The 'Consultation Model' from a Christian Perspective

'Connecting'

What’s my Consultation Model? (Reflection on the GP Consultation Model)

After reading a blog published by a senior GP who considered kindness a 'key' element to a good consultation and personal reward:

'Neal Maskrey: The importance of kindness'

(1 Jul, 14 BMJ)

http://blogs.bmj.com/bmj/2014/07/01/neal-maskrey-the-importance-of-kindness/

It made me reflect on the consultation models available, and try to clarify as to which one I tend to follow in my day-to-day practice, and whether there are any additional changes I tend to make, as part of my practice as a locum GP.

This blog emphasised kindness as an important consideration on retrospective gaze by this retired GP.

It is true that on many occasions I have felt that there were days of new self-discovery in an attempt to find and refine my ‘natural’ model of consultation, before I finally realised the best one for me, that most often resulted positively with consideration to the well-being of the patient and physician (in terms of patient satisfaction through questionnaires and verbal feedback, and personal job satisfaction). I would also have to agree that ‘kindness’ is a key element to the good consultation. However; to inject kindness into many of the rigid 'prescribed' consultation models given to us can be difficult to apply practically during the hectic humdrum lifestyle of modern day medicine, whether on the wards or working in isolation in a practice.

Alongside this, there are other barriers and personal challenges; such as humbling ourselves in practice, interacting genuinely with others to show due care and consideration, and shifting our focus to others. This is so that we can feel supported (knowing we are doing the ‘good’ consultation…not just the ‘acceptable’ consultation) to strengthen others.

However, to progress, we also must fight against the temptation to dismiss and trivialise the importance of these fundamental humanitarian skills and traits (which we ‘sweepingly’ swear oaths to on entering the prestigious medical arena), as playful ‘micky mouse’ medicine of little significance in real day-to-day life.

(Romans 12:9)

'Let love be genuine. Abhor what is evil; hold fast to what is good'.

(2 Corinthians 1:4)

'Who comforts us in all our affliction, so that we may be able to comfort those who are in any affliction, with the comfort with which we ourselves are comforted by God'.

When we revise the guidance from the Oxford Handbook of General Practice in terms of consulting.

It is of no surprise to us that the potential barriers to effective communication with patients fell into lists of:

-Lack of time

-Language problems

-Differing gender

-Age

-Ethnic or social background of doctor and patient (note the care not to mention 'Religious' backgrounds)...although in recent times we have seen more evidence and media coverage of how differing opinions of religious sects have been more dividing in society than uniting...from race/culture to gender acceptance. Surely these personal beliefs of patient and doctor have a potential to be a barrier in communication, particularly the consultation.

But as we read these examples, they form part of a larger divisible list of human traits:

-PRIDE

-SELF-CENTRED

-DISCRIMINATION and STIGMA

-APATHY

...all of which (as human beings we are 'allowed' to entertain to personal degrees (some hidden, some openly expressed) as we operate 'lawfully' within society.

These follow more a moral code of conduct; we may be in-keeping with 'human rights', but may not necessarily be 'righteous'.

…So don’t these deep-seated imbedded (possibly indoctrinated) personality characteristic traits affect our interaction with one another, especially within the 'caring profession'?!

I agree with the adage that Good communication is essential...but can this be achieved through an artificial, prescribed, formulated or algorithmic consultation model? (Especially since, as doctors we learn much this way as part of our learning style in medical school e.g. ‘Treatment of acute myocardial infarction’, or the ‘causes of Pancreatitis’...but can we really apply such rigid frameworks of learning and application to our patients?

One statement which stood out for me, from the General Practice Handbook was; 'The consultation is the cornerstone of general practice and focusses on successful information exchange'. This shows how much emphasis we should put on the consultation in practice, but then when you read further, seeing that 'there is no 'correct' way to perform a consultation', and knowing that 'the approach will vary according to situation and participants', it is easy to feel a bit lost as to ‘where is my cornerstone in choosing the consultation model for me?’. Or ‘should I even have a model at all, if it is going to be in a constant change of flux due to dynamic shifts in ‘problem’ topics, ‘client’ personalities etc.?’

From reading this, I wonder whether compassion and empathy should be integrated into this definition, alongside the successful information exchange (or is that what they deem as 'successful, without alluding to it...or is success the avoidance of complaint?)

