Hema Here!
Give me a Biggg Hi5!
For those who are really busy and have no time for Roger!
I have added what Ramesh says about Roger for a 'Quick Start'!
(I luv Quick Starts when struggling with new techno)
Dr Ramesh Mehay has kindly allowed us to use all of his materials from his website!
The great www.bradfordvts.co.uk.
Thank You, Dr Mehay!
You can access the original article by the following one of the options ( I am still in csa mode)
Option 1 - Google 'Inner Consultation' and follow the 4 th link.( It is working)
Option 2 - Search from www.bradfordvts.co.uk
Option 3 - www.bradfordvts.co.uk/.../0200consultation/consultationmodels/
Let us read what he says about our Roger!
It is five pages! and gives the essence!
THE INNER
CONSULTATION
Roger Neighbour, MA, MB, BChir, DObstRCOG, FRCGP
(C) Roger Neighbour 1989
(C) Roger Neighbour 1989
The Inner Consultation is an approach to the teaching and learning of
consultation skills based on cultivating the doctor's ability to pay high
quality attention to certain information-rich moments in the consultation.
The method is a development of
the 'Inner Game' approach to sports
coaching described by Timothy Gallwey in the fields of tennis, golf and
skiing.
In sport, peak performance is often impeded by the intrusion of self-critical thoughts.
The solution is to direct the player's attention onto external events such as the moment of bounce of the tennis ball, which are relevant to performance but emotionally neutral.
In sport, peak performance is often impeded by the intrusion of self-critical thoughts.
The solution is to direct the player's attention onto external events such as the moment of bounce of the tennis ball, which are relevant to performance but emotionally neutral.
The traditional approach to
teaching consulting skills has been to identify a fairly large number of
component skills (such as asking open-ended questions, checking for
understanding) and tasks (such as achieving rapport, agreeing a management
plan).
While such models are descriptively valid, conscious determination to apply them in real life can come to dominate the doctor's thoughts during the encounter with the patient, to the detriment of both.
Alternatively the doctor, in the heat of the encounter, forgets all about his intended performance and just responds spontaneously.
While such models are descriptively valid, conscious determination to apply them in real life can come to dominate the doctor's thoughts during the encounter with the patient, to the detriment of both.
Alternatively the doctor, in the heat of the encounter, forgets all about his intended performance and just responds spontaneously.
In contrast to a skills-based
approach, the Inner Consultation is a technique not of instruction, but for releasing
communication abilities which by this stage in the doctor's career have already
been installed.
MINIMAL CUES
Patients signal, in various
verbal and non-verbal ways, those moments in the consultation when important
things are happening - when they are thinking seriously, or avoiding sensitive
issues.
If the doctor's attention is fully on the patient at such times, appropriate responses will be made without forcing. But the doctor has first to recognise these information rich moments.
They are signalled by distinct clusters of physical signs - minimal cues.
If the doctor's attention is fully on the patient at such times, appropriate responses will be made without forcing. But the doctor has first to recognise these information rich moments.
They are signalled by distinct clusters of physical signs - minimal cues.
Gambits
- the 'rehearsed' opening remarks made by the patient, defining
his or her starting position for the consultation.
E.g. "I've had a pain in my stomach for 2 weeks."
E.g. "I've had a pain in my stomach for 2 weeks."
Curtain-raisers
- the 'un-rehearsed' unguarded
remarks which often precede the planned gambit, into which may leak information
about the patients emotional state, attitudes or hidden agenda.
E.g. "You'll probably just say it's my nerves; anyway...I've had a pain in my stomach for 2 weeks."
E.g. "You'll probably just say it's my nerves; anyway...I've had a pain in my stomach for 2 weeks."
Internal Search
- a cluster of non-verbal signs
indicating that serious thought is in process, and that whatever is next said
may be of greater significance than average.
The signs are:
The signs are:
Ÿ Sudden brief bodily stillness, sometimes even
'freezing' in mid gesture.
Ÿ Changes in gaze; the eyes either:
(a)
move around very rapidly, as in REM sleep, as the thinker scans numerous
memories, or
(b)
remains steadily fixed in one direction, usually to one side, either upwards or
downwards, or
(c)
become defocused, as if gazing into the far distance.
Turbulence
- a noticeable increase in the energy level of speech. As the speaker approaches 'dangerous
territory', the flow of speech becomes more agitated than before, erratic,
fragmented, with abrupt changes of pace, pitch and volume.
