Models of the Doctor-Patient Consultation Comprehensive Study Guide

Historical Overview of Medical Consultation Models

• The models for doctor–patient consultation have evolved from ancient times to the present day with the objective of providing students and teachers with specific frameworks, philosophies, skills, and behaviors to improve clinical outcomes and patient satisfaction.
• These models offer a structured framework for the learning, teaching, and assessment of the medical consultation (Silverman et al. 2005).
• Several distinct traditions influence these models, including:     - Reductionist/Biomedical.     - Biopsychosocial.     - Patient-centred.     - Relationship-centred.     - Consumerist.     - Systemic (Lussier & Richard 2008).
• Prior to the $1850s$, evidence of consultation interactions is extremely limited; documentation by doctors was scant, often recording only fees, complaints, minimal physical findings, and medications.
• Historical time management was poor; for instance, a doctor might see up to $30$ patients in a $2$-hour clinic, resulting in approximately $5$ minutes per patient (Stoeckle & Billings 1987).

The Standardization of Medical History (1850–1950)

• During the period between $1850$ and $1950$, the content of the medical history became standardized. This content includes the following specific components (Stoeckle & Billings 1987):     - Demographics.     - Presenting problem(s).     - History of presenting problem(s).     - Past medical history.     - Systems enquiry (review of systems).     - Family history.     - Medication history.     - Social history.
• Pedagogical approach: Medical students learned by observing senior physicians question patients at their bedsides in hospital wards.
• Assessment: Success was measured via a viva (oral examination) at specific intervals during medical training.
• Nature of communication: The interaction was characterized as an interrogation rather than a dialogue between equals. While this provided a scientific approach to eliciting and recording health data across a common language, it was criticized for its reductionistic or biomedical focus, as it neglected the illness's effect on the patient's life and psychosocial factors (Keller & Carroll 1994; Kurtz et al. 1996).
• Key functions: Collecting/recording information during clerking, assisting in diagnosis, and facilitating information sharing among medical team members.

Psychosocial Perspectives and the Influence of Balint

• The late $19th$ century saw the rise of psychoanalysis, while the psychological trauma soldiers faced during the two World Wars highlighted the critical role of psychosocial factors in illness (Balint 1957; Stoeckle & Billings 1987).
• Michael Balint and his contemporaries advocated for psychotherapeutic consultations, viewing the patient holistically (physically, psychologically, and socially).
• Key techniques introduced:     - Use of open-ended questions.     - Sensitivity to verbal and non-verbal cues.     - Managing transference and counter-transference.
• Balint Groups: These were weekly group discussions for general practitioners designed to refine consultation skills and focus on the interaction between two human beings. Balint is credited with early use of the term "patient-centred care."
• The focus shifted from pure data collection toward the therapeutic relationship and human interaction (Balint 1957).

Transactional Analysis and Social Influences in the 1960s–1970s

• Eric Berne’s Transactional Analysis ($1964$): Identified human ego states active during consultations: Parent, Adult, and Child.     - In traditional consultations, the doctor often occupied the "Parent" role while the patient adopted the "Child" role.     - Awareness of these states allows practitioners to deliberately change the nature of the relationship.
• The $1960s$ societal shifts: The birth of feminism and the advancement of social and communication sciences brought "consumerism" into healthcare.
• Measurement: Specialized instruments were developed to measure patient experience and satisfaction with clinical care.
• Health Belief Model ($1974$; $1988$): Introduced insights into human variables affecting health behavior, such as a patient's perception of risk, and underscored the importance of including the patient’s perspective in treatment.

Heron's Six Category Intervention Analysis (1976)

• Heron proposed a taxonomy of interaction styles for one-to-one professional interventions, divided into two broad categories:     - Authoritative:         - Prescriptive.         - Informative.         - Confronting.     - Facilitative:         - Cathartic.         - Catalytic.         - Supportive.
• Principle of Application: Heron emphasized that no single approach is inherently superior; effectiveness often stems from a combination of styles depending on the situation.

Empirical Research: Byrne and Long’s Six-Stage Model

• Byrne and Long ($1976$) conducted a landmark study by tape-recording over $2,000$ general practice consultations in the UK.
• They identified a six-stage consultation process:     - 1. The doctor establishes a relationship with the patient.     - 2. The doctor attempts to discover the reasons for the consultation.     - 3. The doctor performs a physical examination or verbal exploration of the problem.     - 4. The doctor, the patient, or both consider the condition.     - 5. The doctor suggests further treatment or investigations.     - 6. The consultation is terminated, usually by the doctor.
• Findings on style: Doctors ranged from "doctor-dominated" (closed questioning) to "facilitative" (listening with minimal interruption).
• Interruption statistic: Beckman and Frankel ($1984$) found that doctors interrupted patients after a mean of only $18$ seconds, which often prevented the full discovery of the patient’s agenda.