Without being flippant; sometimes I find the potential variation in interpretation of instruction for 'Good' general practice and variation in practice of General practice, comparable to how some people judge the variability of interpretations of religious scriptures and application of them in their lives.
Does it mean that, because there isn't a calibrated correct way to perform...(I don't like this word 'perform', it makes the whole process seem artificial like an act, but does this too imply that you can 'act') a consultation out in hundreds of ways, and they won't all necessarily be correct, or good for that matter?

So I think the question then we have to ask ourselves is, “if there isn't a specified correct way to carry out a consultation...is there a GOOD way?”

I like to think there is good way, but the cornerstone is not the consultation, but He carves out the perfect consultation for the occasion, if followed.

'Jesus Christ Himself being the chief cornerstone, in whom the whole building, being fitted together, grows into a holy temple in the Lord, in whom you also are being built together for a dwelling place of God in the Spirit'. (Ephesians 2:20-22)

Also, good communication (although essential) cannot be guaranteed in every consultation; as the situation may appear 'hopeless', spirits may by high and low, personalities passive and aggressive...On BOTH sides (Doctor and Patient)...so how to standardise practice then?

'But the fruit of the Spirit is love, joy, peace, longsuffering, kindness, goodness, faithfulness, gentleness, self-control. Against such there is no law'. (Galatians 5:22)

...I can only speak for myself here, but I know that when the Holy Spirit is working in our consultation, good communication is also a fruit of this; although some patients may not want to find resolve with matters (often psychological and spiritual), again it helps to put forward the question with comfort and authority:

'When Jesus saw him lying there, and knew that he had already been a long time in that condition, He said to him, "Do you wish to get well?" (John 5:6)

...this has helped me many times when faced with the so-called 'Heart-sink patients', who are choosing to continue self-destructive behaviours or addictive habits that they want me to solve, without even wanting to be made well, but have identified with this 'state of sickness'...or otherwise known 'health-seeking behaviour'.

The consultation must be patient-centred, but how can we guarantee to show empathy and compassion to every single person to make that patient feel that they are the centre, and to understand their unique experience of illness (as we so often are instructed to do, with no further advice). I know that whenever I have tried this, from my own proud perspective of 'wanting to be liked', or 'that kind doctor all the patients want to see', I end up exhausted in my own vanity and cannot sustain this practice, and it resorts back to that variable emotional model of 'HOW AM I FEELING TODAY?'

'Behold, is it not of the LORD of hosts that the people shall labour in the very fire, and the people shall weary themselves for very vanity?' (Habakkuk 2:13)

Even, the time constraints in practice can be pressuring on our ability to connect with our patients, particularly those with complex issues.

The UK consultations are a third shorter than those in other parts of the world, but does being shorter equate to better quality? When more thorough holistic consultations (Bio-psycho-socio-spiritual models) can result in less appointments and an overall reduced demand on GPs’ and A&E attendances?

If we give time to our patients (for those that NEED time)...not only need in one area of the health spectrum e.g. physical illness, but also psychological; we will be able to see the BIGGER PICTURE and have a more proactive input in helping find solutions. It could effectively 'tie'/link problems presented (particularly as somatisation of illness and behavioural cause are common presenters), and this could result in improved patient satisfaction of care, less recurrence with repetitive poorly managed problems, by multiple doctors with potential exacerbating 'patient-doctor' barrier issues. It could also account partially for why some of the mental illness spectrum disorders, e.g. Depression are considered recurrent illnesses with ‘unsatisfactory outcomes’.

So, I had a brief read through the targets of some of the available consultation models.

One recurring theme I noticed was that they were more a list of ideals, overall utopic achievements, as opposed to a practical methodology of how to achieve them. For example:

-Balint 1957 (already played down as a philosophy rather than a consultation model)
'Doctors have feelings. Those feelings have a role in the consultation'.
'Doctors need to be trained to be more sensitive to what is going on in the patient's mind during a consultation'
...I agree on these points, but I have to ask how do we train to be more 'sensitive' when we learn to become desensitized to death through regular exposure (to protect our mental health and 'peace of mind'), and when we see so many people with illness, where does this sensitivity come from? Do I have reserves? What if I don't, will I dry and shrivel up and become depressed?! "Aaahhh I think I'm having a panic attack!!!"
...or is there room for us to be more spiritually receptive, so that we might receive comfort through our shared sufferings with patients, so that we too can comfort them.

