Transcript GP SPECIALTY TRAINING – ST1 INTRODUCTION

General Practice
ST1 – GP Placement
Introduction
Educational Solutions for Workforce Development
East Deanery
GP SPECIALTY TRAINING
THREE or FOUR YEARS
YEAR ONE – 6 months medical specialties, 6
months GP
YEAR TWO – other specialties
YEAR THREE – Final GP year [or higher level
specialty post(s) then final 4th year GP]
Educational Solutions for Workforce Development
East Deanery
GP SPECIALTY TRAINING
FIRST SIX MONTHS IN GENERAL PRACTICE – THE
BASICS
1. CONSULTATION + COMMUNICATION SKILLS
2. INFORMATION HANDLING & INFORMATION
TECHNOLOGY
3. “DOING THE JOB”
Educational Solutions for Workforce Development
East Deanery
Communication Skills
East Deanery
Doctor –patient communication is central to
clinical practice
Doctors perform consultations 200 000
in a professional lifetime
There are major problems in communication
between doctors and patients
Effective communication is essential to high
quality medicine
Educational Solutions for Workforce Development
Consultation
East Deanery
•
•
•
•
Consultation Models + understanding
Videos – Analysis & C.O.T.
Role Play
Learning as an Expert
Educational Solutions for Workforce Development
Communication
East Deanery
Do doctors actually want to improve their
consultation skills?
How would you define, communication skills &
consultation skills? How do they differ?
What factors make a successful consultation? –
list
What are the barriers to effective consultation?
Educational Solutions for Workforce Development
Communication
Need for extra effort, time and emotional
commitment
Clinical skills – examination & practical
procedures only
Communication skills – non-clinical aspect
Consultation skills = Clinical skills +
Communication skills
Educational Solutions for Workforce Development
East Deanery
Communication - What you need to
achieve in a consultation?
Discover the reasons for a patients attendance
Define the clinical problems
Address the patients problems
Explain the problems to the patient
Make effective use of the consultation
“The Doctor’s Communication Handbook” Peter Tait
Educational Solutions for Workforce Development
East Deanery
Communication
CONTACT
COMPLAINT
CONTEXT
CONCERNS
CONSENSUS
“The 5 Cs” Donald Gemmell
Educational Solutions for Workforce Development
East Deanery
COMMUNICATION
4 E’s & 2 F’s
Critical communication tasks
ENGAGE
EMPATHISE
EDUCATE
ENLIST
Biomedical tasks
FIND the problem
FIX it
“Bayer educational model”
Educational Solutions for Workforce Development
East Deanery
Communication Skills
Calgary/Cambridge Model – Tasks
1. Initiating the session
2. Gathering information
3. Building the relationship
4. Explanation and planning
5. Closing the session
Educational Solutions for Workforce Development
East Deanery
Communication Skills
“Pendleton’s Rules”
• Briefly clarify any matters of fact
• Encourage the learner to go first
• Consider what has been done well first
• Make recommendations rather than state
weaknesses
Educational Solutions for Workforce Development
East Deanery
Communication Skills
East Deanery
“ALOBA” – agenda led outcome based analysis
•
•
•
•
•
•
Discover and record the learner’s agenda before looking at consultation
Look at consultation
Self-assessment by learner according to stated agenda
Group is invited to add ideas
Range of suggestions of ways to improve created
Learner selects from range what they would like to try next time
Educational Solutions for Workforce Development
Communication
East Deanery
2 dimensional - doctor centred v. patient centred
3 dimensional – physical, psychological, social
4 dimensional – presenting problem, continuing
problems, modifying health-seeking behaviour, health
promotion
5 dimensional – connecting, summarising, hand-over,
safety-netting, housekeeping (& 5 Cs)
Educational Solutions for Workforce Development
Communication
East Deanery
6 dimensional – PHASES > relationship,
agenda, examination, consideration,
treatment, closure; HEALTH BELIEFS >
What? Why? Why me? Why now? What if?
What next?
7 dimensional – agenda, other problems, choice
of action, shared understanding, involvement,
use of resources, maintaining relationships.
Educational Solutions for Workforce Development
Communication Skills
Miller (1990) – Pyramid of clinical competence
DOES
SHOWS HOW
KNOWS HOW
KNOWS
Educational Solutions for Workforce Development
East Deanery
Communication Skills
East Deanery
DOES – sit in or video – real patients, role play or simulated patients
SHOWS HOW
KNOWS HOW – face to face tutorial (formative) oral exam (regulative)
KNOWS – questionnaire or rating scales
Educational Solutions for Workforce Development
Communication Skills
COMPETENCE

PERFORMANCE 
East Deanery
knows how to do
(can do)
actually puts into practice
(does)
Educational Solutions for Workforce Development
Communication Skills
QUALITY IMPROVEMENT
Peer review
Self assessment
(Teacher/Trainer feedback)
Educational Solutions for Workforce Development
East Deanery
Communication Skills
East Deanery
Communication is a core clinical skill – an
essential component of clinical
confidence
Knowledge, communication skills, physical
examination and problem solving are the four
essential components of clinical competence
Without appropriate communication skills, our
knowledge and intellectual efforts are wasted
Communication turns theory into practice
Educational Solutions for Workforce Development
Communication
Defining the broad type of communication
skills
CONTENT SKILLS
PROCESS SKILLS
PERCEPTUAL SKILLS
Educational Solutions for Workforce Development
East Deanery
Communication
CONTENT SKILLS
What doctors communicate – the
substance of their questions and
responses; the information they gather
and give; the treatments they discuss.
