Consultation Process - Coursework Example

Consultation Process The consultation process between the health care worker and patient determines to a great extent the degree to which the practice of medicine produces positive outcomes. The rapport that exists between the patient and the doctor or nurse is a complex interpersonal relationship because it entails a close collaboration between individuals who usually are from very different educational and social backgrounds. In addition, the consultation process is laden with emotion. The patient’s health is at stake and could be facing a life and death situation while at the same time, the health care worker is devoted to giving the best care possible and derives self-satisfaction from positives outcomes. This analysis of the process involved in health care professionals’ consultations to patients includes discussion of both good practices as well as techniques that should be avoided as identified by leading authorities in this field of study. It also addresses proper body language postures, types and appropriateness of questions and the various barriers that the health care professionals face when attempting to effectively communicate to patients. Concepts and structuring theories regarding the consultation process has and will continue to develop. One of the most recognised early works describing the importance of the consultation process was in the 1957 book The Doctor, the Patient and his Illness by Michael Balint (updated 1964). In 1977, the definition of the duties for general practice by the Royal College of General Practitioners included the concern for not only the physical condition of the patient but their social and psychological needs as well. In 1984, in a collaborative effort that included several GP’s in the Oxford area, David Pendleton et al (1984) wrote about what was then the new method of consultations via videotaping. The health care professional (HCP) cannot allocate consultations with the patient if positive results are expected. Generally speaking, for the communication to be effectual, this essential clinical task involves politely and considerately listening to every patient while demonstrating a respect for their viewpoint. The HCP should also provide the patient with honest information delivered in such a way that the patient fully comprehends it while, at the same time, observing their entitlement to be totally involved in the decisions made concerning their treatment (General Medical Council, 1998). Studies have revealed it is not easy for many people to articulate their genuine concerns regarding their health (Barry et al, 2000). Approaches that encourage patients to give an accurate accounting of their situation includes utilizing both open and closed types of questioning, listening intently and the appropriate usage of body language such as maintaining eye contact while listening. The fundamental success of the consultation depends on the capability of the HCP to understand the patient and what they hope to gain from the conversation with regards to their expectations, concerns and ideas (Pendleton et al, 1984). A failure to communicate effectively often contributes to inappropriate decisions being made on behalf of the patient (Britten et al, 2000). A review based on a survey of numerous hospitals exposed an average of 38 per cent of all patients were dissatisfied with the level of communication they experienced. This is a higher rate than those dissatisfied with overall medical competency. Malpractice suits are often the end result of communication blunders (Ley, 1988). The guidelines that govern normal social relationships differ from those that are applicable in the HCP/patient relationship. Although the two individuals may have recently met, they immediately begin health discussions of the most intimate personal nature. Within minutes of this awkward dialogue, the patient is likely required to remove their clothes and acquiesce to a probing and embarrassing physical exam (Maguire, 2006). The consultation process can be divided into segments. The HCP first creates a comfortable rapport with a patient then attempts to determine the purpose of the visit which may not be as readily apparent as it initially seems. There are several goals of the consultation process. The reason for the visit must be clearly defined from the beginning. Following a review of the patient’s medical history, the patient’s symptoms, concerns, ideas and expectations of treatment should be investigated. Continuing factors affecting health such as obesity, smoking and even social considerations should be addressed. The appropriate medical actions follow which could entail a physical exam, referral to a specialist, prescribed medication and/or simply reassurance. The patient should be made to understand the condition, the recommended treatments and the lifestyle choices that hinder their health. The judicious allocation of time is imperative. Inefficient time management might necessitate follow-up consultations or cause misunderstandings. The HCP relationship to the patient is not as paternalistic as it once was. The patient must be able to relate to the HCP. If the HCP appears to be aloof, sanctimonious or disinterested, the patient will withdraw and the consultation will be tainted and less than effectual. There are numerous proficiencies a HCP should develop including an open approach that encourages and acts to comfort the patient so they are more at ease and willing to hold nothing back no matter how personal. The consultation process is perhaps routine to the HCP but it must be remembered that this conversation is never routine to the patient (Neighbour, 2004). The HCP should ask questions that are open-ended so as to learn more from the patient than a ‘yes’ or ‘no’ answer will normally permit. For example, the patient should be asked to describe the ailment, the rate of occurrence and methods by which they have dealt with the condition in the past. Though closed-ended questions are