This web chapter accompanies the book: ‘The Essential Handbook for GP Training & Education’ (Editor: Ramesh

Mehay)

Revisiting Models of the Consultation

Ramesh Mehay (lead author)- TPD (Bradford)
Robin Beaumont - Tutor MSc in Health Informatics (Edinburgh Univ.)
Juliet Draper - Retired GP and trainer. Freelance consultant (communication skills, Cambridge)
Iain Lamb - Associate Advisor (SE Scotland)
Liz Moulton - Ex Deputy Director (Yorkshire & the Humber Deanery)
Damian Kenny - GP Educationalist (Severn Deanery)

How to read this chapter

This chapter is provided as a source of reference rather than as a ‘unit’ to be read from start to
finish. However, if you want to do that then that’s fine but you may find it a bit too intense,
overwhelming and exhausting – especially if a lot of the material is new to you.

We hope this chapter will invoke thought, interest and ‘relight your fire’ through material and
models that you may not have come across before. And whilst we’ve tried to capture the
essence of each model, remember that there is no substitute for the original source.

What we’re going to look at today

Do I need to know about all these models?

No you don’t. We’ve provided a comprehensive list so that you can:
a) Copy it to your trainee to provide an overview on consultation models.
b) Refer to it as a reference resource in case your trainee comes back to you asking for
help in applying a particular model to a particular consultation scenario.
c) Develop your own consultation skills by exploring models which are new and
interesting to you.

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Why consultation models?

The consultation remains the main and basic tool of general practice and as Pendleton
eloquently put it: ‘it’s the central act of medicine which deserves to be understood’. And it is
consultation models that can help us (and our trainees) to understand the GP consultation and
therefore consult better. Consultation models also help to add structure to a consultation –
preventing it from going into all sorts of directions and deteriorating into a chaotic mess.

For example, a consultation model can help us manage a consultation where we are finding it
difficult to make a diagnosis or where the patient doesn’t like the sound of the management
plan. It can also bring to the ‘open arena’ hidden agendas and significant concerns a patient
may have.

Why learn about consultation models?

We subconsciously make models for anything we do regularly.
By studying other people’s models, we can make our own.
Consultation models help us understand the patient’s perspective.
Better understanding means better concordance and less complaints.
Consultation models make us more thorough and therefore safer.
Consultation models help teachers teach on the consultation.

Finally, the framework of the models can help us to help our trainees perform better in some
of the MRCGP assessment tools – namely the Consultation Observation Tool (COT) and the
Clinical Skills Assessment exam (CSA).

First things first – what is a model?

There are different types of models and therefore different definitions. The one that we’re
interested is that which is:
‘a hypothetical description of a complex process’
and not
‘a person who poses for a photographer or painter or sculptor’!

The hypothetical description usually serves as an exemplar - something to be imitated

because we know it will give the outcome we desire.

A model can come in many shapes, sizes, and styles – and you’ll see this reflected in the
different consultation models summarised below. Different trainees will take to different
consultation models but the important thing to remember is that a model is not the real
world but merely a human construct to help us better understand real world systems.

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No matter what model you look at (whether mathematical, scientific or medical), they all
have three things in common:
1. An information input
Rapport (Neighbour), Data Gathering (Calgary Cambridge), Ideas-Concerns-
Expectations (Health Belief Model), What’s happened? (Helman).
2. An information processor
Merging doctor’s and patient’s agendas (McWhinney), Why me-Why now-What if I do
nothing? (Helman), Doctor +/- patient consider the condition (Byrne & Long),
Providing Structure (Calgary Cambridge).
3. An output of results
Shared understanding (Pendleton), Prescriptive-Informative-Cathartic-Catalytic-
Confronting-Supportive (Heron), What should I do? (Helman), Explanation &
Planning (Calgary Cambridge), Safety Netting & Housekeeping (Neighbour).

So, whilst different consultation models place emphasis on different bits, they all have large
degrees of overlap when you look at them in terms of input, processor and output.

Some interesting things famous people have said about models:

’All models are wrong but some are useful.’ George E.P. Box (an eminent statistician)
’Make your theory as simple as possible, but no simpler.’ A. Einstein

Comparing consultation models

All consultation models include the taking of a (medical) history but they differ in their
emphasis - some place more emphasis on diagnosis of the patient while others focus more on
discovering what the actual patient ('consumer') wants. On the whole, consultation models
differ from each other in three main ways:

Some are conceptual frameworks – telling you what needs to be achieved (aims) but not
how to actually achieve them (implementation methods). Others concentrate more on
implementation without a solid conceptual framework. Some (like the Calgary Cambridge)
do both pretty well.

They also differ in terms of doctor versus patient centredness: the extent to which the
consultation’s agenda, process and outcome are determined by the doctor or the patient.
Doctor-centred models describe the doctor’s aims or behaviour whilst patient-centred models
focus on the patient’s.

The final difference is in the degree to which they focus on the tasks to be achieved (or a
checklist of points to be covered - task orientated models) as opposed to the range of
behaviours needed in the consultation (behaviour orientated models). Another way to think
of this axis is to see the task orientated models as looking at the content of the consultation
whilst the behaviour orientated ones focus on the process.

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How trainees adopt a consultation model

We said earlier that different trainees will be attracted to different models. They often start
off with playing around with two or three - finding one that works best for them (and/or fits
in with their ‘personal style’). Even when they’ve found a model, they don’t just blindly
follow it – they’ll continue to play and tweak it until their own adapted version of that model
is born and internalised. As a GP educator, you can start your trainee off on their journey –
help them find their model of ‘enlightenment’!

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ONTO THE CONSULTATION MODELS…

The models described below will provide a taste of the range of approaches. Remember -
there is no one correct model of the consultation – the approach is dependent on the context.
Most of these models tell you what you need to achieve but not how you go about achieving
it – that being left to the doctor’s own free will or experience. Consider the cliché ‘to skin a
cat’, a model tells you that at the end of the day - you need to skin that cat. How you do that
is up to you and your personal style. If one of these models captures your interest, please
remember that this condensed version is not a substitute for reading the original publication.

Model 0 – The Medical Model (the benchmark)

Before we try to understand what the other models are trying to achieve, we must start off the
one which was instilled in us from our
medical school days. It will give us a
benchmark for comparing other
models. It’s called the ‘traditional
medical model’ and it’s by no means a
dead model - most trainees still use it
when they’re in hospital posts. It is a
purely organic approach to managing
patients – where the disease and
diagnostic process are of central
importance. It’s not interested in what
patients think or feel or in what might be going on for them back in their own lives. It’s
purely a functional model to do the main job of sorting out the problem, not necessarily the
patient.

Timothy Lee is a 48 year old taxi driver who presents to A&E with central crushing chest pain. The
Medical on call team take a history, examine him, do various tests and come up with the diagnosis of
an Acute Myocardial Infarction. He is thrombolysed, put on a cocktail of heart drugs and then
discharged a few days later. He is advised not to drive for 6 weeks. They’ve clearly followed the
Medical Model.

But Tim doesn’t know what he is going to live on while he’s off for 6 weeks. Statutory sick pay won’t
meet the mark and monthly prescription charges will financially wreck him. Actually, he’s thinking of
stopping his meds and he doesn’t like tablets in general anyway.

He went to see his GP who explored all of this in some detail. Over a couple of consultations, the GP
was able to help Tim see the importance of not driving especially with regards to the safety towards
others. He also found out that Tim was scared of heart tablets because he had heard from others
about erectile dysfunction. His GP encouraged him to try them and see and he agreed. As for the
prescription charges, the GP decided to issue 2 months prescriptions at a time to help with Tim’s
costs – Tim agreed that it would make things a lot easier.