Educational Solutions for Workforce Development
East Deanery
Communication
East Deanery
PROCESS SKILLS
How they do it – the ways they
communicate with patients; how they go
about discovering the history or
providing information; the verbal and
non-verbal skills they use; how they
develop the relationship with the patient;
the way they organise and structure
communication
Educational Solutions for Workforce Development
Communication
East Deanery
PERCEPTUAL SKILLS
What they are thinking and feeling – their
internal decision making, clinical reasoning
and problem solving; their awareness of
feelings and thoughts about the patient, the
illness and other issues that may be
concerning them; aware of their own selfconcept and confidence, of their own biases,
attitudes, intentions, and distractions
Educational Solutions for Workforce Development
Communication Skills - Video
East Deanery
Presenting
problems
Patient’s agenda
Beliefs
Hopes
Fears
Hidden
problems
Expectations
Secondary problems
Perceived problems
Perceived effects
Information gathering
Fact collecting
Analysing
Further questioning
Clarifying
Interpreting
Verifying
Sharing
understanding
Doctor’s agenda
 Patient centered
Doctor centered 
A power-shift model of styles of consultation
Educational Solutions for Workforce Development
Communication Skills - Video
Symptoms
Signs
Investigations
Stage of life
Personality
Accupation
Aspirations
Family context
Culture
Finances
Negotiation
process
Context
Introduction
Patient cues
Management
A mutual
decision
made
Person
Disease
Illness
Opening Gambit
Rapport Open Qs
Feelings Ideas
Functions
Expectations
Goals established
Process clear
Patient/Doctor roles clear
Patient Centred Clinical
Method
Educational Solutions for Workforce Development
East Deanery
THE GP CURRICULUM
You can only remember three
things…..
3 core domains
3 other domains
3 bits you need to apply the domains
Educational Solutions for Workforce Development
East Deanery
1. Primary care management
To provide quality care –
access
good clinical care – organised and evidence based
good communication
To act in diagnosis and management
coordinate PHCT
refer – secondary care / voluntary services / family
be an advocate
Educational Solutions for Workforce Development
East Deanery
2. Person centred care
Patients want a competent doctor
an active role
to be listened to
a caring doctor
We want to be effective
Why has this patient with this problem come to see me today?
What does this problem mean to this patient?
Educational Solutions for Workforce Development
East Deanery
3. Specific problem solving skills
Tolerate uncertainty
Explore probability
Marginalise danger
vs reduce uncertainty
vs explore possibility
vs marginalise error
You need knowledge of natural history of illness
range of skills
stepwise plan of action
use time – both urgent and at leisure
likelihood information
Educational Solutions for Workforce Development
East Deanery
A comprehensive approach Coping with multiple complaints
Dealing with co-morbidity
Balancing treatment / symptom relief / prevention
Working the system
Community orientation
Public health
Justice
Prioritisation / resource allocation / rationing
A holistic approach
Triple diagnosis
Health beliefs
Cultural and existential
Educational Solutions for Workforce Development
East Deanery
3 “essential features” that will impact on your
ability to apply the competencies
Contextual
The working environment
The practice demography
Pressures you are under
Home and personal circumstances
Attitudinal
Belief and values
Regulatory framework
Legal framework
Ethical principals
Scientific
Knowledge
Basic understanding of medical science
Evidence based medicine
Ability to critically analyse information
Educational Solutions for Workforce Development
East Deanery
Agendas
Doctors agenda
To make a diagnosis
To initiate management
To practice safely
To get through our surgeries
efficiently
East Deanery
Patients agenda
To find out what has happened
To be able to fit this into their
personal circumstances
(knowledge & beliefs)
To understand and agree what
needs done
Educational Solutions for Workforce Development
What do patients want?
Clear information
Mutually agreed goals
An active role
Positive empathy and
support
Sensitivity and support
Involvement
Explanations
Educational Solutions for Workforce Development
East Deanery
What are the benefits?
Patient satisfaction
Compliance
Better health outcomes
Educational Solutions for Workforce Development
East Deanery
What are we trying to achieve?
East Deanery
Doctors
Effective
Patients
agenda
Consulting
Agenda
MERGING AGENDAS
Educational Solutions for Workforce Development