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}}{\lfolevel \listoverrideformat{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\'01o;}{\levelnumbers;}\f2\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li5760\jclisttab\tx5760 }} {\lfolevel\listoverrideformat{\listlevel\levelnfc23\levelnfcn23\leveljc0\leveljcn0\levelfollow0\levelstartat1\levelspace0\levelindent0{\leveltext\'01\u-3929 ?;}{\levelnumbers;}\f14\chbrdr\brdrnone\brdrcf1 \chshdng0\chcfpat1\chcbpat1\fbias0 \fi-360\li6480 \jclisttab\tx6480 }}\ls1}{\listoverride\listid2111269015\listoverridecount0\ls2}{\listoverride\listid780997650\listoverridecount0\ls3}}{\info{\title MODELS OF THE CONSULTATION }{\author Peter Draper}{\operator Peter Draper} {\creatim\yr2002\mo10\dy20\hr19\min45}{\revtim\yr2003\mo10\dy24\hr10\min14}{\printim\yr2003\mo10\dy24\hr10\min8}{\version25}{\edmins242}{\nofpages11}{\nofwords3143}{\nofchars17918}{\*\company Gateway 2000}{\nofcharsws0}{\vern8247}} \paperw11880\paperh16800\margt993\margb870 \widowctrl\ftnbj\aenddoc\hyphhotz0\sprstsp\otblrul\brkfrm\noxlattoyen\expshrtn\noultrlspc\dntblnsbdb\sprstsm\truncex\nolead\nospaceforul\msmcap\lytprtmet\hyphcaps0\horzdoc\fracwidth\dghspace120\dgvspace120 \dghorigin1701\dgvorigin1984\dghshow1\dgvshow0\jexpand\viewkind1\viewscale100\pgbrdrhead\pgbrdrfoot\bdrrlswsix\nolnhtadjtbl\oldas \fet0\sectd \sbknone\linex0\endnhere\sectdefaultcl {\footer \pard\plain \s15\qc \li0\ri0\nowidctlpar \tqc\tx4320\tqr\tx8640\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs20 \chpgn }{ \par }}{\*\pnseclvl1\pnucrm\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang{\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang{\pntxta )}} {\*\pnseclvl5\pndec\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl8 \pnlcltr\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang{\pntxtb (}{\pntxta )}}\pard\plain \qc \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b\fs22 MODELS OF THE CONSULTATION \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\b\fs22 \par }\pard \qc \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\b\fs22 A summary of models that have been proposed over the last 20 years: \par \par }\pard\plain \s17\qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {There have been a number of helpful models of the consultation which hav e been produced over the last 30 years. Some are task-orientated, process or outcome-based; some are skills-based, some incorporate a temporal framework, and some are based on the doctor-patient relationship, or the patient\rquote s perspective of illness. Many incorporate more than one of the above. \par \par Models of the consultation give a framework for learning and teaching the consultation; the toolbox is a useful analogy. Models enable the clinician to think where in the consultation they are experiencing the probl em, and what they and the patient aiming towards. This is helpful in then identifying the skills that are needed to achieve the desired outcome. A particularly useful general book on Understanding the Consultation by Tim Usherwood (see the book list at th e end of this document) describes a number of the models below in more detail, and also includes psychological concepts such as projection, transference and counter-transference. \par \par }\pard\plain \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b\fs22 \par 1.\tab }{\b\fs22\ul \lquote Physical, Psychological and Social\rquote }{\b\fs22 (1972) \par \par }\pard \qj \li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {\fs22 The RCGP model encourages the doctor to extend his thinking practice beyond the purely organic approach to patients, i.e. to include the patient\rquote s \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \tab emotional, family, social and environmental circumstances. \par \par }{\b\fs22 2.\tab }{\b\fs22\ul Stott and Davis}{\b\fs22 ( 1979) \par \par }{\fs22 \tab \'93The exceptional potential in each primary care consultation\'94 suggests that \tab four areas can be systematically explored each time a patient consults. \par \par \tab (a)\tab Management of presenting problems \par \tab (b)\tab Modification of help-seeking behaviours \par \tab (c)\tab Management of continuing problems \par \tab (d)\tab Opportunistic health promotion \par \par }{\b\fs22 3.\tab }{\b\fs22\ul Byrne and Long}{\b\fs22 (1976) \par \par }{\fs22 \tab \'93Doctors talking to patients\'94. Six phases which form a logical structure to the \tab consultation: \par \par \tab Phase I\tab The doctor establishes a relationship with the patient \par \par \tab Phase II\tab The doctor either attempts to discover or actually discovers the \tab \tab \tab \tab reason for the patient\rquote s attendance \par \par \tab Phase III\tab The doctor conducts a verbal or physical examination or both \par \par \tab Phase IV\tab The doctor, or the doctor and the patient , or the patient (in that\tab \tab \tab \tab order of probability) consider the condition \par \par \tab Phase V\tab The doctor, and occasionally the patient, detail further treat- \par \tab \tab \tab ment or further investigation \par \par \tab Phase VI\tab The consultation is terminated usually by the doctor. \par \par }\pard \ql \li720\ri-360\widctlpar\nooverflow\faroman\rin-360\lin720\itap0 {\fs22 Byrne and Long\rquote s study also analysed the range of verbal behaviours doctors used when talking to their patients. They described a spectrum ranging from \tab a heavily doctor-dominated consultation, with any contribution from the patient as good as excluded, to a virtual monologue by the p atient untrammelled by any input from the doctor. Between these extremes, they described a graduation of styles from closed information-gathering to non-directive counselling, depending on whether the doctor was more interested in developing his own line of thought or the patient\rquote s. \par }\pard \ql \li0\ri-360\widctlpar\nooverflow\faroman\rin-360\lin0\itap0 {\fs22 \par \par \par }{\b\fs22 4.