We hope you can see how the Medical Model is not interested in the patient’s illness (effect
of the disease on the patient’s life). It’s only interested in sorting out the problem (the
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disease). But in this case, if it wasn’t for the more patient-centred approach used by the GP,
Tim would have stopped his medication, probably have had a fatal MI at some point –
prematurely leaving behind a young family. If this had happened, what would the medical
model have truly achieved? Illness is personal and unique, disease is impersonal and general.

Pros Cons
Sorts the main problem out What if you can’t come up with a
Medically comprehensive diagnosis?
Is structured Disregards the psycho-social context of a
presenting complaint. Every complaint
can be placed in a psycho-social context
(RCGP)
It disregards the patient as a person (who
has feelings, concerns and an agenda
too). Patients don’t function simply as
machines!
Disregards the doctor as a person (who
has feelings). Doctors don’t function
simply as machines!
Not an effective use of time – covers
areas which may have little relevance.

Model 1 – The Triaxial Model: physical, psychological and social1

This model was proposed by a working party of the RCGP back in 19721 and said ‘A doctor
should be encouraged to extend his thinking and practice beyond the purely organic
approach to patients’. In other words, to consider the patient’s emotional, family, social and
environmental circumstances, all of which can have a profound effect on health. Although
most of us now do this religiously, it was only fifty years ago when many of these questions
would have been considered as irrelevant or prying by patients.

Pros Cons
Covers the patients agenda An over simplification of a patient-centred
Places the presenting complaint in a approach.
psycho-social context

Model 2 – Health Belief Model (1975)2

This model focuses on the patient’s thoughts – not just on the consultation but also about
their attitudes to illness in general and how they see themselves as patients. By exploring the
patient’s Ideas, Concerns and Expectations (I.C.E.) you get a true understanding of where the
patient is coming from. And if you go one step further and incorporate that information into
your management plan, you’re more likely to improve patient concordance.

Patient’s ideas – ‘Had you any thoughts about what might be going on?’
Patient’s concerns – ‘And what particular worries or concerns did you have?’
Patient’s expectation – ‘And what were you hoping that I might do for you?’

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The model came about by a group of American psychologists in the 1950s who were trying to
fathom out what factors encouraged people to participate in a health promotion programme to
identify and eradicate TB. The came up with 6 things:

1. Whether they think they are susceptible to a particular illness

2. Whether the consequences of the illness could be serious, physically or socially.
3. Whether the 'treatment' would confer benefit.
4. Whether there are barriers e.g. costs outweighing the benefits
5. Internal factors such as worrying about symptoms, and external factors such as
media campaigns, advice from family and friends. These triggers that make a
patient seek help are called ‘cues to action’.
6. Whether they have a strong internal or external controller.
Patients vary enormously in the way they accept responsibility for their health.
Those with a strong internal controller control their own health destiny – perhaps
the demanding ‘Guardian reading’ patient? They see the doctor merely as an aid
to achieving the treatment, prescriptions or referrals that they need. They have a
firm idea of their own diagnosis and an equally definitive expectation of what the
doctor should do for them.
Those with a strong external controller are more ‘fatalistic’ – that their likelihood
of developing illness is totally out of their control and they cannot do anything
about it.
There’s another group who are a bit like this last ‘fatalistic’ group but what sets
them apart is that although their health destiny rests externally to them, it can be
influenced by particular individual – the GP for instance. They’re the ones that
‘do as they are told’ and the locus of control rests with the powerful influential
other.

So what! How does all of this help us?

Exploring I.C.E. will help you:
Gauge whether an individual has a general interest in his or her own health matters –
which might correlate with personality, social class and ethnicity.
Appreciate how vulnerable the patient feels to a particular disease and who severe a
threat they feel that disease poses.
Understand the patient’s estimation of the benefits of treatment weighed against costs,
risks or inconvenience of treatment.
Understand the factors that prompt an patient to take action, such as the development
of alarming symptoms, or things said by the family, friends or the mass media.

It’s a particularly useful model when dealing with the worried well, the hypochondriac, the
non-compliant patient, the helpless, the hopeless and patients who frequently miss their
appointments. The model helps you to ‘walk a mile’ in the patient’s shoes and see things
from their perspective for a change.

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Model 3 – Six Category Intervention Analysis (1976)3

In the mid-1970’s, John Heron, a psychologist working at the University of Surrey in
conjunction with the GP VTS day release Course Organisers, developed a simple but
comprehensive model of the array of interventions a doctor (counsellor or therapist) could
use with the patient (client).

When a patient comes to see their doctor, in that brief time, the doctor can influence the
patient’s life journey by intervening in 6 ways:

A note on cathartic interventions: another way we’ve seen this expressed is helping the patient to ‘vomit their
emotions’ in the consultation so that they feel better.
A note on catalytic interventions: non-verbal examples include creating a sense of trust and security, listening
well, showing genuine interest, the effective use of silence. Verbal examples include things like reflecting or
repeating the last word of a patient’s sentence or asking open questions.

You should view this list of interventions as different tracks a doctor may take - the first three
in the list are authoritative (or doctor-centred) and the last three are facilitative (or patient-
centred). Do remember that in any one consultation you will see a number of these
interventions come into play. Heron believed that each category has a clear function within
the total consultation and that each will affect the process and outcome of the consultation.
For example, a welcoming gesture might precipitate tears and therefore be cathartic.

Which interventions are used depends on where the energy lies in the consultation. You need
to be able to identify the required intervention, perform it, and know when to stop and/or
change track. Choosing a wrong intervention can ruin everything that has gone on before.
Follow the patient’s verbal and non-verbal cues – it will help give an early indication if
you’re barking up the wrong tree – enough time for you to switch to something else.
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Pros Cons
Ideas which will last you a life time. High stakes – if you go down the wrong
One of the few models that is responsive path, you can ruin everything!
to the patient’s behaviour rather than the
‘tasks’ you have to achieve.
Reminds you of what you can do as the
doctor (esp. with difficult or heart-sink
patients)

Model 4 - Byrne and Long (1976)4

Byrne and Long (one of whom was a GP and the other a psychologist) spent three-and-a-half
years examining over 2500 audiotapes of consultations from over 100 GPs in New Zealand
and the UK (video was in its infancy and expensive). They formulated a framework of six
tasks or ‘areas to be covered’ for any consultation:

The 6 Phases of the Consultation

Phase I The doctor establishes a relationship with the patient.
Phase II The doctor either attempts or actually discovers the reason for the patient’s attendance.
Phase III The doctor conducts a verbal or physical examination or both.
Phase IV The doctor, doctor and patient, or the patient (in that order) consider the condition.
Phase V The doctor, and occasionally the patient, detail further treatment or further investigation.
Phase VI The consultation is terminated usually by the doctor.

Theirs was the first consultation to consider explicitly the task of introducing and
finishing the consultation.
Again, for the first time the task of considering the problem with the patient was
described.
They discovered 4 distinct styles of consultation and 7 distinct prescribing styles.
They noted that sometimes the style of the consultation reflected the personality of the
doctor and other times it was that of the patient. Sometimes consultations were
doctor-dominated (where the patient said little) to a virtual monologue by the patient
(where the doctor became a passive listener). More detail on the distinct consultation
and prescribing styles can be found in a ‘Byrne and Long’ document on our website
(along with some useful checklists).
They also postulated that dysfunctional consultations resulted as a lack of attention
being paid to Phases 2 (not discovering reason for attendance) and 4 (not considering
the condition with the patient). And doctors who asked more open questions tended
to see their patients less frequently!
Later on, they described Phase VII, called the Parting Shot - where the patient
reveals the real reason why they have come just as they are about to leave.
Pros Cons
Starts to include the patient’s thoughts But the 6 tasks are still predominantly
Starts to move the focus of the doctor-centred.
consultation towards illness

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Model 5 - Stott and Davis (1979)5

Professor Nicholas Stott & R.H. Davis suggested that four areas can be systematically
explored each time a patient consults:

Model 6 - Helman’s ‘Folk Model’ (1981)6

Cecil Helman is a medical anthropologist, with

constantly enlightening insights into the cultural
factors in health and illness. He suggests that a patient
with a problem comes to a doctor seeking answers to
six questions:

Pros Cons
Patient centred – in fact, it’s all based Can be time consuming
around the patient’s agenda Difficult to apply to some problems –
Hence, few patient complaints. what do you say to severe mental health
problems like acute schizophrenia?