often required in the consultation process, these should be alternated with open-ended questions to maintain a high level of patient involvement and circumvent an appearance of a scripted, generic consultation. A sequence of closed-ended questions could be commenced by stating, “Now I’d like to ask you several questions that will give me some important information….” (Stuart & Lieberman, 1986). Outside of routine closed-type questions that are essential for gathering pertinent information, the questions should be open which gives the patient an opportunity to broaden the discussion. Closed questions offer limited information and leading questions could result in false information. However, the HCP may have to revert back to closed questions to extract a meaningful and precise response from particular individuals. “Closed questions are probably better for obtaining immediate and objective information rapidly; they are less useful for initiating or deepening discussion. Open, non-structured, questions are appropriate for opening a discussion and for delving into a particular area” (Geisler, 1991). Interruptions in the conversation should be kept to a minimum. The conversation should be allowed to flow although sometimes patients may stray from the specific topic and need to be reined back in or mention something that requires further clarification. It is improper to interrupt their train of thought, so it may be useful to take brief notes. However, note taking should be kept to a minimum (Baird, 2004). The HCP should appear to the patient as attentive. This is achieved by maintaining eye contact. Attentiveness also includes listening to the patient’s words as well as noticing body language and non-verbal signals. The caregiver’s response entails clarification, summarization and conveying understanding of the situation. The language used should be at the patient’s level of comprehension with the most imperative information stated first. Important points should be restated so as to ascertain what the patient has grasped. In addition, visual aids could be of help as well. The consultation should be closed with the patient and the HCP clearly understanding what the next step will be (Neighbour, 204). The consultation style generally reflects both the approach to people managing and personality of the HCP, with the patient’s personality shaping it to a varying extent. The style can describe a wide range of interactions. On one end of the spectrum, consultations are strongly dominated by the HCP where the patient participation is unwelcome. On the other end, the patient practically delivers a monologue while the HCP listens passively and stimulates the conversation by asking only the most basic questions (Byrne & Long, 1984). A HCP’s personality shapes their individual style but it is difficult to alter unlike ‘people skills’ which can be developed with practice if the HCP is willing to be self-critical while measuring their progress. The development of consultation skills must consider the many communication barriers that exist between patients and HCPs such as cultural, language and philosophical differences. “Practitioners should be aware that they may not all speak the same healthcare ‘language’ or be looking for the same type of patient response” (Zollman & Vickers, 2000). If the consultation is to be effectual, the cultural and language barriers that may exist must be breached. The HCP should first examine and acknowledge their own culture, its particular traditions and value system. Next, the HCP should develop at least a basic understanding of other cultures with which they may potentially interact including nutritional practices, varying definitions of good health and the religious or moral considerations of the patient and their family. The consultation with the patient should begin by ascertaining their proficiency with the English language and it is important to quickly learn how the patient of a differing ethnicity or culture wishes to be addressed. An interpreter should be used if necessary. HCPs should be mindful however that one-quarter to one-half of consultations that use the most convenient translator such as a fellow office employee result in incorrect translations. If the patient’s friend or member of their family is brought in to interpret, the patient may consider this as a severe violation of their right to confidentiality (Ebden et al, 1988). If an interpreter is used, the HCP should direct their questions and attention to the patient, not the interpreter. The style of delivery and rate of speech should be tailored to the individual. Technical terminology, complicated sentences and use of slang should be avoided. As with any consultation, the patient should be seated comfortably and at eye level and the HCP should be aware of any body language that may be considered offensive. “Understanding someone’s cultural background assists in the development of an individualized, comprehensive plan of care” (Kleinman et al, 1978). Questions that are tailored to the individual patient assists the HCP to establish the trusting relationship that is vital when deriving information from patients. “It is important to understand that individuals have cultural or religious beliefs or traditions and that these beliefs may or may not affect their experience of the illness” (Rundle, 1999). It is of great importance that the HCP avoids identifying a patient or their needs based simply on their cultural affiliation. Effective consultations includes both verbal and nonverbal types of communication. In addition to the spoken language, body language communicates the thoughts of the HCP. The arms should not be folded across the chest because this signals to the patient that a barrier exists between them and the HCP. A relaxed posture should be maintained whether sitting or standing. The HCP should face the patient directly and lean forward slightly when conversing while at the same time keeping a suitable distance (two to four feet) from the patient. This