The structure of the consultation




Silverman et al¹ provide a detailed description of the structure of a medical consultation which incorporates the approaches outlined above,
and the skills required at each stage.







Initiating the session






• Establishing the initial rapport


• Identifying the reasons for the consultation






Gathering information






• Exploration of the problems


• Understanding the patient's perspective


• Providing structure to the consultation






Building the relationship






• Developing rapport


• Involving the patient






Explanation and planning






• Providing the correct amount and type of information


• Aiding accurate recall and understanding


• Achieving a shared understanding: incorporating the patient's perspective


• Planning: shared decision making


• Options in explanation and planning
  
  
  
  • If discussing opinion and significance of problems
  
  
  • If negotiating mutual plan of action
  
  
  • If discussing investigations and procedures
  
  
  
  






Closing the session

Reflective activity 4 - cultural differences




What cultural differences have you identified or experienced with both patients and doctors in terms of:





• Health beliefs?


• Concepts of the doctor's role?


• Concepts of the patient's role?


• Expectations of the consultation?


• Expressions of distress?


• Concordance?






Examples might include:




• Health beliefs: different beliefs about the causation of illness; self-treatments; urgency and when to seek medical attention;
  different delivery systems for medications; recovery paths
  


• Concepts of the doctor's role: authoritarian or partnership approach; disease or whole person focused; team member or head
  of a hierarchy
  


• Concepts of the patient's role: passive, active participant, or consumer


• Expectations of the consultation: admission to hospital; a prescription; unlimited or constrained time


• Expressions of distress: stoic or demonstrative; physical presentations of emotional distress


• Compliance: doctor's "orders" must be followed, or doctors provide advice which the patient may choose to follow or not.

Communication and outcomes for doctors

Effective communication also has many positive outcomes for doctors such as more accurate and efficient consultations^{1 2}; increased doctor satisfaction, and decreased frustration.^{1 2}

Reflective activity 3 - patient's concerns

Reflective activity 2 - the environment

Identify some of the differences in the consulting environment between a private consulting room and an emergency room cubicle.
How might these impact on communication?

Symptom relief and physiological outcomes




A number of different studies have demonstrated an association between doctor patient communication and physiological measures
such as:






• Resolution of chronic headache²
  


• Post-surgical recovery and decreased length of hospitalisation^{1 3}
  


• Post-myocardial analgesia²
  


• Blood pressure and blood sugar measurements^{1-3 9}
  


• Improved symptoms and function of patients with rheumatoid arthritis and peptic ulcer disease^{1 9}
  


• Perceived health status and daily functioning³
  


• Duration of sore throat,¹ and even
  


• The possibility of improved survival rates from breast cancer.¹