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Model 7 – Pendleton, Schofield, Tate and Havelock (1984)7

David Pendleton, a social psychologist, wrote his PhD thesis was on the analysis of
consultations. He worked with a number of GPs in the Oxford region and was the person
who pioneered the use of video (a new medium at the time) in the analysis of consultations.
Subsequently, he developed safeguards for the use of video which forms the basis of the
current recommendations. In addition to the use of video, he also formulated ‘Pendleton’s
rules for feedback’ and ‘Pendleton’s model of the consultation’.

In Pendleton’s model, the personal and psychological aspects of the illness are further
developed. The model describes 7 tasks: the first 5 tasks are concerned with what the doctor
needs to achieve and the final two deal with the use of time/resources and creating an
effective relationship.

Pendleton, Schofield, Tate & Havelock (1984)

1) To define the reason for the patient’s attendance, including:
a) the nature and history of the problems
b) their aetiology
c) the patient’s ideas, concerns and expectations
d) the effects of the problems
2) To consider other problems: i) continuing problems ii) at-risk factors
3) With the patient, to choose an appropriate action for each problem
4) To achieve a shared understanding of the problems with the patient
5) To involve the patient in the management and encourage him to accept
appropriate responsibility
6) To use time and resources appropriately: i) in the consultation ii) in the long term
7) To establish or maintain a relationship with the patient which helps to achieve the
other tasks.

PATIENT’S AGENDA = 1c + 1d = ideas, concerns, expectations + effects of the problems

Most of the performance criteria in the Consultation Observation Tool (COT) are taken from
this model. Therefore, it’s worth reading the book! The second edition of their book, called
‘the new consultation’, includes the relevant research evidence. The book is divided into two
section – the first part which looks at the consultation and their model, and the second part
which is concerned with teaching effective communication skills.

Pros Cons
Patient’s thoughts assume an important Although set out in logical sequence, not
role in this model. all consultations will follow this order.
It encourages patient responsibility Not particularly appropriate for acute
It’s the framework which is used in the settings like emergencies.
MRCGP Consultation Observation Tool

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Model 8 – Problem Based Interviewing (1985)8

Problem Based Interviewing, or PBI for short, places heavy emphasis on the detection of
psycho-social distress. It consists of two big skill sets – problem detection and problem
management.

Problem Detection Skills Problem Management Skills

Generally, this bit of the consultation is about: Generally, this bit of the consultation is about:
1) problem sensing 4) problem assessment
2) problem detection 5) problem treatment
3) problem description & clarification 6) evaluation
Specifically, to do it, you need to: Specifically, to do it, you need to:
Begin the interview Allow the patient to ventilate
Pick up verbal cues Negotiate with the patient to initiate change
Respond to verbal cues Problem solve (like directive counselling)
Pick up non-verbal cues Re-attribute symptoms
Respond to non-verbal cues Give information
Demonstrate empathy Special skills(special therapies)
Explore health beliefs
Control the pace of the interview

Model 9 – McWhinney’s Disease-Illness model (1986)9, 10, 11, 12

We urge you all to become familiar

with this model by reading Patient-
centred medicine by Moira Stewart12.

This simple model can transform the

way your ‘new’ trainee approaches the
GP consultation (especially those
who’ve just come out of hospital
posts).

After qualifying, most doctors are more

concerned with getting the information
they want to make a diagnosis rather
than what the patient might want to
express. This doctor-centred model,
where only the doctor’s agenda
matters, is often referred to as the
‘Disease Framework’ (represented by
the blue arrow in the diagram).

In 1984 McWhinney9 and his colleagues at the University of Western Ontario proposed a
‘transformed clinical
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Method’. Their approach, later revived in 1997 by Stewart and Rotter, has also been called
‘patient-centred clinical interviewing’: they say that whilst the doctor’s agenda is important
(blue arrow in the diagram), so too is the patient’s (green arrow). Therefore, they suggest a
consultation where the doctor weaves to and fro between his agenda and that of the patient’s
(purple arrow). In this way, a management plan is formulated which satisfies the patient’s
ideas, concerns and expectations (and thus helps them make sense of what is happening to
them) whilst at the same time conforming to good clinical practice.

This model helps you realise that disease is the cause of sickness whereas illness is the
unique experience of the sickness. Patients can have illness without disease – for example,
a patient who complains of ‘Tiredness All The Time’ for which no medical cause can be
found. And it can be the other way around too – where patients can have a disease without
illness, hypertension being a prime example. We hope you can see how different diseases
can cause different illnesses (i.e. experiences) in different patients. Therefore, the doctor has
the unique responsibility to elicit two sets of ‘content’ of the patient’s story: the traditional
biomedical history, and the patient’s experience of their illness.

You see Mrs. Templeton who comes in with abdominal pain for the eighth time. It’s getting no better.
All the tests haven’t shown anything and there are no alarm symptoms. Despite reassurances, she
just keeps coming back. Three months later, she comes back to see you about her ‘cough and cold’.
She says that her tummy pain seems to have miraculously settled down. You see from the notes that
after your last consult with her, she saw a colleague who explored her ideas, concerns and
expectations and found out that she was particularly worried about gastric carcinoma – her mother
had it at around her age and had a rapid and awful decline thereafter. It’s clear that he empathised,
validated her feelings and reassured her.
You see a patient with low back pain for 1 week following a recent bout of painting and decorating.
You spend 15 minutes going into detail about an explanation of the diagnosis and the management
plan. As you move towards the end of the consultation, the patient says ‘Can I have a sick-note?’
Reflection: The patient probably realised it was muscular and just wanted a sick note! Was that level
of explanatory detail really necessary and could you have saved time?

Pros Cons
Provides a balance between satisfying Takes a little extra time and commitment.
both doctor’s and patient’s agendas
Both patient and doctor happy
Nice simple practical framework

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Model 10 - Neighbour (1987)13

Roger Neighbour, a GP from

Watford, developed this model after
working with his local Trainers’
Workshop. This model provides a
journey with 5 intuitive check points
for answering the question: ‘Where
shall we make for next and how shall
we get there?’.
Connecting with the patient; establishing a working
Rapport Building Skills
relationship through empathy and building rapport.
Summarising the reasons why the patient has come having
discovered their ideas, concerns, expectations. This makes
sure that both of you are on the same track and allows for Eliciting Skills
corrections. This enables one to formulate a diagnosis and
initial management plan.
Handing over is returning patient control and responsibility
for some aspects of their health through a shared Communication Skills
management plan, negotiating and gift wrapping.
Safety netting is making a contingency plan in case things
do not go according to plan. Safety netting considers ‘What
Predicting Skills
If…?’ scenarios – worrying symptoms or signs that should
make the patient return or seek urgent opinion.
Housekeeping is looking after yourself between patients.
Answers the question: ‘Am I in good enough shape for the
next patient?’ It recognises the need to attend to fatigue, Stress Management
boredom, stress, lack of concentration, distraction and other Skills
powerful emotions – for example, the need to vent off to a
colleague about a patient who has upset you.

Pros Cons
Empowers the patient by ensuring the Is a bit doctor centred at times
doctor hands back responsibility The style of the book is a bit like Marmite
The first model to reecognise the – you either love it or hate it. Flick
importance of safe doctoring (safety through it before you buy!
netting) and being a healthy doctor
(housekeeping).
The 5 checklists are easy to remember.
A good starter for new GP trainees.

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The Doctor’s Two Heads

Neighbour also describes the two different heads of the doctor in the consultation. One is
called the Organiser. This doctor-centred head is busy trying to:
manage the organisation of the consultation,
asking questions and deciding to examine
planning and negotiating clinical management
time keeping – like slowing and speeding consultations
and making records.