Speech censoring
- various ways in which the speaker consciously or unconsciously
attempts to avoid going into explicit detail about matters that might be
sensitive, embarrassing or worrying.
Forms of speech censoring include:
Forms of speech censoring include:
Hesitations & Prevarications
- long pauses, "Errm..", "Well.."
Imprecisions
- using vague words and phrases such as "things like that", or "you know what I mean".
- long pauses, "Errm..", "Well.."
Imprecisions
- using vague words and phrases such as "things like that", or "you know what I mean".
Non sequiturs
- remarks that don't appear to make sense, because intermediate connecting thoughts have been left out.
E.g.
"My period was late so I ate lots of fruit," (omitting the
intermediate "I thought constipation could be the reason.")
APPLICATION
In the Inner Consultation, the
doctor practises alerting himself or herself to the constant flow of minimal
cues emitted by the patient, using them as signals (should attention have
wandered) to redirect full attention onto the patient.
lt is NOT necessary to try to interpret the significance of every minimal cue; if there is significant meaning, it will be recognised without conscious effort, just as we all do in everyday social conversation.
The benefit arises from the fact that the doctor, in endeavouring to spot minimal cues, changes the quality of the attention paid to the patient.
From this improved attention come more astute perception, better communication and more effective consulting
lt is NOT necessary to try to interpret the significance of every minimal cue; if there is significant meaning, it will be recognised without conscious effort, just as we all do in everyday social conversation.
The benefit arises from the fact that the doctor, in endeavouring to spot minimal cues, changes the quality of the attention paid to the patient.
From this improved attention come more astute perception, better communication and more effective consulting
REFERENCES
Neighbour, R.H. (1987) The Inner Consultation - how to develop an
effective and intuitive consulting style.
Lancaster, Kluwer Academic Press
Neighbour, R.H. (1992) The Inner Apprentice - an awareness-centred
approach to vocational training for
general practice. Lancaster, Kluwer
Academic Press
A '5 - CHECKPOINT' MODEL OF
CONSULTING
Think of every consultation as a journey with 5
stops en route. Or a better image would
be of an orienteering course, with 5 checkpoints, at each of which you have to
report before proceeding to the next.
How you get from one to the next is up to you - a matter of your own skill and judgement - but a map and some basic fitness training help.
How you get from one to the next is up to you - a matter of your own skill and judgement - but a map and some basic fitness training help.
As you move through the consultation from start
to finish, direct a part of your free attention towards attaining each of the
following 'Checkpoints' in turn.
1. CONNECTING
- achieving a working rapport with the patient;
getting on the same wavelength.
Sometimes this is easy, but may have to be
consciously worked at.
The usual problem is suppressing our own internal dialogue, prejudices and assumptions.
This is best done by non-judgementally noticing the patient's physical, verbal, para-verbal, non-verbal, postural and behavioural characteristics.
It may then be helpful intentionally to 'match' some of these by adjusting your own behaviour accordingly.
The usual problem is suppressing our own internal dialogue, prejudices and assumptions.
This is best done by non-judgementally noticing the patient's physical, verbal, para-verbal, non-verbal, postural and behavioural characteristics.
It may then be helpful intentionally to 'match' some of these by adjusting your own behaviour accordingly.
2. SUMMARIZING
- obtaining a sufficiently comprehensive idea of
the patient's real reason for consulting you.
The best way of checking that you have a clear
understanding, and thereby reducing the chances of missing the underlying
concerns, is to offer the patient an explicit summary of your perception of his
or her needs or expectations.
If you take the sort of history and facilitate the sort of communication that puts you in a position where you can summarize with confidence, you will find yourself becoming more insightful and more economical.
If you take the sort of history and facilitate the sort of communication that puts you in a position where you can summarize with confidence, you will find yourself becoming more insightful and more economical.
3. HANDING-OVER
- making sure the patient is happy with the
outcome of the consultation.
Every general practice consultation results in
some form of management plan. This may
be implied or expressed, precise or vague, clinical or managerial, immediate or
long-term, doctor- or patient-centred.
Reaching and 'handing over' an acceptable management plan may involve strategies, and 'gift-wrapping' - expressing your plan in terms to the patient.
Otherwise compliance may suffer.