}{\fs22 \tab }{\b\fs22\ul Six Category Intervention Analysis}{\b\fs22 (1975)}{\fs22 \par \par \tab In the mid-1970\rquote s the humanist Psychologist John Heron developed a simple but \tab comprehensive model of the array of interventions a doctor (counsellor or \tab \par }\pard \ql \li720\ri-360\widctlpar\nooverflow\faroman\rin-360\lin720\itap0 {\fs22 therapist) could use with the patient (client). Within an overall setting of concern \tab for the patient\rquote s best interests, the doctor\rquote s interventions fall into one of six \par }\pard \ql \li0\ri-360\widctlpar\nooverflow\faroman\rin-360\lin0\itap0 {\fs22 \tab categories: \par \par \tab (1)\tab }{\b\fs22 Prescriptive}{\fs22 \tab - giving advice or instructions, being critical or directive \par \par \tab (2)\tab }{\b\fs22 Informative\tab }{\fs22 -}{\b\fs22 }{\fs22 imparting new knowledge, instructing or interpreting \par \par \tab (3)\tab }{\b\fs22 Confronting \tab }{\fs22 -}{\b\fs22 }{\fs22 challenging a restrictive attitude or behaviour, giving \par \tab \tab \tab \tab direct feedback within a caring context \par \par \tab (4)\tab }{\b\fs22 Cathartic \tab }{\fs22 - seeking to release emotion in the form of weeping, \par \tab \tab \tab \tab laughter, trembling or anger \par \par \tab (5)\tab }{\b\fs22 Catalytic}{\fs22 \tab - encouraging the patient to discover and explore his own \tab \tab \tab \tab latent thoughts and feelings \par \par \tab (6)\tab }{\b\fs22 Supportive\tab }{\fs22 - offering comfort and approval, affirming the patient\rquote s \par \tab \tab \tab \tab intrinsic value. \par \par \tab Each category has a clear function within the total consultation. \par \par \par }{\b\fs22 5.}{\fs22 \tab }{\b\fs22\ul Helman\rquote s \lquote Folk Model\rquote }{\b\fs22 (1981) \par \par \tab }{\fs22 Cecil Helman is a Medical Anthropologist, with constantly enlightening insights \par \tab into the cultural factors in health and illness. He suggests that a patient with a \par \tab problem comes to a doctor seeing answers to six questions: \par \par \tab (1)\tab What has happened? \par \tab (2)\tab Why has it happened? \par \tab (3)\tab Why to me? \par \tab (4)\tab Why now? \par \tab (5)\tab What would happen if nothing was done about it? \par \tab (6)\tab What should I do about it or whom should I consult for further help? \par \par }{\b\fs22 6.\tab }{\b\fs22\ul Transactional Analysis }{\b\fs22 (1964) \par \par }{\fs22 \tab Many doctors will be familiar with Eric Berne\rquote s model of the human psyche as \par \tab consisting of three \lquote ego-states\rquote - Parent, Adult and Child. At any given moment \par \tab each of us is in a state of mind when we think, feel, behave, react and have \par \tab attitudes as if we were either a critical or caring Parent, a logical Adult, or a \par \tab spontaneous or dependent Child. Many general practice consultations are \par \tab conducted between a Parental doctor and a Child-like patient. This transaction \par \tab is not always in the best interests of either party, and a familiarity with TA \par \tab introduces a welcome flexibility into the doctor\rquote s repertoire which can break \par \tab out of the repetitious cycles of behaviour (\lquote games\rquote ) into which some \par \tab consultations can degenerate. \par }{\b\fs22 \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\b\fs22 7.\tab }{\b\fs22\ul Pendleton, Schofield, Tate and Havelock }{\b\fs22 (1984, 2003) \par \par \tab }{\fs22 \lquote The Consultation - An Approach to Learning and Teaching\rquote describe seven \tab tasks which taken together form comprehensive and coherent aims for any \par \tab consultation. \par \par \tab }{\b\fs22 (1)\tab To define the reason for the patient\rquote s attendance, including: \par }{\fs22 \par \tab \tab i)\tab the nature and history of the problems \par \tab \tab ii)\tab their aetiology \par \tab \tab iii)\tab the patient\rquote s ideas, concerns and expectations \par \tab \tab iv)\tab the effects of the problems \par \par \tab }{\b\fs22 (2)\tab To consider other problems: \par }{\fs22 \par \tab \tab i)\tab continuing problems \par \tab \tab ii)\tab at-risk factors \par \tab \par \tab }{\b\fs22 (3)\tab With the patient, to choose an appropriate action for each \tab \tab \tab \tab problem \par }{\fs22 \par \tab }{\b\fs22 (4)\tab To achieve a shared understanding of the problems with the \tab \tab \tab \tab patient \par }{\fs22 \par \tab }{\b\fs22 (5)\tab To involve the patient in the management and encourage him to \tab \tab \tab accept appropriate responsibility \par }{\fs22 \par \tab (}{\b\fs22 6)\tab To use time and resources appropriately:}{\fs22 \par \par \tab \tab i)\tab in the consultation \par \tab \tab ii)\tab in the long term \par \par \tab }{\b\fs22 (7)}{\fs22 \tab }{\b\fs22 To establish or maintain a relationship with the patient which \tab \tab \tab helps to achieve the other tasks. \par \par \par }{\fs22 The authors\rquote 2}{\fs22\super nd}{\fs22 edition, \'93The new consultation\'94 includes recent relevant research material and a wealth of experience accumulated by the authors since their first publication. The first part of the book covers the consultation; the \'93central act of medicine\'94 , and puts both the perspectives of the doctor and the patient, and the outcomes that both are looking for at the heart of the process of the medical interview. The second half of the book is concerned with learning and teaching effective consulting. \par \par }{\b\fs22 \page 8.