The 1980s: Standardizing Patient-Centredness

• Societal changes (feminism and consumerism) and the development of psychosocial sciences began to shift the focus from solely treating illness to illness prevention and behavior change identification.
• Pendleton et al.’s Model of Good Practice ($1984$): Defined seven specific tasks for consultation:     - Discovery of the reasons for the visit.     - Exploration of problems other than the presenting complaint.     - Sharing understanding and decision-making.     - Involving the patient in the consultation.     - Empowering the patient to accept responsibility for diagnosis, prognosis, and treatment.     - Managing time and resources effectively.     - Building/maintaining a therapeutic relationship.
• McWhinney’s Disease-Illness Model ($1989$): Distinguished between the "Disease Framework" (the doctor’s agenda) and the "Illness Framework" (the patient’s agenda/experience).     - Integration of these agendas yields greater patient satisfaction and shared decision-making.
• Specific skills recommended in this era: Attentive listening, open and closed questions, clarification, and summarizing.

Specific Task-Oriented Models (Neighbour and Cohen-Cole)

• Neighbour’s Model ($1987$): Focused on five core tasks:     - Connecting.     - Summarizing.     - Handing over.     - Safety netting.     - Housekeeping.
• Cohen-Cole’s Three-Function Approach ($1991$):     - 1. Building an effective relationship.     - 2. Assessing problems.     - 3. Managing problems.

The Calgary-Cambridge Guide and Modern Frameworks

• Legitimacy in the UK: The General Medical Council’s "Tomorrow’s Doctors" ($1993$) made clinical communication teaching mandatory.
• Calgary-Cambridge Guide ($1996$): Created by Kurtz and Silverman to provide a coherent framework for teaching and assessment. It divides the interview into five tasks:     - 1. Initiation.     - 2. Information gathering.     - 3. Physical examination.     - 4. Explanation and planning.     - 5. Closing the consultation.
• The model includes roughly $70$ specific skills and emphasizes structuring the consultation and building the relationship throughout.
• American Models of the $1990s$:     - E4 Model (Keller & Carroll $1994$): Engage, Empathise, Educate, Enlist.     - Four Habits Model (Frankel & Stein $1996$): 1. Invest in the beginning; 2. Elicit the patient's perspective; 3. Demonstrate empathy; 4. Invest in the end.

21st Century Practices and Specialized Situations

• Narrative-Based Medicine (Launer $2002$): Emphasizes the patient telling their story and the co-creation of a common story.
• BARD Model (Warren $2006$): Focuses on the roles of both the doctor and patient, utilizing four tools: Behavior, Aims, Room (environment), and Dialogue.
• SPIKES Protocol: A six-step model designed specifically for the task of breaking bad news (Baile et al. $2000$).
• Shared Decision Making (Elwyn et al. $2012$): A three-step clinical model:     - 1. Introducing choice.     - 2. Describing options (using patient decision support).     - 3. Helping patients explore preferences to make a decision.
• OPTION grid: A tool used to measure clinician performance in involving patients in decision-making.
• Motivational Interviewing: Introduced into consultations in the first decade of the $21st$ century to support long-term behavior change (Rollnick et al. $2008$).

Consensus Statements and Future Contexts

• US SEGUE Framework: Created at the Kalamazoo meeting (Makoul $2001a, b$).
• UK Council Consensus Statement ($2008$): Provides a holistic picture of clinical communication including tasks, professional ideology, and the "hidden curriculum" (the culture outside the classroom).
• Contextual Flexibility: The doctor's role changes based on the illness and setting (Lussier & Richard $2008$):     - Emergency Room (e.g., heart attack): The doctor is the "expert-in-charge."     - Chronic unstable condition (e.g., unstable diabetes): The doctor is the "expert-guide."     - Chronic stable condition: The doctor acts as a "partner."     - Chronic minor condition (e.g., IBS): The doctor acts as a "facilitator."
• Future trends: Likely increase in research regarding the effectiveness of communication training, the impact of the internet, and the growth of e-learning in consultation models.