Consultation skills

Question 1

Calgary Cambridge Model

• What are the 5 stages?
• For each, what is involved?

Answer 1

1. Initiating the session: preparation, introductions, allow patient to speak (‘Golden Minute’), identify list of relevant problems, summarise, signpost, set agenda and expectations
2. Gathering information: ask open and closed (red flags, etc.) questions to gather all relevant info, summarise
3. Physical examination
4. Explanation and planning: explore likely diagnosis and management. Shared decision making. Must be individualised to patient need (e.g. occupation)
5. Closing the session: summarise, safety nets, chunk and checks with patient, next steps (e.g. review)

Question 2

Dealing with difficult/confrontational patients.

a) Reasons for difficulties
b) Techniques to deal with them

Answer 2

a) Patient (psychiatric, substance abuse, uncooperative, demanding, etc.), Doctor (HALT- hungry, angry, late, tired), Disease (e.g. MUS, chronic pain, poor outcome), System (limited resources, support, time pressures, etc.)

b) - Verbalise the difficulty/elephant in the room (“It’s clear we have a difference of opinion here”).
- Explore reasons for hostility (e.g. patient anxiety) and re-frame the problem.
- Find common ground.
- Set boundaries and be consistent (beneficial in the long-run.
- Focus on the solutions not the problems and agree on a plan.

Question 3

Breaking bad news: SPIKES (step 1 - S)

Answer 3

Setting up the interview:

• Setting (private room)
• Significant others (family, etc.)
• Sit down
• Silence bleep

Question 4

Breaking bad news: SPIKES (step 2 - P)

Answer 4

Perception:

• Establish what patient knows so far
• ‘What have you been told so far?/ What do you know about X?’

Question 5

Breaking bad news: SPIKES (step 3 - I)

Answer 5

Invitation:

- Obtain the patient’s/relative’s invitation to proceed in telling them the difficult news

Question 6

Breaking bad news: SPIKES (step 4 - K)

Answer 6

Knowledge:

• Give the patient knowledge of the news.
• “I am afraid I have some bad news to tell you”

Question 7

Breaking bad news: SPIKES (step 5 - E)

Answer 7

Emotion and empathy:

• Identify the patient’s emotion (shock, sadness, disbelief)
• Respond to it empathetically (“I can see this must be hard for you”, “I wish we could have had a better outcome”, etc.)

Question 8

Breaking bad news: SPIKES (step 6 - S)

Answer 8

Strategy and summary.

- Devise clear plan with the patient (shared decision making)