity What are the legal and regulatory re2. Conciseness quirements for patient clinical records? 3. Contemporaneous (written in the time) IMPORTANT!!! 4. Completeness 5. Confidentiality The RMCoP described four characteristics of an authoritative record. The characteristics that are relevant for all patient records are: • Authentic- make sure it is what it says it is, and that it was written at the time • Reliable- ensure it is factual and all the What is the Records Management Code information is true of Practice 2021? IMPORTANT!!! • Integrity- ensure it is complete and unaltered, but if any amendments were made then ensure the change is authorised with a counter-signature • Useable- ensure it is clearly contextualised, to the point, accessible and meaningful 13 / 14 • Avoid jargon, especially if directed to patients and families • Store it securely for future reference How can you make sure written commu- • Ensure it remains confidential nication is effective? • Ensure the information written is accurate • Ensure handwriting is legible • Ensure instructions are clear • They speed up the process of writing Why are acronyms used in written com- • They provide the conciseness required munication? in certain pieces of writing eg some sections in a record have minimal space 14 / 14