Presented by Dr Duaa Hiasat Objective Definition Tasks

Presented by: Dr. Duaa Hiasat

Objective Definition Tasks Dr. role in consultation Make effective use of consultation

Definition The essential unit of medical practice is the occasion when the intimacy of the consultation room a person who is ill or believes him self to be ill, seeks the advice of a doctor whom he trust. Sir. James Spence

Tasks Discover the reason for pt. attendance Define the pt. problems Address pt. problem Explain the problem to the pt. Make effective use of consultation.

Dr. role in consultation Problem definition Management Caring Support Prevention Education

THE CONSULTATION The following description of a consultation is an ideal to aim for but the reality is that in a 10 minute general practice consultation, one has to cut corners and only select what is most appropriate for that individual consultation

WELCOMING THE PATIENT Welcome the patient, preferably with a smile. “Good-morning, Mr. Al-Mughrabi” “Take a seat please”. You may shake hands if you wish. If you feel tired after a consultation, take a minute or two off before calling in the next patient.

IDENTIFYING THE REASONS FOR THE PATIENT’S ATTENDANCE. • Start by asking the patient, “What can I do to help? ” or “How can I help? ” • Don’t ask questions, and not even to think of questions. just “listen”. • “encouragers” from you, such as Yes, Go on, Right, uhm, or nods of the head.

• The patient must feel satisfied that he/she has had adequate time to explain his problem and that you understood. • One of the most important aims of the consultation is to discover the real reasons for attendance, ( hidden agenda). Failure to do so will usually end in an unsatisfactory consultation

LISTENING • • It establishes a good patient-doctor relationship. Concentrate on what the patient is saying. avoid thinking of questions you may ask. Try to be empathic.

• Develop the art of making the patient feel you have enough time for him, even when you are running late. • Make eye-to-eye contact, without staring, • listen preferably without anything in your hands

In Consultation • Use simple language, • Use open rather than closed questions. • Watch the patient’s appearance and body language. Facial expressions, sad or worried look, eye contact, dress, make-up, etc.

• Use encouragers to move conversation on. • Do not miss clues. Respond to them. • Summarising what has been said can be useful. “Let us see if I’ve got it right. You said that. . . ”

THE DOCTOR SHOULD BE AWARE OF HIS OWN FEELING DURING CONSULTATIONS • If he dislikes the patient , or he likes the patient more than others, he should ask himself why. • If he gets frustrated or even angry, he should be aware of it, and why. • A doctor should also be aware of his “off days”.

SOCIAL AND PSYCHOLOGICAL ASPECTS OF THE CONDITION • If appropriate, discuss how the condition affects the patient, not only physically, but also socially and psychologically

TIME MANAGEMENT • Time is limited. Do not aim for the perfect consultation. Make maximum use of time. • Develop the skills of rapidly gathering and exclude any serious condition. • Avoid asking unnecessary question. • Experienced doctors often continue taking the history while examining the patient.

• Do not follow up the patient unnecessarily, or sooner than is necessary. • Deal with simple cases quickly. Try to save a minute or two, so that you can spend these with a patient who needs more time. • Avoid spending more time with patients you like.

AVOID CLOSING YOUR MIND Even when the diagnosis seems “obvious”, avoid closing your mind to other possibilities.

BE SAFE • FIRST DON’T DO HARM • For every set of symptoms, ask yourself what is the most dangerous condition to exclude. • If appropriate, ask the patient to contact you if worse.

PHYSICAL EXAMINATION • An experienced doctor may continue taking the history while examining the patient. • A male doctor must never examine the female breasts or do a pelvic examination without a chaperone. • Be considerate. Give her a sheet to cover herself with. • Explain what examination you are about to carry out and the reason for the examination.

• Give a running commentary while you examine. For example, “Your blood pressure is 158 over 94. We should aim for 140 over 85”. Avoid dead silence during physical examination and procedures • Always examine the part the patient complains of, even if the real problem is elsewhere

INVESTIGATION • Investigate appropriately, to confirm or exclude the diagnosis, or to help in the management of the condition. • Give adequate explanation why we do a test, what it involves, etc. • If the condition is not painful or serious, do not ask the patient to come too soon for the result.

THE DOCTOR HAS TO BE SAFE AND NOT MISS AN IMPORTANT DIAGNOSIS • The doctor has to exclude significant diagnoses. For example, back pains in an older man should lead to exclusion of secondaries e. g. from cancer of the prostate or from myeloma.

MANAGEMENT • By the end. the doctor should in most cases be in the position to make a clinically appropriate working diagnosis, or at least to identify the problem. • If you are not sure why the patient has consulted, ask him in a different way.

• If you do not know the diagnosis, tell him so. • If he asks you a question and you do not know the answer, admit it and say you will look it up.

THE PHASE BEFORE PRESCRIBING Explanation Education Reassurance Sharing management with the pt.

NEED TO CHECK PATIENT’S UNDERSTANDING Feed back

TEAM WORK Consider involving other members of the primary care team as appropriate. (nurse, physiotherapist) And also social worker etc.

DRUG TREATMENT Prescribing must be appropriate and costeffective. Explain what the drug is for, How and when to take it, before, during or after meal, What side effects to expect, How long before benefit is felt.

For how long the patient will be on the drug, and whether it is for life. . If necessary, check that the patient has understood what you have said. Lower the patient’s expectation to a realistic level.

FOLLOW-UP Make sure that, when appropriate, you give clear follow-up advice or review. Make sure that the interval is not unnecessarily too short, to avoid creating unnecessary work for yourself.

OPPORTUNISTIC HEALTH PROMOTION The doctor should at this stage, if he is not too pressed for time, consider preventive measures. (screening).

REFERRAL Discuss any referral with the patient. Quite often patients appear in out-patient departments without knowing why they have been referred, and what to expect

ENDING THE CONSULTATION You may end a consultation in one of many ways: Breaking eye contact Writing a prescription Closing the notes Standing up and opening the door

MISCELLANEOUS Reduce interruptions during consultations such as nonurgent phone calls, receptionists coming into your room, etc. Be aware of your own prejudice (racial, class, single mothers, drunks, drug abusers, etc. ) Spot yourself stereotyping. Be aware of your own feeling during the consultation.

Develop the ability to know when you are tired or stressed. Take a short break if necessary. Know why you do not like the patient, or even why you like a patient. Learn to enjoy difficult patients or activities. Accept things that you cannot chang