The other is called the Responder. This patient-centred head tries to make sure that you are:
Being attentive through listening properly
Taking time to think and process information
Creating and testing ideas
Being empathic.

The skilled doctor needs to find a fine balance between Organiser and Responder modes whilst
journeying through the five tasks of the consultation. It’s a bit like driving a car whilst talking to a
passenger. Your Organiser pays attention to the steering wheel, pedals and gears whilst the
Responder maintains the conversation. In heavy traffic or at the traffic lights, your Organiser will
take over and you temporarily stop engaging with the passenger. But when things are calm and
easy again, the Organiser will relax allowing the Responder to come back in and maintain the
conversation. The Organiser continues to lurk in the back ground, keeping an eye on the road, in
case it’s needed again at short notice. The journey within a GP consultation follows something
similar.

Later on, you will come across Balint, who described ‘the doctor as a drug’ – a metaphorical
drug that patients ‘take’ to make things better. Neighbour’s model sees the doctor as a
catalyst rather than a drug – who facilitates problem solving or change by revisiting
awareness raising questions like Who, What, Where, When, How? For example, ‘Where is
the patient now?’, ‘What do they need to do next?, ‘Where shall we make for next?’, ‘How
shall we get there?’. Some of these questions will be shared with the patient whilst others
may simply reside in the doctor’s head. Now you will understand why Neighbour describes
the consultation as a journey (not a destination) in which there is ‘reflective conversation with
the situation’.

Balint’s Doctor as Drug (the doctor fixes things):

Side effects: addiction/dependency on the doctor, withdrawal when doctor moves on, potential for
practitioner burnout unless he/she recharges self.

Neighbour’s Doctor as a catalyst (the doctor facilitates problem-solving/change):

Practitioner emerges unscathed, with occasional contamination.

By the way, Neighbour has a second book called ‘The Inner Apprentice’ which uses a similar
style as ‘The Inner Consultation’ but focusing on teaching communication skills instead.

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Model 11 – Tate’s Model (1994)14

Peter Tate is a retired GP and former Convenor of the MRCGP examinations - he’s the one
who introduced the MRCGP video module in 1996. He also helped co-author Pendleton’s
original model. He continued to develop some of the themes from that model (particularly
the importance of the patient’s ideas, concerns and expectations) to come up with a scheme
that is now used in his book.

New trainees (especially those who have come out of hospital posts practising the ‘traditional
medical model’) will find this book most insightful. Like Pendleton’s model, it covers a
number of the competencies on which the MRCGP Consultation Observation Tool (COT) is
based. He also outlines useful strategies and skills as well as succinctly reviewing how
consultations have changed with the advent of the internet and the availability of information.
It’s the one to read if you haven’t the time for any of the others and is dead easy to read.

Discover reasons for attendance

Encourage patient’s contribution
Observe and use cues
Obtain relevant social and occupational information
Explore patient’s health understanding
Define the clinical problem(s)
Sufficient info not to miss any serious condition
Reasonable examination
Appropriate working diagnosis
Explain the problem(s) to the patient
Explain diagnosis, management, effects of treatment
Use appropriate language
Use the patient’s health understanding
Check their understanding
Manage the patient’s problem
Make sure the plan is appropriate for the working diagnosis
Share the management options
Make effective use of the consultation
Use time appropriately
Prescribe appropriately
Develop and use your relationship
Give opportunistic health advice

Pros Cons
Patient centred
Easy to read, follow and implement

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Model 12 – The Calgary Cambridge Model (1996)15

We think this is currently the most favoured model in the UK (and no doubt in Calgary too!).
It’s the only comprehensive model which marries each of its components with the available
research evidence on the skills that aid doctor-patient communication.

Basically, it outlines 5 steps each consultation must go through. These 5 steps capture both
the disease and illness frameworks illustrated in McWhinney’s Disease-Illness model. It
combines process with content in a logical schema – emphasising the continuous need to
provide structure to the interview and to build the relationship with the patient whilst
journeying through the 5 steps.

The model also identifies the skills and behaviours required in each of these 5 steps. We’ve
listed a few in the diagram below to give you a taster. Across the whole 5 steps, 71 micro-
skills have been identified – you can now understand why trainees become all anxious and
apprehensive when they see this list for the first time. However, if you take some time to
read the 71 skills, you will come to realise that
a) It isn’t rocket science - most of them are things you probably do in day to day
communication with your family and friends
b) The authors don’t expect you to remember them all. Instead, they suggest you see the
71 skills like the tools in an electrician’s tool box. The electrician doesn’t use every
tool in his/her box to do a particular job – only the ones that are required. Likewise,
you’re not expected to use every one of those 71 skills to do a consultation – only the
right ones for the job.
c) Actually, if you tot up the skills that you’re unfamiliar with, you’ll probably find that
they’re only a handful.

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Pros Cons
Comprehensive – covers both disease The 71 micro-skills puts people off
and illness frameworks (i.e. it is doctor Probably best read after having read one
and patient centred). of the other more introductory ones first
It is comprehensive - applicable to all (like Tate’s Doctor Communication
medical interviews with patients. Handbook or Neighbour’s Inner
The only model that is evidence based Consultation).
Two separate books are available – one
for learning and one for teaching on it.

Skills (behaviours) in the Calgary-Cambridge Model

1. Introduction & Orientation • Greetings
• Introduction - self, role, nature of interview, requests consent
• Respect - demonstrates interest, concern and respect, attends to
patient’s physical comfort
• Opening question to identify problem that patient wishes to
address
• Listening without interruption
• Screening - checks if other problems patient is concerned about
• Agenda setting negotiates agenda taking both patient’s and
physician’s needs into account.
2. Gathering Information • Encourages patient to tell story chronologically
• Question style open to closed
• Listening attentively, not interrupting, allowing patient time
• Facilitation – use of encouragement, silence, repetition, etc.
• Cues
• Clarification
• Summarisation to patient - at intervals to check own understanding
• Language
3. Understanding Patient’s • Ideas/Concerns/Beliefs/Feelings
Perspective • Effects
• Expectations
• Picks up on cues
4. Providing Structure • Summarising
• Signposting
• Sequencing – logical sequence
• Timing & keeping to task
5. Developing Rapport • Non-verbal behaviour
• Appropriate level of note taking
• Not judgmental
• Empathy & support
• Sensitive
6. Involving the patient • Explaining thinking/rationale
• Explaining examination
7. Explanation • Comprehensive & appropriate information according to each
patient’s needs.
• Correct type, amount & level of information
• Clear information – avoid jargon
• Timing of information
• Avoiding premature reassurance
8. Aiding Recall and • Emphasis and use of aids
Understanding • Prioritising information
• Asking patient to restate
9. Achieving a Shared • Explanations linked to patients’ views, problems & requests for
Understanding information
• Invites questions
• Sensitive to patients’ signs of puzzlement, overload, etc. – picks up
cues
• Asks how patient feels about information

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10. Planning • Shared decision making

• Negotiates, offers choices, encourages patient to contribute ideas
and preferences, checks patient’s acceptance
• and decisions
11. Closure • Summarises, Agrees next step, Any final questions
Some of these skills will be second nature to you, some will be self-explanatory and others
will need further explanation.

Model 13 - The Three Function Model (2000)16

Cohen-Cole’s book16 has some really interesting and useful chapters – understanding the
patient’s emotional response, managing communication challenges, overcoming cultural and
language barriers, troubling personality styles and somatisation – just to mention a few!

The central concept in this model is that the interview has three primary functions

1. Gathering data to understand the

patient’s problems.
2. Developing rapport and
responding to the patient’s
emotions.
3. Patient education and motivation
(and thus behaviour).

