The consultation

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					      The consultation

The art of accompanying the patient
          Ghislaine Young
           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
• “It is more important to know what sort of
  person has a disease then to know what sort
  of disease a patent has”
Alan Alda
   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. It’s almost
  always the other person who causes you to
  say what you say next. You don’t have to
  figure out how you’ll say it.”
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…”
          Real Listening is..
• “ a willingness to let the other person
  change you. When I’m willing to let them
  change me, something happens between us
  that is more interesting than a pair of
  duelling monologues. “
    Don’t just do something, sit
• 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
• Nursing is… about being with the patient-
  Stephen Wright
            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
           The examination
• If you don’t look you don’t see!
• Seek your patient’s permission and explain
  the process
• Be comprehensive and use it to build your
  hypothesis (don’t skimp!)
• Notice, notice, notice! The clues are there!
            The hypothesis
• Is developed to understand the patient’s
  experience and concerns, fears ,
• To reach a diagnosis
• To facilitate a treatment pathway and or
  care plan
              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!
          Ay, there’s 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
            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
 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-
• The patient condition is dynamic so re-
  evaluate as necessary and don’t over rely on
  colleagues’ findings or judgements!
        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.
         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”.
    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”
    Communicating back to the
• Share your findings and thoughts
• Explain rationale
• Involve the patient at every step
• Be empathic and deal with sensitive issues
• Be alert to cultural or ethnic issues
• Provide support
     Explanation and planning
• The Calgary- Cambridge Model
• “ chunks and checks” give information in
  manageable chunks, check for
  understanding, uses patient’s response as a
  guide to how to proceed
• Tell the patient what you going to say, say
  it, then repeat what you have said….
    Aiding Accurate Recall and
• 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 patient’s own
  frame of reference and context
     Shared Understanding and
         Decision Making
• Encourage patient to contribute own ideas and
  thoughts (Nothing about Me without Me- Don
• 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
 The 15 minute hour- Stuart and
• “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.
       The BATHE technique
• Background: “what is going on in your
• Affect/feeling: “how are you feeling about
• Trouble: “what troubles you the most?”
• Handling: “how are you handling that?”
• Empathy: “that must be very difficult”
           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
              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
• Focus on strengths
• Aim for small wins
• Encourage to own responsibility for
  behavioural change
• The past is gone
• The future is not yet here
• We can only act/feel in the here and now
       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”
Beware the steroptypes
     The medical consultation
• Is there a difference if managed by a nurse
  or doctor?
• If there is is it personal, ideological or
• 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..
      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
• Differences may be imagined or are some a
Thank you! Any questions??

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