Medical Consultation Models

In 2016, 66% of general practices in the UK were frequently using telephone consultations and none were using video [1].

Remote Consultations in COVID-19

During the Covid-19 pandemic in 2020, remote consultations have been used as alternatives to face-to-face consultations where at all possible. They are being used to triage and treat patients and have been introduced to protect staff and patients. Other healthcare professionals, for example, physiotherapists, pharmacists and nurses may also need to conduct remote consultations. The core principles of good medical practice apply to remote consultations. These principles include the need to:

• obtain adequate patient consent
• ensure patient confidentiality
• keep contemporaneous notes
• make an appropriate assessment of the patient’s symptoms
• communicate with other doctors to ensure continuity of care, especially when seeing people who may be registered with another GP
• have appropriate indemnity in place for the work you undertake. [2]

Medical Consultation Models

This step presents an overview of some consultation models that incorporate the principles of good medical practice.

Consultation models provide a structure for the complex interactions that occur between patients and clinicians. An unstructured consultation can lead to failure to recognise the real issues raised by the patient and may also lead to an unclear shared management plan with the patient.

There are a variety of approaches to the consultation process. A number of models have been developed that encourage a patient-centred, task oriented and structured approach.

The Calgary-Cambridge model, Pendelton model and Neighbour model are the more structured and task-oriented models and we will focus on these three models in this section.

Calgary-Cambridge Model

The Calgary-Cambridge model [3] splits the consultation into five steps:

1. Initiating the Session
2. Gathering Information
3. Building the Relationship
4. Explanation and Planning
5. Closing the Session

Pendelton Model

The Pendelton model [4] describes seven tasks that the doctor and patient should complete in the consultation. These are:

1. Establishing the reason for attendance
2. Considering if there are other problems
3. Choose an appropriate management plan for each problem
4. Work together to achieve a shared understanding of each problem
5. Involve the patient in the management plan and encourage the patient to adopt an appropriate degree of responsibility for each problem
6. Use time and resources efficiently, both in the consultation and the longer term
7. Establish and maintain a lasting relationship with the patient that helps to achieve other tasks

Neighbour Model

The Neighbour model [5] includes five consultation tasks to help uncover the patients’ unspoken agenda. These tasks are:

1. Connecting – establishing rapport with the patient
2. Summarising – getting to the point of why the patient has come using eliciting skills to discover their ideas, concerns, expectations and summarising back to the patient
3. Handover – the doctor and the patient formulate a management plan together and the patient takes responsibility from some aspects of the management plan
4. Safety-netting – The doctor and patient plan together to manage uncertainty. This empowers the patient to be aware of worrying signs or symptoms that should make them return or seek urgent care
5. Housekeeping – This is an opportunity for the clinician to ‘check-in’ with themselves before their next patient. It is a way of managing stress and recognises the need to deal with powerful emotions such as fatigue, stress, anxiety so that doesn’t get carried into the next patient encounter

Remote Consultations

These models were all developed for face-to-face consultations. One important critique of the Calgary-Cambridge and Neighbour model within a remote consultation is that the lack of face-to-face contact can mean it is hard to detect many of the cues described within the models. In addition, there are several cues that you need to be alert for on the telephone that are not included in these models, such as silence and hesitation. If these cues are missed, the rapport-building and connecting stages of the consultation may be affected. This could impact on subsequent stages. In spite of this, several sources have encouraged the use of the Neighbour model for remote consultations.

No Perfect Consultation Model

There will never be a model that covers every eventuality within either a face-to-face or a remote consultation. The key principle when selecting a model to use is to consider the context and use the model that will achieve the best outcome for the patient.

Reflecting on your consultation style

In this section we encourage you to reflect on your own style of consultation in practice and how you need to enhance it to fit a remote setting.

We have provided an overview of three commonly used consultations models. Think about the questions below in relation to your experience of using these models.

• What is your experience of using the three consultation models presented in this step?

• Which model do you prefer to use in your current consultations?

• How do you think you need to adapt your consultation style for a remote setting?

Bibliography

[1] Brant, H., Atherton, H., Ziebland, S., McKinstry, B., Campbell, J.L. and Salisbury, C., 2016. Using alternatives to face-to-face consultations: a survey of prevalence and attitudes in general practice. British Journal of General Practice, 66(648), pp.e460-e466.

[2] General Medical Council. Remote Consultations [online]. 2020. [Accessed 3 July 2020].

[3] Kurtz, SM. and Silverman, JD., 1996. The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organising teaching in communication training programmes. Medical Education, 30, 83-9

[4] Pendleton, D., Schofield, T., Tate, P., Havelock, P., 1984. The Consultation: an approach to learning and teaching, Oxford, Oxford University Press.

[5] Neighbour, R., 1987. The inner consultation. Oxford, UK: Radcliffe Medical Press