Each of these is served by a particular set of skills. Clearly this is a deliberate simplification
but provides a framework for analysis.
Function Skills
Data Gathering 1. Attentive listening
To understand the patient’s problems. This must 2. Open-ended questions
be accurate and appropriate to elicit all relevant 3. Open to closed cone
biological and psychosocial data. This is crucial 4. Understandable terms – simple language
not only for diagnosis but also for understanding 5. Facilitating
personal and social context so that treatment 6. Checking
planning can be realistic. 7. Survey/Scanning of other problems
8. Negotiate priorities
9. Clarifying and directing
10.Summarising
11.Elicit patient's expectations
12.Elicit patient's ideas about aetiology
13.Elicit impact of illness on patient's quality of life
Emotions 1. Reflection – state the observed patient
Developing rapport and responding to patient’s emotion. This communicates a deep sense of
emotion. In other words, handling the emotional understanding and thus facilitates empathy =
and relationship component of communication to Rapport.
promote a positive relationship between doctor 2. Legitimation – a sense of the understandability
and patient. In this model, there are five types of of the emotion. Validating the patient’s
empathic responses a doctor can give feelings leads to trust and rapport.
(expressed verbally or non-verbally). 3. Support – provide emotional support
4. Partnership - collaborative doctor–patient
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relationships are generally more effective than

authoritarian relationships.
5. Respect - think about commenting on what the
patient is doing well. Need to be genuine.
Education & Motivation (Behaviour) 1. Eliciting patient’s existing views and
Motivating and educating patients to develop a knowledge
clear and shared understanding about the nature 2. Education about illness – readily understood
of the problems, what needs to be done about advice, giving rationale, checking
them and a shared commitment to carry this out. understanding
3. Negotiation and maintenance of a treatment
plan
4. Motivation of non-adherent patients – reinforce
common ground and partnership

Model 14 – BARD (2002)17

The BARD model focuses on the relationship between GP and patient and the roles each is
playing out. This model understands that the personality of the doctor and his/her previous
experience with that patient will affect the consultation. In doing so, it tries to raise our
awareness of the different roles being enacted and thus help us identify ways in which the
doctor’s personality and behaviour can be used to best effect. Warren says BARD aims o
‘encompass everything that happens during a consultation’ with reflection continuously
streaming in the background.

BARD summarised:
Behaviour How patients behave depends on how doctors behave – and we can change the
(verbal & way we behave! Being aware and making effective use of our behaviour at the ‘just
non-verbal) right’ points (the use of touch, for instance) will have a profound influence on the
direction of the rest of the consultation.
Aims The aims of the consultation need to be teased out and be made very clear. Both
patient and doctor need to have a shared understanding. If you don’t know where
you are heading, how will either of you know when you have arrived?
Room The environment will also influence the doctor-patient interaction – for example,
the seating arrangements.
Dialogue How you talk to the patient is crucial – your tone of voice, what you say, how you
say it. Does your dialogue marry with your behaviour?

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OTHER APPROACHES TO THE CONSULTATION

01 – Balint (pronounced Bay-lint) (1957)18

Michael Balint, the son of a GP, was born in Budapest in 1896. He came to Manchester in
1939 together with his wife, Alice, who unfortunately died soon after. He remarried shortly
after to Edna, but that didn’t last long either – ending in divorce. He then moved to London
in the late 40s and together with his third wife, Enid, started groups for GPs in the 1950s at
the Tavistock clinic. Enid played an instrumental role in Balint work but unfortunately never
seems to get the credit she deserves.

Anyway, they described an approach rather than a model. The GP groups engaged in case
discussion seminars about their difficult patients. If you read the book, you’ll realise that
many of those ‘difficult’ patients are what we call today ‘heartsinks’. The format eventually
settled into something like this:

Format of a Balint group discussion:

The group are reminded that the doctor-patient relationship is the central focus of
Balint group discussions. They are not there to problem-solve but to explore the
dynamics between the doctor and the patient.
Balint groups begin with the phrase ‘Has anyone a case today?’
A doctor then tells the story of a patient who is bothering him.
The group then discuss the case to help the doctor to identify and explore the blocks
which are obstructing the exploration and management of the patient’s problem.

Balint groups are still popular today. Doctors should be encourage to form and participate in
Balint groups because they are a powerful way of learning - one is studying and evaluating
one’s own experience and performance rather than analysing it in terms of an academic or
theoretical framework.

In their work with Balint groups, Michael and Enid developed a number of ideas and
philosophies which have significantly aided our understanding of the GP consultation. We
will describe the main ones below.

Patients cannot be divided into physical, psychological and social categories

because the three always co-exist. Psychological problems can manifest with physical
symptoms and organic disease can have psychological consequences. Doctors should
therefore try and understand the whole picture rather than colluding with patients in
medicalising their psychosomatic complaints.
Doctors can develop the skills necessary to explore psychological problems. It used
to be thought that whether a doctor explores the psycho-social domain depended on
his or her personality. Actually, it simply depends on using the right micro-skills.

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For example, attentive listening helps patients open up and feel better. Balint
described listening as a skill and held that ‘asking questions only gets you answers’.
Watch out for the simple ‘entry ticket’ – there may be something deeper lurking
behind. Balint suggested that we pay close attention to those patients who present
with a simple, discrete and easily fixed problem, like a cough and cold. Some of them
may be assessing the doctor’s approachability and whether they feel comfortable
enough to disclose the ‘real’ problem. He coined the term ‘hidden agenda’ for this
real problem and urges us to go look for it when things appear too simple and straight
forward.
Take control, otherwise no-one will and there will be a collusion of anonymity. A GP
needs to take overall responsibility for a patient with physical complaints as a result of
emotional distress (i.e. the somatising patient). Otherwise, that patient can end up
being referred and then be passed from specialist to specialist as each one investigates
and investigates before bouncing it to another department when they come to realise
that the problem has nothing to do with their specialty. This is not good for anyone –
the patient becomes more anxious, the hospital departments more overstretched and a
waste of NHS (taxpayers’) money.
Doctors have feelings and those feelings have a function in the consultation. An
awareness of those feelings might lead to insights which might help the doctor to
become more sensitive to the patient.
‘Selective attention’ and ‘selective neglect’ – whilst patients might reveal all their
cards on the table, what issues get carried forward is often decided by the doctor.
Doctors impose constraints on what is acceptable to explore in the consultation, often
unconsciously. For example, a doctor may have ‘incidentally’ picked up that a
patient has a problem with alcohol but veers away from exploring this because his
father died from similar problems and the feelings remain quite raw. The patient
might not be particularly keen either and that can lead to collusion.
The doctor as a drug refers to the doctor as a metaphorical drug that patients take
periodically to improve their health. The most powerful therapeutic tool in the
consulting room is the doctor – an effect over and above anything the doctor actually
does. Doctors who listen to their feelings can use this to powerfully influence the
patient’s thoughts and hence their total health – without even writing a prescription!
But be careful - the doctor, like a drug, may be therapeutic but can also have adverse
effects and invoke dependency.
Mutual Investment Fund – It’s important for GPs to invest in their patients through
spending time building relationships, sharing experiences and gaining trust. With
time, this creates a powerful bond that can be used to encourage patients to try
interventions which they previously would not have anticipated.
The apostolic function of the doctor – All of us have core values and beliefs. In the
consultation, a doctor can often transmit some of his core values and beliefs onto
patients – things like how they expect patients ought to behave and so on.
Sometimes this is done overtly but other times it is more subtle or implied.

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The Flash is that point in a series of consultations where you’ve suddenly fathomed
out what might be going on. During the flash, the doctor usually becomes aware of
his feelings in the consultation which he then feeds back in a way that can give the
patient some insight into the problem. Example: Dr Turner sighs as he sees Maude
Temple, a miserable and negative 64 year old on his list. He can feel her grating on
him. But wait! After all those consultations, he has a flash… He wonders if she
grates other people too. Perhaps people have divorced themselves from her. He also
wonders if he’s the only person she has. As he walks down the corridor to call her
into his room, he ponders on how he is going to explore this with her.