}{\fs22 \tab }{\b\fs22\ul Neighbour}{\b\fs22 (1987)}{\fs22 \par \par \tab \par Five check points: \lquote where shall we make for next and how shall we get there?\rquote \par \par \tab (1)\tab }{\b\fs22 Connecting}{\fs22 \tab -\tab establishing rapport with the patient \par \par \tab (2)\tab }{\b\fs22 Summarising}{\fs22 -\tab getting to the point of why the patient has come \par \tab \tab \tab \tab \tab using eliciting skills to discover their ideas, \tab \tab \tab \tab \tab \tab concerns, expectations and summarising back to \par \tab \tab \tab \tab \tab the patient. \par \par \tab (3)\tab }{\b\fs22 Handing over -\tab }{\fs22 doctors\rquote and patients\rquote agendas are agreed. \par \tab \tab \tab \tab \tab Negotiating, influencing and gift wrapping. \par \par \tab (4)\tab }{\b\fs22 Safety net}{\fs22 \tab -\tab \'93What if?\rquote : consider what the doctor might do in \par \tab \tab \tab \tab \tab each case. \par \par \tab (5)\tab }{\b\fs22 Housekeeping -}{\fs22 \tab \lquote Am I in good enough shape for the next \tab \tab \tab \tab \tab \tab patient?\rquote \par \par \par \par \par }\pard \qc \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\b\fs22 9.\tab }{\b\fs22\ul The Disease - Illness Model }{\b\fs22 (1984) \par \par }\pard \ql \li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {\fs22 McWhinney and his colleagues at the University of Western Ontario have proposed a \'93transformed clinical method\'94. Their approach has also been called \'93 patient-centred clinical interviewing\'94 to differentiate it from the more traditional \'93doctor-centred\'94 method that attempts to interpret the patient\rquote s illness only from the doctor\rquote s perspective of disease and pathology.}{\b\fs22 \par \par }{\fs22 The disease-illness model below attempts to provide a practical way of using these ideas in our everyday clinical practice. The doctor has the unique responsibility to elicit two sets of \'93content\'94 of the patient\rquote s story: the traditional biomedical history, and the patient\rquote s experience of their illness. \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \par }\pard \qj \li0\ri-180\widctlpar\nooverflow\faroman\rin-180\lin0\itap0 {\b\fs22 \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \par \page }{\f0 \par }\pard \qc \fi-360\li360\ri-180\widctlpar\brdrt\brdrsh\brdrdb\brdrw15\brsp20 \brdrl\brdrsh\brdrdb\brdrw15\brsp20 \brdrb\brdrsh\brdrdb\brdrw15\brsp620 \brdrr\brdrsh\brdrdb\brdrw15\brsp20 \tx763\tx1483\tx2203\tx2923\tx3643\tx4363\tx5083\tx5803\tx6523\tx7243\tx7963\tx8683\tx9403\tx10123\tx10843\tx11563\tx12283\nooverflow\faroman\rin-180\lin360\itap0 {\f0 }{\b\f0\fs20 Patient presents problem \par \par Gathering information \par \par Parallel search of two frameworks \par \par }\pard \ql 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hspNext}{\sv 1027}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn fLayoutInCell}{\sv 1}}{\sp{\sn fLayoutInCell}{\sv 1}}{\shptxt \pard\plain \ql \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\f0\fs20\highlight7 Weaving back \par and forth between the two frameworks}{\f0\fs20 \par }}}{\shprslt{\*\do\dobxcolumn\dobypara\dodhgt8192\dptxbx\dptxlrtb{\dptxbxtext\pard\plain \ql \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\f0\fs20\highlight7 Weaving back \par and forth between the two frameworks}{\f0\fs20 \par }}\dpx3381\dpy180\dpxsize2280\dpysize1080\dpfillfgcr255\dpfillfgcg255\dpfillfgcb255\dpfillbgcr255\dpfillbgcg255\dpfillbgcb255\dpfillpat1\dplinehollow}}}}{\b\f0\fs20 \tab }{\b\f0\fs20\ul Disease framework}{\b\f0\fs20 \tab \tab \tab \tab \tab \tab }{ \b\f0\fs20\ul Illness framework}{\b\f0\fs20 \tab \tab \tab \tab \tab \tab \par \tab The biomedical perspective\tab \tab \tab \tab \tab The patient\rquote s perspective\tab \tab \tab \tab \tab \tab \par \par \par \par }{\b\fs20 \tab }{\b\fs20\ul Symptoms}{\b\fs20 \tab \tab \tab \tab \tab \tab \tab Ideas\tab \par \tab Signs\tab \tab \tab \tab \tab \tab \tab Concerns \par }\pard\plain \s19\ql \fi-360\li360\ri-180\widctlpar\brdrt\brdrsh\brdrdb\brdrw15\brsp20 \brdrl\brdrsh\brdrdb\brdrw15\brsp20 \brdrb\brdrsh\brdrdb\brdrw15\brsp620 \brdrr\brdrsh\brdrdb\brdrw15\brsp20 \tx284\tx1483\tx2203\tx2923\tx3643\tx4363\tx5083\tx5803\tx6523\tx7243\tx7963\tx8683\tx9403\tx10123\tx10843\tx11563\tx12283\nooverflow\faroman\rin-180\lin360\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b\fs20 \tab Investigations \tab \tab \tab \tab \tab \tab Expectations\tab \tab \tab \tab \tab \tab Feelings and thoughts \par }\pard\plain \ql \fi-360\li360\ri-180\widctlpar\brdrt\brdrsh\brdrdb\brdrw15\brsp20 \brdrl\brdrsh\brdrdb\brdrw15\brsp20 \brdrb\brdrsh\brdrdb\brdrw15\brsp620 \brdrr\brdrsh\brdrdb\brdrw15\brsp20 \tx763\tx1483\tx2203\tx2923\tx3643\tx4363\tx5083\tx5803\tx6523\tx7243\tx7963\tx8683\tx9403\tx10123\tx10843\tx11563\tx12283\nooverflow\faroman\rin-180\lin360\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b\fs20 \tab Underlying pathology\tab \tab \tab \tab \tab Feelings and thoughts\tab \par }\pard\plain \s3\ql \fi-360\li360\ri-180\keepn\widctlpar\brdrt\brdrsh\brdrdb\brdrw15\brsp20 \brdrl\brdrsh\brdrdb\brdrw15\brsp20 \brdrb\brdrsh\brdrdb\brdrw15\brsp620 \brdrr\brdrsh\brdrdb\brdrw15\brsp20 \tx763\tx1483\tx2203\tx2923\tx3643\tx4363\tx5083\tx5803\tx6523\tx7243\tx7963\tx8683\tx9403\tx10123\tx10843\tx11563\tx12283\nooverflow\faroman\outlinelevel2\rin-180\lin360\itap0 \b\f4\fs20\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\tab \tab \tab \tab \tab \tab \tab \tab \tab Effects on life \par \tab \par \par \tab Differential diagnosis\tab \tab \tab \tab \tab \tab Understanding the patient\rquote s \par \tab \tab \tab \tab \tab \tab \tab \tab \tab Unique experience of the \par \tab \tab \tab \tab \tab \tab \tab \tab \tab illness \par \par \tab \tab \tab \tab \tab Integration of the two frameworks \par \tab \tab \tab \tab \tab \par \tab \tab \tab \tab \tab Explanation and planning \par \tab \tab \tab \tab \tab Shared understanding and decision-making \par \par \tab }{\b0\i After Levenstien et al in Stewart and Roter (1989) and }{\b0\i\f0 Stewart et al }{\b0\i\f0 (}{\b0\i\f0 1995 & 2003}{\b0\i\f0 )}{\b0\i \tab \tab \tab \tab \par }\pard\plain \ql \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 { \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \par \par }\pard\plain \s17\qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\f0\fs20 Levenstein JH, Belle Brown J Weston WW et al (1989) Patient-centred clinical interviewing. In }{\i\f0\fs20 Communicating with medical patients}{\f0\fs20 (eds M Stewart and D Roter) Sage Publications, Newbury Park, CA. \par Stewart M. (2001) Towards a global definition of patient centred care. BMJ. 322(7284):444-5, \par Stewart M et al (2003) Patient-centred medicine: transforming the clinical method. Radcliffe Medical Press Abingdon Oxford \par }\pard\plain \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 \par }{\b\fs22 \page \par 10.\tab }{\b\fs22\ul The Three Function Approach to the Medical Interview}{\b\fs22 (1989) \par \par \tab }{\fs22 Cohen-Cole and Bird have developed a model of the consultation that has \tab been adopted by The American Academy on Physician and Patient as their \tab model for teaching the Medical Interview. \par \par \tab }{\b\fs22 (1)\tab Gathering data to understand the patient\rquote s problems \par \par \tab (2)\tab Developing rapport and responding to patient\rquote s emotion \par \par \tab (3)\tab Patient education and motivation \par }{\fs22 \par \par \tab }{\b\fs22 Functions\tab \tab \tab \tab Skills}{\fs22 \par \par \tab 1.\tab Gathering data\tab \tab a)\tab Open-ended questions \par \tab \tab \tab \tab \tab \tab b)\tab Open to closed cone \par \tab \tab \tab \tab \tab \tab c)\tab Facilitation \par \tab \tab \tab \tab \tab \tab d)\tab Checking \par \tab \tab \tab \tab \tab \tab e)\tab Survey of problems \par \tab \tab \tab \tab \tab \tab f)\tab Negotiate priorities \par \tab \tab \tab \tab \tab \tab g)\tab Clarification and direction \par \tab \tab \tab \tab \tab \tab h)\tab Summarising \par \tab \tab \tab \tab \tab \tab i)\tab Elicit patient\rquote s expectations \par \tab \tab \tab \tab \tab \tab j)\tab Elicit patient\rquote s ideas about \par \tab \tab \tab \tab \tab \tab \tab aetiology \par \tab \tab \tab \tab \tab \tab k)\tab Elicit impact of illness on \tab \tab \tab \tab \tab \tab \tab \tab patient\rquote s quality of life \par \tab \tab \tab \tab \tab \tab \par \par \tab 2\tab Developing rapport\tab \tab a)\tab Reflection \par \tab \tab \tab \tab \tab \tab b)\tab Legitimation \par \tab \tab \tab \tab \tab \tab c)\tab Support \par \tab \tab \tab \tab \tab \tab d)\tab Partnership \par \tab \tab \tab \tab \tab \tab e)\tab Respect \par \par \tab 3\tab Education and motivation}{\b\fs22 \tab }{\fs22 a)\tab Education about illness \par \tab \tab \tab \tab \tab \tab b)\tab Negotiation and maintenance of a \tab \tab \tab \tab \tab \tab \tab treatment plan \par }\pard \ql \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \tab \tab \tab \tab \tab \tab c)\tab Motivation of non-adherent \tab \tab \tab \tab \tab \tab \tab \tab patients \par \par \par In 2000 the authors published a second edition, where they altered the order of the three functions of effective interviewing, putting \'93Building the relationship\'94 in front of \'93Assessing the patient\rquote s problems\'94, and \'93 Managing the patient\rquote s problems\'94. \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\b\fs22 \par }{\fs22 The authors have included three excellent chapters on : \par {\listtext\pard\plain\f14\fs22\lang2057\langfe1033\langnp2057 \loch\af14\dbch\af0\hich\f14 \'a7\tab}}\pard \qj \fi-360\li720\ri0\widctlpar\jclisttab\tx720\nooverflow\faroman\ls3\rin0\lin720\itap0 {\fs22 Understanding the patient\rquote s emotional response \par {\listtext\pard\plain\s2 \f14\fs22\lang2057\langfe1033\langnp2057 \loch\af14\dbch\af0\hich\f14 \'a7\tab}}\pard\plain \s2\qj \fi-360\li720\ri0\keepn\widctlpar\jclisttab\tx720\nooverflow\faroman\ls3\outlinelevel1\rin0\lin720\itap0 \b\f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b0 Managing communication challenges \par {\listtext\pard\plain\f14\fs22\lang2057\langfe1033\langnp2057 \loch\af14\dbch\af0\hich\f14 \'a7\tab}}\pard\plain \qj \fi-360\li720\ri0\widctlpar\jclisttab\tx720\nooverflow\faroman\ls3\rin0\lin720\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 Higher order skills \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 The section on overcoming cultural and language barriers and troubling personality styles and somatisation are particularly helpful. \par }{\b\fs22 \page 11.\tab }{\b\fs22\ul The Calgary-Cambridge Approach to Communication Skills Teaching}{\fs22\ul }{\fs22 \par \tab \tab \tab \tab \tab \tab \tab \tab \tab \tab }{\b\fs22 (1996)}{\fs22 \par \par }\pard\plain \s16\qj \fi-709\li709\ri0\widctlpar\nooverflow\faroman\rin0\lin709\itap0 \i\f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\i0\fs22 \tab Suzanne Kurtz & Jonathan Silverman have developed a model of the \tab consultation, encapsulated within a practical teaching tool, the Calgary \tab Cambridge Observation Guides. The guide is continuing to evolve and now includes Structuring the consultation. The Guides define the content of a communication skills curriculum by delineating and structuring the skills that have been shown by research and theory to aid doctor-patient communication. The guides also make accessible a concise and accessible summary for facilitators and learners alike which can be used as an aide-\tab memoire during teaching sessions \par }\pard\plain \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 \par \tab The following is the structure of the consultation proposed by the guides: \par \par \tab }{\b\fs22 (1)\tab Initiating the Session \par \tab \tab }{\fs22 a) \tab preparation \par }{\b\fs22 \tab \tab }{\fs22 b) \tab establishing initial rapport \par \tab \tab c)\tab identifying the reason(s) for the consultation \par \par \tab }{\b\fs22 (2)\tab Gathering Information}{\fs22 \par \par \tab \tab exploration of of the patient\rquote s problems to discover the: \par \tab \tab a) \tab biomedical perspective \par \tab \tab b)\tab the patient\rquote s perspective \par }\pard \qj \fi720\li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {\fs22 c) \tab background information - context \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \tab \par \tab }{\b\fs22 (3)\tab Building the Relationship \par }{\fs22 \par \tab \tab a) \tab using appropriate non-verbal behaviour \par \tab \tab b)\tab developing rapport \par \tab \tab c)\tab involving the patient \par \par \tab }{\b\fs22 (4)}{\fs22 \tab }{\b\fs22 Providing structure \par }{\fs22 \par \tab \tab a) making organisation overt \par \tab \tab b) attending to flow \par \tab \tab \par \tab }{\b\fs22 (5)\tab Explanation and Planning \par }{\fs22 \par \tab \tab a)\tab providing the correct amount and type of information \par \tab \tab b)\tab aiding accurate recall and understanding \par \tab \tab c)\tab achieving a shared understanding: incorporating the patient\rquote s \tab \tab \tab \tab perspective \par \tab \tab d)\tab planning: shared decision making \par \par \tab }{\b\fs22 (6)\tab Closing the Session \par \par }{\fs22 \tab \tab a) ensuring appropriate point of closure \par \tab \tab b) forward planning \par \par \par }{\b\fs22 12. \tab Comprehensive Clinical Method/Calgary-Cambridge Guide Mark 2. (2002) \par }\pard\plain \s17\qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 { This method combines the traditional method of taking a clinical history including the functional enquiry, past medical his tory, social and family history, together with the drug history, with the Calgary-Cambridge Guide. It places the Disease-Illness model at the centre of gathering information. It combines process with content in a logical schema; it is comprehensive and a pplicable to all medical interviews with patients, whatever the context. \par Below is an example of the skills required to elicit the disease, the illness and the background content when gathering information. \par \par \par \par \par \par \par }\pard\plain \s18\qc \li0\ri0\widctlpar\brdrt\brdrs\brdrw15\brsp20 \brdrl\brdrs\brdrw15\brsp20 \brdrb\brdrs\brdrw15\brsp20 \brdrr\brdrs\brdrw15\brsp20 \aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \shading1000 \b\caps\f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\caps0\fs20 Gathering Information}{\i\caps0\fs20 \par }\pard\plain \qc \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\i\fs20\ul \par }\pard \ql \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\i\fs20\ul \par }\pard \qc \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\i\fs20\ul \par }\pard\plain \s17\qj \fi720\li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 \f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\i\fs20\ul\chshdng1000\chcfpat0\chcbpat0 process skills for exploration of the patient\rquote s problems }{ \i\fs20\ul \par }\pard\plain \s16\qj \fi-709\li709\ri0\widctlpar\tx10440\nooverflow\faroman\rin0\lin709\itap0 \i\f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b\i0\fs20 (the bio-medical perspective and the patient\rquote s perspective) \par }\pard\plain \ql \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\i\fs20 \par {\pntext\pard\plain\f3\fs20\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \li2880\ri15\nowidctlpar \tx1440\tx2160\tqc\tx4460\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf3\pnstart1\pnindent283\pnhang{\pntxtb \'b7}} \nooverflow\faroman\ls1\rin15\lin2880\itap0 {\fs20 patient\rquote s narrative \par {\pntext\pard\plain\f3\fs20\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \li2880\ri15\nowidctlpar \tx1440\tx2160\tqc\tx4460\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf3\pnstart1\pnindent283\pnhang{\pntxtb \'b7}} \nooverflow\faroman\ls1\rin15\lin2880\itap0 {\fs20 question style: open to closed cone \par {\pntext\pard\plain\f3\fs20\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \li2880\ri15\nowidctlpar \tx1440\tx2160\tqc\tx4460\tqr\tx8440\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\tx18882{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf3\pnstart1\pnindent283\pnhang{\pntxtb \'b7}} \nooverflow\faroman\ls1\rin15\lin2880\itap0 {\fs20 attentive listening \par {\pntext\pard\plain\f3\fs20\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \li2880\ri15\nowidctlpar \tx1440\tx2160\tqc\tx4460\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf3\pnstart1\pnindent283\pnhang{\pntxtb \'b7}} \nooverflow\faroman\ls1\rin15\lin2880\itap0 {\fs20 facilitative response \par {\pntext\pard\plain\f3\fs20\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \li2880\ri15\nowidctlpar \tx1440\tx2160\tqc\tx4460\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf3\pnstart1\pnindent283\pnhang{\pntxtb \'b7}} \nooverflow\faroman\ls1\rin15\lin2880\itap0 {\fs20 picking up cues \par {\pntext\pard\plain\f3\fs20\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \li2880\ri15\nowidctlpar \tx1440\tx2160\tqc\tx4460\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf3\pnstart1\pnindent283\pnhang{\pntxtb \'b7}} \nooverflow\faroman\ls1\rin15\lin2880\itap0 {\fs20 clarification \par {\pntext\pard\plain\f3\fs20\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \li2880\ri15\nowidctlpar \tx1440\tx2160\tqc\tx4460\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf3\pnstart1\pnindent283\pnhang{\pntxtb \'b7}} \nooverflow\faroman\ls1\rin15\lin2880\itap0 {\fs20 time-framing \par {\pntext\pard\plain\f3\fs20\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \li2880\ri15\nowidctlpar \tx1440\tx2160\tqc\tx4460\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf3\pnstart1\pnindent283\pnhang{\pntxtb \'b7}} \nooverflow\faroman\ls1\rin15\lin2880\itap0 {\fs20 internal summary \par {\pntext\pard\plain\f3\fs20\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \li2880\ri15\nowidctlpar \tx1440\tx2160\tqc\tx4460\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf3\pnstart1\pnindent283\pnhang{\pntxtb \'b7}} \nooverflow\faroman\ls1\rin15\lin2880\itap0 {\fs20 appropriate use of language \par {\pntext\pard\plain\f3\fs20\lang2057\langfe1033\langnp2057 \loch\af3\dbch\af0\hich\f3 \'b7\tab}}\pard \ql \li2880\ri15\nowidctlpar \tx1440\tx2160\tqc\tx4460\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162{\*\pn \pnlvlblt\ilvl0\ls1\pnrnot0\pnf3\pnstart1\pnindent283\pnhang{\pntxtb \'b7}} \nooverflow\faroman\ls1\rin15\lin2880\itap0 {\fs20 additional skills for understanding patient\rquote s perspective \par }\pard\plain \s17\qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\i\fs20 \par }\pard\plain \ql \li0\ri-787\widctlpar\nooverflow\faroman\rin-787\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs20 \par }\pard\plain \s16\qj \fi-709\li709\ri0\widctlpar\nooverflow\faroman\rin0\lin709\itap0 \i\f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b\i0\fs20 \tab }{\b\i0\fs20\chshdng1000\chcfpat0\chcbpat0 \tab \tab }{ \b\i0\fs20\ul\chshdng1000\chcfpat0\chcbpat0 content to be discovered:}{\b\i0\fs20\ul \par }\pard\plain \ql \li0\ri-787\widctlpar\nooverflow\faroman\rin-787\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\i\fs20 \par }\pard \ql \li-630\ri-787\widctlpar\nooverflow\faroman\rin-787\lin-630\itap0 {\i\fs20 \par }\pard\plain \s16\qj \fi-709\li709\ri0\widctlpar\nooverflow\faroman\rin0\lin709\itap0 \i\f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b\fs20 the bio-medical perspective \tab \tab \tab the patient\rquote s perspective \par }{\b\i0\fs20 }{\b\fs20 (disease) \tab \tab (illness) \par }\pard\plain \ql \li0\ri-787\nowidctlpar\tx1440\tqc\tx4460\tx6660\tqr\tx7880\tx8802\tx9810\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin-787\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b\fs20 \par }\pard \ql \li0\ri-787\nowidctlpar\tx1440\tqc\tx4460\tx6096\tqr\tx7880\tx8802\tx9810\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin-787\lin0\itap0 {\fs20 sequence of events \tab \tab ideas and concerns \par }\pard \ql \li0\ri-787\nowidctlpar\tx1440\tqc\tx4460\tx5954\tqr\tx7880\tx8082\tx8802\tx9810\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin-787\lin0\itap0 {\fs20 symptom analysis\tab \tab \tab expectations \par }\pard \ql \li0\ri-787\nowidctlpar\tx1440\tqc\tx4460\tx6096\tqr\tx7880\tx8082\tx8802\tx9810\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin-787\lin0\itap0 {\fs20 relevant functional enquiry\tab \tab effects \par \tab \tab \tab feelings and thoughts \par }\pard \qc \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs20 \tab \tab \par }\pard \ql \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs20 \par }\pard \qc \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\i\fs20 \par }\pard\plain \s17\qj \fi720\li2160\ri0\widctlpar\nooverflow\faroman\rin0\lin2160\itap0 \f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs20\ul essential background information \par }\pard\plain \qc \li0\ri15\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin15\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\b\fs20 \par }{\fs20 past medical history \par drug and allergy history \par social history \par family history \par functional enquiry \par \par \par \par \par }\pard \qj \li0\ri15\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin15\lin0\itap0 {\b\fs22 13. BARD 2002 Ed Warren (2002) \par }\pard\plain \s16\qj \li0\ri15\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin15\lin0\itap0 \i\f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\i0\fs22 The BARD model attempts to consider the totality of the relationship between a GP and a patient and the roles that are being enacted. The personality of the doctor will have considerable influence on the doctor-patient encounter, as will the doctor \rquote s previous experience of the patient. The model attempts to include how the doctor\rquote s personality can be used to best effect, and looks specifically at the doctor and patient roles in the medical encounter. It aims to \'93 encompass everything that happens during a consultation\'94 and encourage reflection. It is important that GPs play to their strengths, and use their role and personality and behaviour positively for the benefit of the patient. \par }\pard\plain \qj \li0\ri15\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin15\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 \par The four proposed avenues for analysis are: \par }{\b\fs22 B}{\fs22 ehaviour \par }{\b\fs22 A}{\fs22 ims \par }{\b\fs22 R}{\fs22 oom \par }{\b\fs22 D}{\fs22 ialogue \par \par \par }\pard\plain \s1\qj \li0\ri15\keepn\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\outlinelevel0\rin15\lin0\itap0 \b\f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Behaviour \par }\pard\plain \qj \li0\ri15\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin15\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 A doctor has many alternatives in how they present to a patient, and these choices will reflect the needs of the patient and the personality of the GP. It includes non-verbal and verbal skills as well as confidence, \'93lightness of touch\'94, and