'Who comforts us in all our affliction so that we will be able to comfort those who are in any affliction with the comfort with which we ourselves are comforted by God'. (2 Corinthians 1:4)

-RCGP, 1972 'The Triaxial approach'-which looks at the physical, psychological and social aspects of the consultation...but not the spiritual (because there is no evidence...a model that requires faith)

...but hold on, some of these other existing models require faith as well:

-Becker and Maiman, 1975 Health Belief Model: which involves exploration of concerns, beliefs and expectations of the patient.
...surely this must be difficult for the doctor to explore if they have no beliefs of their own that they have explored!
Also these beliefs still fall into a worldly model of 'seeing is believing', and this can give unrealistic expectations from both the doctor ("Nowadays we can cure practically everything") and the patient ("The doctor can solve everything").
It's no wonder so many physicians have had a tendency to fall to the 'god-like' complex!

Some models follow more of an EMOTIONAL route, for example the:

-Helman Folk Model 1981, with the series of questions:
What's happened? Why has this happened? Why me? Why now? etc.
...This tries to target more those emotive 'reflex' questions...but the patient still has to believe in the doctor's answer. If they don't then this model also fails. So it requires faith in the doctor.
It's a bit like the Emotional 'Spiritual' questions people often ask: "what if God doesn't exist?" "What if I'm wrong?"...knowing that there is no answer because faith is fundamental as part of the healing process.

'Now faith is confidence in what we hope for and assurance about what we do not see'. (Hebrews 11:1)

And models like Pendleton et al, 1984; although are trying to reach a shared understanding between doctor and patient, it still relies on the authoritative opinion of the doctor to:
-'DEFINE the reason for the patient's attendance'
-'CHOOSE an appropriate action...'
...in reaching a 'shared' understanding (that may not always be equal)
Although I commend the involvement of the patient in the management and encourage the patient to accept appropriate responsibility, which I believe is important as part of being peaceful, to the best of our extent, and so people can do some soul searching and change behaviours that could be self-destructive (e.g. addiction and relationship problems).

Some patients' think we are supposed to treat this 'deep-seated' psychological and spiritual wound with some 'superficial coping plaster' like, "try a Nicorette patch", or "pull yourself together", with awareness of the danger of things getting worse if they CHOOSE to continue, so that we can SUPPORT, not do the work for them.

'If possible, so far as it depends on you, be at peace with all men'. (Romans 12:18)

It was funny, on this reflection to note that I have always gravitated towards the Neighbour model (The Inner Consultation), 1987, which has five branches:
-Connecting
-Summarising
-Handing over
-Safety netting
-Housekeeping

...broadly speaking these still feel like a list of ideals, but I have come to realise that it allows for a 'deeper' spiritual dimension (particularly in the CONNECTING), according to individual belief and interpretation.
...So (for me) I have incorporated (as part of my list of ideals) into this model, three sections from the book of Romans chapter 12, which I will share:

'Let love be without hypocrisy. Abhor what is evil; cling to what is good. Be devoted to one another in brotherly love; give preference to one another in honour; not lagging behind in diligence, fervent in spirit, serving the Lord'. (Romans 12:9-11)

My hermeneutics thus:
+Love in Christ (He is my cornerstone) and God is love and will strengthen you to Love others. He will also testify for Himself through your deeds... never agree to force your religious beliefs on others, although you should continue to live by them.
+Be kind and honest (IT IS NOT AN ACT): I like to think that I am speaking with a brother, a sister, a mother, a father (who is created good by God)...and I must behave as such. When I do this, I often show the right amount of love and compassion to my patients. I shared this advice with a Hindu friend who was sitting her CSA exam, and she struggled with the anxiety of the 'artificial environment' of the exam setting. I advised her, (if not in Christ), to see each patient as family. She then managed to be aware of some of the hidden agendas, which you or I would not normally allow to escape from a conversation with our most trusted beloved members of family and friends. I personally don't know why we don't continue to do this with other people...we are dealing with people at the end of the day in a vulnerable and trusted capacity. It isn't the same setting as for a business client or a shop keeper; we have a personal responsibility to our patients, so shouldn't we also respect this role with such care and persistence?
+Be assertive: speak up against those who are trying to disrupt the peace, for example those who are manipulating you, doesn't mean that you have to sit there and be manipulated or abused verbally; you can speak up peacefully, expressing your limitations, your views, being overwhelmed with some of the 'shopping lists' and can fairly HAND OVER responsibility to the patient.
+Be passionate in the spirit: for example, look forward to seeing your patients (sometimes go out of your room to greet them and walk in to the consultation with them).