02 - Transactional Analysis (TA) (1964)19, 20

Many doctors will be familiar with Eric Berne’s (an American psycho-analyst), 1960's model
of the human psyche as consisting of three ‘ego-states’ or states of mind - Parent, Adult and
Child19.
Every single one of us has each of these three states. Berne said that at any given
moment, each of us is in a state of mind where we think, feel, behave, react or have
attitudes like that of a Parent, Adult or Child. Try and see each state like a video tape:
which one we ‘play’ at any given moment depends on the circumstance.
The one we play the most often, is our predominant ego state.
Two individuals who come together might interact well or badly depending on which
ego state each one is in. Some ego states are more successful at interacting than
others. The most successful consultations happen when both patient and doctor play
their Adult tapes.
Hence, TA helps us to look at consultations by focusing on the ego state the doctor
and the patient is in. If we (the doctors) can change our ego state, we can influence
which ego ‘tape’ the patient then decides to play.
TA is particularly useful for looking at difficult consultations with unsatisfactory
outcomes.

The three ego states are briefly defined here:

PARENT – takes away autonomy and control off the other person.
The foundation for this state comes from your experience of life with your parents and teachers. The
parent ego has two sides – the controlling, disciplining, restricting parent and the caring, loving,
helpful patient. The controlling parent is the one who scolds when their child comes home late for
supper after school. The caring parent is the one who is happy they arrived safely home. When we
feel, think, talk and behave in the way we remember our parents did, then we are playing our parent
tape. It’s usually the tape we play when we’re involved in any sort of evaluative process.
Critical Parent – words and phrases Caring Parent – words and phrases
Critical Doctor ‘You must stop smoking. Look Caring Doctor ‘Poor you. Your chest sounds
how bad your chest has become. You’ve only dreadful. Let’s see if I can make things better for
yourself to blame’ you.’
Critical Patient ‘I pay my taxes. Why can’t I have Caring Patient ‘Not to worry doctor. You’ve tried
antibiotics? This is just ridiculous’ your best’
Others Others

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that’s the limit, Oh dear!, what a shame,

why haven’t you…, take care to,
you must never… please remember to,
right and wrong – should and should’nt don’t be afraid to,
always and never – must and mustn’t I’ll help you,
good and bad - sensible and careless Oh Poor you.

ADULT – tends to be logical, factual, calm and collected.

The adult ego state is logical, rational and says things based on common sense. It is the mature and
deliberating part of your personality. As a result, your actions will be sensible and well considered.
The adult ego collects information, evaluates it, works out probabilities, tackles and solves problems,
all in a logical, calm and collected way. An adult ego asks questions and clarifies to seek ‘the truth’.
Words and Phrases
What do you think? Let’s experiment..
What are the choices? How can we move forwards from here?
Shall we find out…. How can we handle it best?

CHILD – tends to emotional!

This ego state represents the child you once were. It reacts emotionally with the feelings and instincts
of childhood. Like the parent state, there are two subdivisions of the child state. The natural (free)
child is primitive, impulsive, instinctive, undisciplined and demanding – that healthy uninhibited part of
us that is up for having fun, being playful and created. The adapted child ‘does as he is told’ and
gives rise to guilt, rebellion, disobedience and compromises. The adapted child lacks natural
spontaneity and can be petulant or sulky!
Natural (Free) Child – words and phrases Adapted Child – words and phrases
Yeah, that option sounds fab. I can’t do that because…
I want that one please. Okay, I’ll give it a try but…
Ugghhh.. I hate tablets. Can’t you…. Well, I hope that works

Many general practice consultations are conducted between a Parental doctor and a Child-like
patient. Although a Parent doctor can work effectively with a Child patient, this transaction is
not always in the best interests of either party. The ultimate goal is to achieve an Adult-Adult
type of consultation because we know it works the best. For example, if you make a contract
with the patient on Adult-Adult terms:
There has to be something in it for both parties – it is never one way.
The contract has to be equitable – mutual win if kept and mutual loss if broken
Breaking the contract needs to be stated in terms of consequences not punishment
It has to be renegotiable – if it is not working it could be because people or situations
have changed.

The key to understanding TA is to be able to identify which ego state the patient is in and to
decide whether it is a helpful or unhelpful state for them. If unhelpful, the doctor would
actively decide to use an ego state that would encourage the patient to play his/her adult one
instead.

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The ‘chronically sick’ or the ‘worried well’ often assume an unhelpful adapted child state.
Look at this example to see how the doctor can change all of that.
Patient: Oh doctor, those tablets, didn’t do a thing. In fact, they made things worse. Oh,
never again. (Adapted Child)
Doctor: In what way did they make you feel worse? (Adult – seeks facts)
Patient: Uggh… they didn’t agree with my stomach. Please, don’t ever do that to me again.
(Adapted Child)
Doctor: Okay, had you any thoughts about how we can move forwards from here? (Adult)
Patient: How about a different set of tablets? (Adult)
Doctor: The thing is we’ve already tried 10 different sets of tablets and you’ve tried other
things with other doctors. Does that say anything to you? (Adult)
Patient: Mmmmm…. Another tablet isn’t going to make a difference is it? We’re barking up
the wrong tree. (Adult)
Doctor: Mmmm. I think you might be right. So where do we go from here? (Adult)
Patient: Mmmm, sounds like I’m going to have to learn to start living with it. (Adult)
Doctor: What would help you do that? ……….(Adult)

The patient started off playing her Adapted Child tape. The doctor persisted with playing his
Adult tape and in doing so, eventually got the patient to play her Adult tape too. We hope
you can see how a familiarity with TA introduces a welcome flexibility into the doctor’s
repertoire which can help us break out of the repetitious cycles of behaviour (or what Berne
called ‘games’) into which some consultations can degenerate.

Ego state profiles – how to recognise which state your patient is in

Parent Parent Adult Child Child
Critical Nurturing Natural Adapted
WORDS THEY USE
Never Good Correct Fantastic Can’t
Should Nice How Fun Wish
Ought I love you What Want Try
Must Splendid Why Won’t Hope
Bad Tender Results Hate Please
Always Poor thing Practical Scared Thank you
Good Don’t worry Alternative Hi! Sorry
Ridiculous There, there Quantity Super Ought
Do Let me Where Mine Excuse me
Don’t Be careful Objective Secret After You
TONE OF VOICE
Critical Loving Even Free Whining
Condescending Encouraging Confident Excited Defiant
Sneering Comforting Inquiring Loud Manipulating
Disgusted Sympathetic Calm Giggling Apologetic
GESTURES/EXPRESSIONS
Closed Open arms Thoughtful Uninhibited Pouting
Points fingers Accepting Alert Loose Sad
Frowning Smiling Open Spontaneous Helpless
Rigid Caressing Straight Flirtatious Immobile
Angry Consoling Interested Wide-eyed Sullen
ATTITUDE
Judgemental Understanding Open Curious Agreeing
Moralistic Caring Level Fun-loving Compliant
Authoritarian Giving Evaluative Changeable Ashamed

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03 - Neurolinguistic Programming (NLP), (2002)21

In its basic form, NLP is a model based on determining how another person’s brain handles
information by observing their verbal and non-verbal signs. If you can pick out patterns and
match them then you are more likely to successfully influence them (i.e. getting onto the
same wavelength).

By looking at a patient, hearing what they are saying and sensing what they are feeling, you
should get some idea of
a) what a patient does inside their head as they think and
b) how they code information using their sensory systems - their internal representation
system.
Tapping into the perceptual system they use to ‘view the world’ will help you to ‘connect’
better with them.

There are three main types of internal representation, modal or perceptual systems:
(V) Visual (seeing),
(A) Auditory (hearing) and
(K) Kinaesthetic (feeling).

How can I tell if a person is predominantly visual, auditory or kinaesthetic?