beh aviours which feel \'93just right\'94. The key is for the doctor to choose the most appropriate behaviour with each patient in front of them \par \par }\pard\plain \s1\qj \li0\ri15\keepn\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\outlinelevel0\rin15\lin0\itap0 \b\f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Aims \par }\pard\plain \s16\qj \li0\ri15\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin15\lin0\itap0 \i\f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\i0\fs22 It is important for the aims of a consultation to be clear in order to help the doctor and the patient to head in the right direction. However not all the aims will necessarily need to be achieved in one consultation, and priorities have to be clarified. \par }\pard\plain \qj \li0\ri15\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin15\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 \par }\pard\plain \s1\qj \li0\ri15\keepn\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\outlinelevel0\rin15\lin0\itap0 \b\f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Room \par }\pard\plain \qj \li0\ri15\nowidctlpar\tx1440\tqc\tx4460\tx5760\tqr\tx7880\tx8082\tx8802\tx10242\tx10800\tx10962\tx11682\tx12402\tx13122\tx13842\tx14562\tx15282\tx16002\tx16722\tx17442\tx18162\nooverflow\faroman\rin15\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 The consultation will be affected by the environment in which the doctor works, as well as for example, where the doctor sits, or whether a side room is used for the examination. \par }\pard\plain \s17\qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 { \par }{\b Dialogue \par }{How you talk to the patient is crucial. Tone of voice, what you say, language, the ability to confront or challenge needs thought. How can you be sure that both you and the patient are talking the same language? \par }\pard\plain \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 \par \par \par }{\b\fs22 14. Balint 1986 \par }{\fs22 Michael Balint and his wife Enid, who were both psychoanalysts, started to research the GP/patient relationship in the 1950s, and over many years ran case-discussion seminars with GPs to look at their difficulties with patients. The groups\rquote experiences formed the basis for a very important contribution to the general practice literature; }{\i\fs22 The doctor, the patient and the illness}{\fs22 . In exploring the doctor-patient relationship in depth, Balint helped genera tions of doctors to understand the importance of transference and counter-transference, and how the doctor himself is often the treatment or drug. Balint groups are still popular, and are usually run on psychodynamic lines and often one of the group leade rs is a psychotherapist. Balint\rquote s tenet was that doctors decide what is allowable for discussion from the patient\rquote s offer of problems, and that doctors impose constraints on what is acceptable to explore in the consultation, often unconsciously. This }{\i\fs22 selective neglect}{\fs22 or avoidance is often related to something in the doctors life which is threatening. For example a doctor may not wish to explore alcoholism in a patient if he or she either drinks to excess themselves, or someone close to the doctor has an al cohol problem. It the patient is also reluctant to discuss the issue then this can lead to collusion. \par \par Balint groups commonly begin with \'93has anyone a case today?\'94 A doctor then tells the story of a patient who is bothering him and the group will help the doctor to identify and explore the blocks which are constraining exploration and management of the patient\rquote s problem. \par \par }{\b\fs22 15. Narrative-based Medicine \par }{\b Launer J (2002) \par }\pard\plain \s17\qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {N arrative studies explore the way people tell stories. The modernist approach had been to be attentive to these stories and the particular approach described in this book is a specific one, developed by a team of teachers at the Tavistock Clinic in London. In primary care we have an option not only to reflect on these stories, we can respond to and even challenge them. Thus the post-modern and more radical view would be that a clinical interaction is one in which two parties bring their own individual conte xts and preferences, to create what is a unique and developing conversation. For example, in the context of the consultation between a patient and the GP, there is often no \'93ultimate truth\'94 to the answer to the question \'93 why has the patient attended\'94, or what the patient is hoping for from the doctor, because in an attempt to explore these important questions, even more important questions and ideas will emerge. \par }\pard\plain \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 \par Skil ls which help the patient to understand better what is happening to them not only include the basic skills of listening, and empathising. Question style is crucial; appropriately timed questions asked with respect and in the spirit of caring about the eve ntual outcome for the patient can }{\f0\fs22 be used with great effect in contexts where the clinician is trying to help the patient look at a problem from a different point of view, and encourage behaviour change. They might be compared with to Socratic questioning, and form the basis of narrative-based interviewing and originally come from family systems therapy.