will put the patient at ease while also conveying the sense that the HCP is personally engaged in the consultation. The HCP should not peer over their eyeglasses because this action is off-putting to the patient as it is often perceived as a gesture that displays superiority. Conversely, “taking the glasses off while the patient is speaking conveys a caring, empathic response to what you are hearing” (Peterson et al, 1992). The HCP’s body should remain motionless. This conveys to the patient that what they are saying is important. Studies have demonstrated many people cannot easily express their genuine problems to the HCP in the initial consultation (Barry, 2000). This situation is exacerbated by poor listening practices which often leads to significant misunderstandings in the HCP/patient relationship. It is a subconscious act to resist listening when bored or tired. If this inclination is not avoided, the patient will feel that the subject of their health does not interest the HCP. Pretending to be attentive is a learned response that is used as a defensive mechanism during boring meetings or while attempting to be polite while engaged in uninteresting conversations. This is a risky practice when consulting with patients because people can almost always distinguish if someone is only pretending to listen when in a one-on-one situation. HCP’s have usually avoided dispensing data that they judge too sophisticated for the patient. While the conversation should be limited to words the patient can easily understand, all levels of material should be dispensed or recommended. Patients are willing to learn when it involves their health. Another barrier to the overall effectiveness of the consultation are interruptions. Health care facilities are generally busy places where distractions are common. Uninterrupted consultations create a more comforting atmosphere for the patient and facilitates a greater amount of substantive information conveyed. In some instances, the HCP becomes distracted by the patient’s behavior or appearance. It is recommended that if the HCP concentrates on a person’s mannerisms or looks, it should only be their own. Focusing on the substance of the consultation alone is learned over time by honest self-evaluation (Nichols, 1957). Giving one’s full concentration to the smallest details of an often complex medical condition is a difficult task in the best of working conditions. Because people comprehend words at a rate of about 500 words per minute but only speak at about 125, the mind has surplus time in which to think of other things while the patient is speaking. “Communication is more effective if you focus only on what is being said” (Nichols, 1957). In recent decades, research has uncovered the importance of patient consultations and the methods by which to ask questions, formulate relationships and extract the most pertinent information from patients. Still, medical training is based mainly on cold facts and silent figures. As a result, HCPs have often failed to appropriately consider the similarly significant factors that affect medical assessments such as that the patient’s intent, their emotions and behaviour in addition to cultural and language barriers during the important consultation process. To be an effective HCP, then, it is necessary to continuously work on developing the skills necessary to achieve the best communication possible with patients that come for help. References Balint, M. (1957; update 1964). The Doctor, His Patient and the Illness. New York: Chruchill Livingston. Baird, Anne. (24 March, 2004). “Focus On… The Consultation.” Nurse-Prescriber. Accessed 28 December, 2006 from Barry CA, Bradley CP, Britten N, Stevenson FA & Barber N. (6 May 2000). “Patients unvoiced agendas in general practice consultations: Qualitative study.” British Medical Journal. Vol. 320, I. 7244, pp. 1246-50. Britten N, Stevenson FA, Barry CA, Barber N, Bradley CP. (19 February 2000). “Misunderstandings in prescribing decisions in general practice: Qualitative study.” British Medical Journal. Vol. 320, I. 7233, pp. 484-8. Byrne PS & Long BEL. (1984). Doctors Talking to Patients. Royal College of General Practitioners. Ebden P, Bhatt A, Carey OJ et al. (1998). “The bilingual consultation.” The Lancet. Vol. 13, p. 347. General Medical Council. (1998). Good Medical Practice. London: GMC. Geisler, Linus. (1991). Doctor and Patient: A Partnership through Dialogue. Frankfurt, Germany: Pharma Verlag. Accessed 28 December, 2006 from Kleinman, et al. (1978). “Culture, Illness and Care: Clinical Lessons From Anthropologic and Cross-Cultural Research.” Annals of Internal Medicine. Vol. 88, pp. 251-258.  Ley P. (1988). Communicating with Patients. London: Croom Helm. Maguire, Kathy. (2006). “Doctor/patient relations.” Sociologies of Health and Illness. E-Learning Database: University of Cambridge School of Clinical Medicine. Accessed 28 December, 2006 from Neighbour R. (2004). The Inner Consultation: How to Develop an Effective and Intuitive Consulting Style. (2nd ed.). Oxford: Radcliffe Medical Press. Nichols, Ralph G. (1957). Are You Listening? New York: McGraw Hill. Accessed 28 December, 2006 from Pendleton D, Schofield T, Tate P & Havelock P. (1984). The Consultation: An Approach to Learning and Teaching. Oxford: Oxford University Press. Peterson MC, Holbrook JH, von Hales D, et al. (1992). “Contributions of the history, physical examination, and laboratory investigation in making medical diagnoses.” Western Journal of Medicine. Vol. 156, I. 2, pp. 163-5. Rundle, Anne Knights. (1999). MNA Member Author’s Book on Honoring Patient Preferences in Multicultural Context. Massachusetts Nurses Association. Accessed 28 December, 2006 from Stuart MR & Lieberman JA. (1986). The Fifteen Minute Hour: Applied Psychotherapy for the Primary Care Physician. New York: Prager. Zollman, Catherine & Vickers, Andrew. (Spring 2000). The ABC of Complementary Medicine. London: Council for Complementary Medicine. Accessed 28 December, 2006 from Read More