NLP is more interested in how a person expresses something rather than the content of that
expression (i.e. process over content). The golden rule of NLP is therefore to watch, listen
and feel the form and not to get too bogged down by the content.

In General:
Visual people see the world predominantly with their eyes. They memorise things by seeing
pictures and are often good spellers. They would rather read than be read to. They tend to be
organised, neat and orderly. They may even dress well – either flamboyantly or carefully
colour matching their dress code. They tend not to be distracted by noise and prefer visual
instruction over verbal instruction (for instance, when giving directions). Give them too long
an explanation and their minds will wander off. They use phrases like: see you later, let’s
look at this, I see what you mean, that looks great, let’s be clear about that, keep an eye on it
and so on.

Auditory people sound out the world with their ears. For instance, when talking to them,
they might repeat some of your words. They learn by listening and will prefer hearing
someone speak as opposed to looking at their PowerPoint slides. Unlike Visual people, they
are distracted easily by noise (they need peace and quiet in order to revise!). Be careful with
what you say – they will respond to the set of words you use and the tone in which you say
them. They use phrases like: hope to hear from you soon, let’s sound that out, I hear what
you’re saying, that sounds brill, we need to keep our ears firmly on the ground…

If a person talk to him or herself (as if they’re in a conversation with themselves) they are
more likely to Auditory Digital than Auditory.

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Kinaesthetic people make sense of the world through feelings and emotions. They stand
close to people and physically interact with them. In fact, they’re often physical themselves –
of athletic build and always seem ‘on the go’. They learn things by doing, practising or
playing – for instance, they’ll often dive in and start playing with a new electrical gadget
rather than read the instructions. They use phrases like: keep in touch, let’s get a feel for
what it would be like, I sense that what you’re saying is, that feels brill, we need to keep our
fingers firmly on the pulse, she needs get a grip….

Listen carefully to what people say

The words people use help construct the life they lead. From the general descriptions above,
we hope you’ve noticed how the words tell you what sort of internal dialogue they use and
how they see the external world. If you listen carefully to their words, you should be able to
identify whether a person is V, A or K. For instance, if you explain something to somebody
and they now understand your point of view:
A visual person would say ‘I see what you mean’
An auditory person would say ‘I hear what you’re saying’
A kinaesthetic person would say ‘I’m totally in touch with you’ or ‘I know the feeling’.
(More examples of phrases to differentiate the three modal systems on our website.)

In the context of the GP consultation:

Listen carefully to the patient’s use of words
Then try doing the management and explanation using words from the patient’s
primary modal system.
You might use pictures and diagrams to explain something to a visual patient, give
clear verbal instruction to the auditory patient, and demonstrate and get the patient to
have a go for the kinaesthetic.
Look into their eyes…
You can also figure out what modal system a person is in by following their eye
movements

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Visual imagination – seeing into the future, constructing visual fantasies

Visual memory – seeing the past
Auditory imagination – hearing the future, constructing sounds and words
Auditory memory – hearing the past, remembered sounds and words.
Feelings – current feelings – both tactile (touch, temp etc.) and emotional (happy, sad etc.)
Inner dialogue/Auditory digital – making sense of what is going on, self-talk (often people who
talk to themselves – engage in the dialogue within).
Eyes defocused, looking straight ahead: quick access of sensory data, usually visual

In some cases (for example some left handed people), these visual accessing cues are
opposite – e.g. visual imagination is where visual memory would normally be and vice versa.
Ask some of the questions in the diagram above to see if they match.

The next time you have a conversation with someone, pay attention to their eye movements.
However, watching their eye cues does not tell you what they are thinking. Instead, it tells
you which representational system they are thinking – V, A or K – are they remembering or
constructing something or are they in a conversation with themselves (self-talk). Also
remember that the power to influence others depends on you moderating your external
dialogue to match (or accommodate) their predominant ‘modal’ style.
Hey, try this…
The next time you go to the dentist, look up and visualise something. Why? Because
looking down is where your touchy-feely sensitive and emotional side is – and if you do that,
you will intensify your focus on the drilling and grinding.
If you’re feeling a little miserable today, look upwards. Why? Emotions are connected
with looking down (feelings).
If you ask someone a question and they look down before they answer you… beware
of the truth in the response. Why? Looking down means they had a conversation with
themself before deciding on what to say to you.

Pace, Pace and Lead

Another (one of many) NLP technique to influence people is pace, pace and lead. This
involves match what the other person has just said (or what you expect they are thinking) and
then leading them to a new, hopefully more beneficial ‘answer’. In practical terms, this
means stating two truisms that you know the other person will agree with before introducing
your own statement of influence. For example, to a patient with depression you might say:
‘I know that you’ve really had to pluck up the courage to come and talk to me today’ (she nods)
‘And I know that you’re a bit apprehensive about being referred to a counsellor’ (she nods)
‘But sometimes you have to take chances and give things a try to be truly happy. Perhaps giving
counselling a try?’ (she nods)

By adding your own statement to two things you know the other person will agree to, the
more likely it is that they will automatically agree to the third statement and accept it as true.

NLP has become a sort of panacea treatment for ‘everything’ from anxiety and phobias to
teaching and learning – just type in NLP into an internet search engine to get a flavour of all
the things NLPists claim they can do! Lewis Walker’s book21 focuses on NLP techniques
purely to improve communication with patients.
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04 - Narrative Medicine (2002)22

Most of us consult by focusing and analysing the patient’s behaviour – ‘Mmm… she doesn’t
seem so upset by that. I wonder why that is. Is it because…’. A narrative approach
encourages us to more away from this ‘need to analyse’ and instead concentrate, understand
and become involved with the way a patient describes their story – for example, their
experience of the illness. Narrative studies explore the way people tell stories and narrative
medicine focuses on patients’ histories as story-telling.

A narrative approach is not saying that you ignore the biomedical model. Nor is it saying
forget about evidence-based medicine. At a basic level, all these frameworks are different
ways of looking at the same thing. If you do the evidence based or biomedical bit without
paying any attention to the narrative, then you are only exploring one aspect of the truth.
Moving flexibly between the models will help you get closer to the ‘real truth’.

A narrative approach is important because the way we all interact with people around us and
the way we understand the world is based on ‘shared stories’ – and if we can help patients
‘weave’ new stories, perhaps we can change their view of reality.

People using a narrative approach are not trying to peel away the layers of an onion, looking for the
‘inner meaning’ concealed at the centre. Instead, they see reality more like a tapestry of language that
is continually being woven.
23
John Launer, www.johnlauner.com

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The Seven Cs of Narrative Medicine

John Launer23 talks about the Seven Cs that are needed to help you get into the right frame of
mind when you’re contemplating on consulting in a narrative way.

Conversations. A conversation is a true two way dialogue to help you both to

understand things better and hopefully develop new insights (and not just to collate
facts). And don’t forget that the conversation process in itself can be therapeutic in its
own right – getting people to think, reflect, reframe and redefine their stories.
Curiosity. You have to get involved with the conversation and that means genuinely
being interested and curious. Those queries you raise will help the other to think and
reflect – and perhaps helping them to reframe and redefine their stories.
Contexts. Conversations are nothing if they are not in context (i.e. in the context of
their families, friends, community, beliefs, values and so on). Note the context in
which the story teller puts his/her story. How have they decided to ‘frame’ their
story? Be curious and clarify.
Complexity. Life is not simple. So why do we (doctors) always try to fix life’s
problems with concrete and rigid solutions? Try and move away from that. Move
away from ‘cause and effect’ mentality; simply go with the patient, his/her story and
see where that interaction takes you. Don’t worry too much about not knowing where
you’re heading.
Creativity. Can you help patient’s create a better account of what’s going on for
them? Can you help them make a better story? Better stories create better realities.
Caution. Sometimes, patients come in with straightforward problems/questions for
which they want straight forward answers. Don’t hammer this approach where it just
doesn’t fit in.
Care. You have to show genuine care for the narrative approach to work. That
means being truly listening, showing respect, treating others as equal and showing a
true genuine interest in wanting to help the person.