}{\b\f0\fs22 \par }{\f0\fs22 The six key concepts are: \par {\listtext\pard\plain\f14\fs22\lang2057\langfe1033\langnp2057 \loch\af14\dbch\af0\hich\f14 \'a7\tab}}\pard \qj \fi-360\li720\ri0\widctlpar\jclisttab\tx720\nooverflow\faroman\ls2\rin0\lin720\itap0 {\f0\fs22 conversations \par {\listtext\pard\plain\f14\fs22\lang2057\langfe1033\langnp2057 \loch\af14\dbch\af0\hich\f14 \'a7\tab}curiosity \par {\listtext\pard\plain\f14\fs22\lang2057\langfe1033\langnp2057 \loch\af14\dbch\af0\hich\f14 \'a7\tab}circularity \par {\listtext\pard\plain\f14\fs22\lang2057\langfe1033\langnp2057 \loch\af14\dbch\af0\hich\f14 \'a7\tab}contexts \par {\listtext\pard\plain\f14\fs22\lang2057\langfe1033\langnp2057 \loch\af14\dbch\af0\hich\f14 \'a7\tab}co-creation \par {\listtext\pard\plain\f14\fs22\lang2057\langfe1033\langnp2057 \loch\af14\dbch\af0\hich\f14 \'a7\tab}caution \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\b\f0\fs22 \par }\pard\plain \s17\qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\f0 Some examples: \par }{\'93When you get home, what do you think your husband might say when you tell him what we have been talking about?\'94 \par }\pard\plain \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 \'93Who in the family thinks you are depressed as well as your husband?\'94 \par \'93If we can\rquote t get to the bottom of your problem, what do you think you might do next?\'94 \par \par Constructing a genogram with the patient is a good example of one of the other techniques used in narrative-based medicine. \par \par }{\i\fs22 \par }\pard \qc \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \par }{\b\fs22\ul REFERENCES}{\fs22 \par \par }\pard \ql \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \par 1\tab Working Party of the Royal College of General Practitioners ( 1972) \par \par 2\tab Stott N C H & Davis R H ( 1979) \par \tab The Exceptional Potential in each Primary Care Consultation: \par \tab J R Coll. Gen. Pract. vol 29 pp 201-5 \par \par 3\tab Byrne P S & Long B E L (1976) \par \tab Doctors talking to Patients: London HMSO \par \par 4\tab Heron J (1975) \par \tab A Six Category Intervention Analysis: Human Potential Research \par \tab Project, University of Surrey \par \par 5\tab Helman C G (1981) \par \tab Disease versus Illness in General Practice \par \tab J R Coll. Gen. Pract. vol 31 pp 548-62 \par \par 6\tab Stewart Ian, Jones Vann (1991) \par \tab T A Today: A New Introduction to Transactional Analysis \par \tab Lifespace Publishing \par \par 7\tab Pendelton D, Schofield T, Tate P & Havelock P (1984) \par \tab The Consultation: An Approach to Learning and Teaching: \par \tab Oxford: OUP \par \par 8\tab Neighbour R (1987) \par \tab The Inner Consultation \par }\pard \ql \fi720\li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 MTO Press; Lancaster \par }\pard \ql \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \par }{\fs22\lang1036\langfe1033\langnp1036 9\tab Stewart M et al (1995) \par \tab }{\fs22 Patient Centred Medicine \par \tab Sage Publications \par \par 10\tab Cohen-Cole, S (1991) \par \tab The Medical Interview, The Three Function Approach \par \tab Mosby-Year Book \par \tab Cohen-Cole S, Bird J. (2000) 2}{\fs22\super nd}{\fs22 edition Mosby Inc. \par \par 11\tab Kurtz S & Silverman J (1996) \par \tab The Calgary-Cambridge Observation Guides: an aid to defining the \par \tab curriculum and organising the teaching in Communication Training \par \tab Programmes. \par \tab Med Education 30, 83-9 \par \par }\pard \qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\fs22 \tab }{\f0 Silverman J, Kurtz S and Draper J, (1998) \par }\pard \qj \fi720\li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\f0 Skills for Communicating with Patients \par Radcliffe Medical Press, (2}{\f0\super nd}{\f0 edition in preparation) \par }\pard \ql \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 {\f0\fs20 \tab }{\fs22 \par 12\tab Kurtz S, Silverman J, Benson J, Draper J. (}{2003)}{\fs22 \par }\pard\plain \s16\qj \li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 \i\f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\i0 Marrying Content and Pro cess in Clinical Method Teaching; Enhancing the Calgary-Cambridge Guides Academic Medicine\~\~ volume 78 no. 8 pp 802-809 (see also www.SkillsCascade.com) \par }\pard\plain \ql \li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 \par }\pard\plain \s17\qj \li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {13. \tab Warren E. (2002) \par }\pard\plain \qj \fi720\li0\ri0\widctlpar\nooverflow\faroman\rin0\lin0\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 An introduction to BARD: a new consultation model \par }\pard \qj \li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {\fs22 Update 5.9.02 152-154 \par \par }\pard \qj \fi-720\li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {\fs22 14.\tab Balint M. (1986) \par \tab The Doctor, the Patient and the Illness \par }\pard \qj \li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {\fs22 Edinburgh: Churchill Livingstone \par \par }\pard \qj \fi-720\li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {\fs22 15.\tab Launer J. (2002) \par }\pard \qj \li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {Narrative-based primary Care: a practical guide. Radcliffe Medical Press Abingdon Oxford}{\fs22 \par }\pard \qj \fi-720\li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {\fs22 \par \par }\pard\plain \s4\qj \fi-720\li720\ri0\keepn\widctlpar\nooverflow\faroman\outlinelevel3\rin0\lin720\itap0 \b\f4\fs22\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {Other useful texts \par }\pard\plain \qj \li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 \f4\fs24\lang2057\langfe1033\cgrid\langnp2057\langfenp1033 {\fs22 Usherwood T (1999) \par }\pard \qj \fi-720\li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {\fs22 \tab Understanding the consultation: evidence, theory and practice \par }\pard \qj \li720\ri0\widctlpar\nooverflow\faroman\rin0\lin720\itap0 {\fs22 OUP Buckingham Philadelphia \par }}