'Bless those who persecute you; bless and do not curse. Rejoice with those who rejoice, and weep with those who weep. Be of the same mind toward one another; do not be haughty in mind, but associate with the lowly. Do not be wise in your own estimation. Never pay back evil for evil to anyone. Respect what is right in the sight of all men. If possible, so far as it depends on you, be at peace with all men'. (Romans 12:14-18)

+Don't get upset with those who are aggressive (remember people suffer and express fear and upset differently).
+Rejoice with them: (this is also encouraging for patients when they have tried, and had any success (regardless big or small), e.g. a reduction of weight, change of lifestyle to a better one, this should be genuinely praised).
+Don't be afraid to show sadness (we are emotional beings), and this does help us CONNECT with our patients when appropriate.
+Be humble in practice. This is a privilege, and should be respected as such, it is not something we deserve, but it is a place that we have been put to serve others.

…I believe if you give the consultation to God, regardless of your work-setting, He will refine it and create the perfect Model for you.

(1 Thessalonians 4:4)

That each one of you know how to control his own body in holiness and honour’.

Further suggestions to part of the consultation, particularly those in General Practice:

1) Consecration of the clinic: pray beforehand for your patients and the Holy Spirit to flow in the clinic, and consider that you are sitting in with Christ.
'Be anxious for nothing, but in everything by prayer and supplication with thanksgiving let your requests be made known to God. And the peace of God, which surpasses all comprehension, will guard your hearts and your minds in -Christ Jesus'. (Philippians 4:6-7)

2) Prepare for the clinic
'Prepare your work outside and make it ready for yourself in the field; Afterwards, then, build your house'.(Proverbs 24:27)
...Possibly try to come to surgery early to go through the patients and summarise the main points (e.g. relevant blood results, last consultation queries, recent hospital appointments etc.), trust God will give you what else you need to know, or will show you how to find it...and He will never let you down.
The ‘Johari window’ of knowledge (they often teach to medical students) puts a box there for the things ‘you don’t know that you don’t know’…well God knows this and more, including the things that are not contained within the Johari’s box, for instance things you think you know, and everyone thinks they know, but actually do not know…for example the corrupted article on Autism linked with MMR vaccine. How many of us at the time knew this was not true?! So I would advise to never rely only on your own understanding.

3) Always take time to pray. Even if you don't always get time to prepare for clinic for whatever reason (e.g. weather conditions delaying my arrival, visits etc.), but know that praying will prioritise your trust that God will organise and prepare yourself for your work.

'One hand full of rest is better than two fists full of labour and striving after wind'. (Ecclesiastes 4:6)

…also for any of those blessed to work in Christian practices or with Christian colleagues, I would urge you to take opportunity of this; maybe to have prayer meetings for patients you might be worried about. Also for Christian fellowship and support for what is potentially a demanding, emotionally draining, yet rewarding career. And never rule out praying with patients, I would say (particularly for some of my palliative patients), praying together, (with expressed permission from the patient) has been strengthening to both in times of despair.

4) Thank God always for the surgery/clinic and then try and forget, or 'let the clinic go' in your mind.
Many a time, I've realised that if I dwell on ‘my’ deeds, even after a good clinic...the devil has tried to exhaust me in pride and vanity, and may even bring doubt and worry to my mind. Better to ‘Let Go and Let God’, and you will be renewed in strength in Christ for further clinics.
And by giving Him the glory protects you from pride, which is a barrier between you and God, and yourself and others.
'I can do all things through Him who strengthens me'. (Philippians 4:13)

...So in conclusion, my consultation is the ROMAN NEIGHBOUR MODEL (not Roger Neighbour) and follows this commandment (which still incorporates my NEIGHBOUR...without Roger :)) :

And he answered, "YOU SHALL LOVE THE LORD YOUR GOD WITH ALL YOUR HEART, AND WITH ALL YOUR SOUL, AND WITH ALL YOUR STRENGTH, AND WITH ALL YOUR MIND; AND YOUR NEIGHBOUR AS YOURSELF." And He said to him, "You have answered correctly (Luke 10:27).

…So what is your Consultation Model?

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