Pros Cons
A different way of looking at things rather Patients have questions and most want
th
than the traditional 18 Century traditional explanations.
mind/body dual theories – is science the Takes time – we work in a pressurised
only truth? NHS.
Expands our own development and How do you know you’re not opening a
thinking – of cultures, our beliefs and of can of worms? No-one should play post-
life. modernist games with patients’ lives.
Encourages patients to define THEIR
own stories and lives (and take
responsibility)

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Getting trainees to think in terms of constructs and triads

Some trainees will find it useful to think in terms of constructs and triads because
a) They provide a framework for a particular situation
b) In doing so, they encourage them to think more laterally
c) They help uncertain situations become more certain.

Constructs
Constructs are mental grids or frameworks that can help a trainee handle a specific situation.
Management options (RAPRIOP) Who can you involve in patient care?
Mr. Simons comes to see you regarding back Practice Staff – practice/district nurse, HV,
pain. What are the options available to you? midwife
R Reassure Hospital – consultant, physio, OT, etc.
A Advise (or Educate +/- leaflets) Social Services – social worker, home
P Prescribe (or Carry out a procedure) care, meals on wheels, day centre,
R Refer sheltered housing, residential or nursing
I Investigate care, respite care.
O Observe and follow up Voluntary Sector – CAB, CRUSE, Care
P Prevention and Health Promotion groups
Breaking bad news (A KISS S) Dealing with the angry patient (AFVER)
A Anxiety - acknowledge Mr Trueman is furious over not being antibiotics
K Knowledge– what do they already know? over the phone. How would you manage this?
I Information–how much info do they A Avoid Confrontation
want? Keep it simple, avoid overload. F Facilitate discussion
S Sympathy + emotional management V Ventilate Feelings
S Support – ask what would help E Explore Reasons
S Summarise strategy and key points R Refer/Investigate
24
Conflict situations Reattribution of somatising patients
What would you do with a patient who demands a
specialist referral for something you consider 1. Feeling understood
trivial? 2. Broadening the Agenda
D Disagree 3. Making the link
A Agree 4. Negotiating treatment
N Negotiate a compromise
C Counsel Type the words ‘reattribution gask’ into Google if
E Educate you want to learn more about this.
rd
R Refer to 3 party
Ethical considerations (ABC+CDE) Planning change (APRIE)
A Autonomy (patient) – be fair (Justice) e.g. you’re thinking of setting up a new sexual
B Beneficence health clinic
- ‘above all, do no harm’
- ‘do good where possible’ A Assess - consider all problem areas
- Moral theories (Aristotle) P Plan – decide what needs to be done.
C+C Consent + Confidentiality R Resource – availability, fund raising
D Do not lie (Honesty) I Implement – who does what, when etc.
E Everybody else (Society vs. Individual) E Evaluate - the service and fine tune.
- virtue, duty, utility and rights.

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Triads:

There’s too much. Just give me some recommendations.

For new trainees, encourage them to read one of:
Roger Neighbour’s The inner consultation13
Peter Tate’s The doctor’s communication handbook14

For ST3 trainees, encourage them to read (both?):

Silverman et al Skills for communicating with patients15 (Calgary Cambridge)
- really good in terms of tackling core generic skills common to all consultations.
Liz Moulton’s The Naked Consultation25
-trainees find this book invaluable in terms of consultation skills for specific situations
(which often come up in the CSA).

As a GP Educator (if you’ve read the above) consider reading:

Salinsky and Sackin’s What are you feeling, doctor? 26 (Balint’esque)
Donovan and Suckling’s Difficult consultations with adolescents27
John Launer’s Narrative based primary care22
Lewis Walker’s Consulting with NLP21

Closing Statement
Having a wide array of models can be seen as either confusing or as adding richness. We’ve
presented a comprehensive list of them because we see them as useful toys. Why limit
yourself or your trainee to just one toy? By playing with several you will, eventually, find
your personal favourite. Exactly how you play with your newly found favourite toy
thereafter (= your consulting style) is entirely up to you.

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 This web chapter accompanies the book: ‘The Essential Handbook for GP Training & Education’ (Editor: Ramesh Mehay)

Other resources on our web

Byrne & Long on the Consultation
The Seven Cs of Narrative Medicine
A model for working with somatisers – Reattribution

Other chapters you should read

In the book - Chapter 23: Road Maps for Teaching on the Consultation

References
1. ‘The Future General Practitioner - Learning and Teaching’ by a Working Party of The Royal College of General
Practitioners (1972)
2. Med Care. 1975 Jan;13(1):10-24.Sociobehavioral determinants of compliance with health and medical care
recommendations.Becker MH, Maiman LA.
3. Publication: Six Category Intervention Analysis in British Journal of Guidance & Counselling, Heron (1976)
4. Publication: ‘Doctors Talking to Patients’ by Byrne PS & Long BEL (1976. A very detailed analysis and not very
easy to read!
5. Publication: ‘The Exceptional Potential in each Primary Care Consultation’, Stott & Davis (1979) J R Coll Gen
Pract. 1979 Apr;29(201):201-5.
6. Publication: Disease versus Illness in General Practice in J R Coll. Gen. Pract. vol 31 pp 548-62, Helman CG
(1981)
7. Publication: The Consultation: An Approach to Learning and Teaching by Pendleton D, Schofield T, Tate P &
Havelock P (1984). Second Edition is easy to read.
8. Publication: Problem-based interviewing in general practice: a model., Lesser AL., Med Educ. 1985 Jul;19(4):299-
304.
9. Publication: JH Levenstein, EC McCracken, IR McWhinney, MA Stewart, and JB Brown, The patient-centred
clinical method. 1. A model for the doctor-patient interaction in family medicine, Fam. Pract. 3: 24-30. 1986
10. Levenstein JH, Belle Brown J Weston WW et al (1989) Patient-centred clinical interviewing. In Communicating
with medical patients (eds M Stewart and D Roter) Sage Publications, Newbury Park, CA.
11. Roter DL, Stewart M, Putnam SM, et al; Communication patterns of primary care physicians. JAMA. 1997 Jan 22-
29;277(4):350-6.
12. Stewart M et al (2003) Patient-centred medicine: transforming the clinical method. Radcliffe Medical Press
Abingdon Oxford
13. Neighbour R, The Inner Consultation: how to develop an effective and intuitive consulting style. Roger
Neighbour (original 1987, 2nd Edition 2004)
14. Tate, P. The Doctor’s Communication Handbook by Peter Tate (Original 1994, 6th Edition 2010)
15. Silvermann, Kurtz and Draper, Skills for Communicating with Patients by Silvermann, Kurtz and Draper (1996)
16. Publication: The Medical Interview: The Three-Function Approach by Cohen-Cole & Bird (2000).
17. Publication: An introduction to BARD: a new consultation model, by E Warren (2002)
18. Publication: The doctor, his patient and the illness. Michael Balint. First published 1957, update 1964.
19. Publication: Games People Play: The Psychology of Human Relationships, Eric Berne (1964). A difficult book to
read – try looking for a modern version like:
20. T A Today: A New Introduction to Transactional Analysis by Ian Stewart and Vann Jones (1991) or I’m Okay,
You’re Okay by Thomas Harris.
21. Publication: Consulting with NLP by Lewis Walker (2002)
22. Launer J, Narrative-based Primary Care: a practical guide. John Launer (2002)
23. http://www.johnlauner.com accessed 18/02/2011
24. Reattribution by Linda Gask – the paper.
25. Moulton, L. The Naked Consultation: a practical guide to primary care consultation skills
26. Salinsky & Sackin. What are you feeling, doctor.
27. Donovan & Suckling. Difficult consultations with adolescents.

Source of this document: www.essentialgptrainingbook.com

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