Reaching and 'handing over' an acceptable management plan may involve strategies, and 'gift-wrapping' - expressing your plan in terms to the patient.
Otherwise compliance may suffer.
4. SAFETY-NETTING
- planning for the unexpected.
Both you and the patient will feel better if you
acknowledge that general practice is the art of managing uncertainty, and
things don't always go according to plan.
Your confidence will benefit if you qualify your management plan by asking yourself three questions:-
Your confidence will benefit if you qualify your management plan by asking yourself three questions:-
Ÿ If I'm right, what do I expect
to happen?
Ÿ How will I know if I'm wrong?
Ÿ What would I do then?
5. HOUSEKEEPING
- taking care of yourself.
Doctors have needs too; we get tired, bored,
irritated, tense and so on.
We have a professional responsibility to do whatever it takes to keep ourselves in the best possible state for each successive patient.
A consultation is not finished until you are ready for the next one.
We have a professional responsibility to do whatever it takes to keep ourselves in the best possible state for each successive patient.
A consultation is not finished until you are ready for the next one.
MINIMAL CUES
Internal Search:
Brief bodily stillness, eyes uplifted to left or right, or downcast, then
returning to normal gaze.
Brief bodily stillness, eyes uplifted to left or right, or downcast, then
returning to normal gaze.
Turbulence:
Noticeable increased agitation or fragmentation in the flow of
speech.
Noticeable increased agitation or fragmentation in the flow of
speech.
Speech censoring:
A noticeable imprecision, vagueness, circumlocution, evasiveness,
hesitancy, suggesting the speaker is guarding his/her words.
A noticeable imprecision, vagueness, circumlocution, evasiveness,
hesitancy, suggesting the speaker is guarding his/her words.
Attention shift:
An abrupt shift in the focus of the speaker's attention, e.g. external to
internal, present time to past or future.
An abrupt shift in the focus of the speaker's attention, e.g. external to
internal, present time to past or future.
SUMMARIZING (ELICITING)
Checking:
A mini-summary, e.g. "If I understand you ... Let me see if I've got this right".
A mini-summary, e.g. "If I understand you ... Let me see if I've got this right".
Echoing:
Repeating
either verbatim or paraphrased the speaker's last words or
idea, in order to prompt further development.
idea, in order to prompt further development.
Explain why you're asking:
E.g. "So that I
can tell why you might be particularly worried, tell
me whether any of your relatives ever had cancer".
me whether any of your relatives ever had cancer".
Statements make good questions:
E.g. "Blood in the motions can be an important symptom",
"Every magazine seems to have something about allergies".
E.g. "Blood in the motions can be an important symptom",
"Every magazine seems to have something about allergies".
My friend
John:
Inviting comparison with a 'proxy' figure,
e.g. "Some patients are embarrassed to mention impotence",
"A lot of people think antibiotics cure colds".
HANDING OVER
Questions make good statements:
E.g. "Did you perhaps think antibiotics were a cure for colds?"
Questions make good statements:
E.g. "Did you perhaps think antibiotics were a cure for colds?"
Presupposition:
Assuming the desired response has already been made, e.g. "Would
you prefer to come to me or to the clinic for your smear test?"
Pre-empting:
Anticipating and dealing with possible resistance,
e.g. "You'll probably curse me for wanting another blood test, but. "
Overlapping a series of explanations or instructions so that each leads inexorably to the next.
"A causes B. Because of B, then C. Therefore D".
My friend John (again):
E.g. "I had another patient like you who..",
"Someone less sensible than yourself might have ... "
E.g. "I had another patient like you who..",
"Someone less sensible than yourself might have ... "
INNER
CONSULTATION CUES CHECKLIST
CURTAIN
RAISERS
|
|
GAMBITS
|
|
INTERNAL
SEARCH
|
|
TURBULENCE
|
|
IMPRECISION
|
|
SPEECH
CENSORING
|
|
NON
SEQUITURS
|
|
ATTENTION
SHIFTS
|
Once again, Thank you, Dr Ramesh Mehay!
You can buy 'The Inner Consultation' from the Biggg Amazon website.
But, Please Buy from one of our websites :-)
http://www.rcgp.org.uk/bookshop/info_1857756797.html
OR
www.bradfordvts.co.uk via
http://astore.amazon.co.uk/go2emedia0c1-21
I think from penninevts website as well. Not sure!
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