The consultation

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The consultation

• The art of accompanying the patient
• By
• Ghislaine Young

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Sir James Spence

• A consultation is
• An occasion when, in the intimacy of the
  consulting room a person who is ill or believes
  himself to be ill, seeks the advice of a doctor
  whom he trusts.
• 2 orientations the illness and the patient
• A meeting of experts

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Hippocrates

• It is more important to know what sort of person
  has a disease then to know what sort of disease a
  patent has

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Alan Alda
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Never have your dog stuffed!

• I began to understand that what I do in the
  scene is not as important as what happens between
  me and the other person. And listening is what
  lets it happen. Its almost always the other
  person who causes you to say what you say next.
  You dont have to figure out how youll say it.

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Listening, or are you pretending?

• you have to listen so simply, so innocently,
  that the other person brings about a change in
  you that makes you say it and informs the way you
  say it. The difference between listening and
  pretending to listen.. Is enormous one is fluid,
  the other rigid. One is alive, the other stuffed

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Real Listening is..

• a willingness to let the other person change
  you. When Im willing to let them change me,
  something happens between us that is more
  interesting than a pair of duelling monologues.

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Dont just do something, sit there!

• The way to do is to be. Lao Tzu
• being is a fundamental mode of existence or
  orientation to the world, one of aliveness and
  authentic relatedness- Joseph Jaworski
• Nursing is about being with the patient- Stephen
  Wright

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The Dialogue

• A flow of meaning
• Is used to deepen the therapeutic relationship
  and develop rapport
• To shine a light on any symptoms the patient
  presents with, and
• Symptoms are shaped by prior context and
  perceptions of the patient

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HALT!
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The examination

• If you dont look you dont see!
• Seek your patients permission and explain the
  process
• Be comprehensive and use it to build your
  hypothesis (dont skimp!)
• Notice, notice, notice! The clues are there!

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The hypothesis

• Is developed to understand the patients
  experience and concerns, fears , expectations
• To reach a diagnosis
• To facilitate a treatment pathway and or care plan

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Karl Popper

• knowledge is advanced by the positing and
  testing of hypotheses. Countless hypotheses are
  being tested at once in the unconscious mind
  only the winning shortlist is handed to our
  consciousness
• Developing a hypothesis is about discerning the
  truth. There are facts and there are perceptions
  of the facts!

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Ay, theres the rub!

• Symptoms are only given meaning and so expression
  by the patient
• The clinician too is influenced by his or her
  prior context and experience, education and level
  of training and most of all by their attitude.

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Confirmation Bias

• Ron Berghmans and Harry Schouten
• Is a tendency for people to favour information
  that confirms their preconceptions or hypotheses
  regardless of whether the information is true
• The danger is that GPs look for diagnosis by
  confirming their initial thoughts. But if you are
  only looking for white swans that is all you
  will see.

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The art of managing uncertainty

• Most common things happen most commonly, but have
  you ruled out the rare?
• Be open and prepared to challenge your
  pre-conceptions
• The patient condition is dynamic so re-evaluate
  as necessary and dont over rely on colleagues
  findings or judgements!

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Making the diagnosis

• Making a diagnosis
• The word comes from the Greek meaning through
  or between and knowing.
• Dossey suggests that making a diagnosis involves
  using the right brain or intuition to infer
  patterns that are woven through facts and between
  data.

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Diagnosis as tapestry

• making a diagnosis is like confronting a
  tapestry. Our task is to absorb the pattern, to
  grasp the the design, not to bludgeon our way
  through with linear reasoning.

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The art of intuition and the science of logic

• Blaise Pascal (1657, Pensees)
• There are two excesses to exclude reason, to
  admit nothing but reason
• Or as Einstein puts it
• the intuitive mind is a sacred gift, the
  rational mind is a faithful servant

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Communicating back to the patient

• Share your findings and thoughts
• Explain rationale
• Involve the patient at every step
• Be empathic and deal with sensitive issues
  appropriately
• Be alert to cultural or ethnic issues
• Provide support

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Explanation and planning

• The Calgary- Cambridge Model
• chunks and checks give information in
  manageable chunks, check for understanding, uses
  patients response as a guide to how to proceed
• Tell the patient what you going to say, say it,
  then repeat what you have said.

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Aiding Accurate Recall and Understanding

• Use concise, easily understood language
• Use diagrams or models
• Use patient information leaflets (CKS Patient Co
  UK)
• Self management plans
• Relate any explanations to the patients own
  frame of reference and context

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Shared Understanding and Decision Making

• Encourage patient to contribute own ideas and
  thoughts (Nothing about Me without Me- Don
  Berwick)
• Work in mutual partnership
• Negotiate plan of action and offer informed
  choices where appropriate or possible
• ask about support systems, but also aim to
  empower the patient to take the lead in their own
  care

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The 15 minute hour- Stuart and Lieberman

• The sorrow which has no vent in tears may make
  other organs weep. (Henry Maudsley)
• People become stressed when they are unable to
  adapt to external or internal environments and
  this in turn predisposes to further ill health
  and accounts for much presentation in primary
  care
• Goal of therapy enhance coping mechanism and
  patient self esteem, restore functioning, prevent
  further decline.

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The BATHE technique

• Background what is going on in your life?
• Affect/feeling how are you feeling about that?
• Trouble what troubles you the most?
• Handling how are you handling that?
• Empathy that must be very difficult

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Sharing the story..

• We are constantly telling ourselves and other
  stories about ourselves
• These stories create our reality and affect our
  experience
• These stories determine what we are capable of
  doing

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Therapy means..

• 1. Hearing the story
• 2. Reflecting the story back with empathy
• 3. Limits must be challenged
• Introduce the word YET it infers possibility of
  change in the future for we are not totally
  imprisoned by the past

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Reframing..

• Focus on strengths
• Aim for small wins
• Encourage to own responsibility for behavioural
  change

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Remember

• The past is gone
• The future is not yet here
• We can only act/feel in the here and now

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Ralph Waldo Emerson

• Finish everyday and be done with it. You have
  done what you could, some blunders and
  absurdities no doubt crept in forget them as
  soon as you can. Tomorrow is a new day. You shall
  begin it serenely and with too high a spirit to
  be encumbered with your old nonsense

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Beware the steroptypes
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The medical consultation

• Is there a difference if managed by a nurse or
  doctor?
• If there is is it personal, ideological or
  instinctive?
• Cohn defines the consultation as the sword and
  bow ie a tool to reach a correct diagnosis and
  plan the right care
• Balint the drug is the doctor..

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The nursing consultation

• Is the bedrock of developing rapport with the
  patient and sharing their experience of their
  illness or symptoms- presencing
• Can be the means to the end, but also the
  fundamental process in aiding recovery in itself
• Differences may be imagined or are some a
  reality?

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Thank you! Any questions??