RACGP Five domains of General

Practice
1. communication skills and the doctor–patient
relationship
2. applied professional knowledge and skills
3. population health and the context of general
4. practice professional and ethical role
5. organisational and legal dimensions
 The patient-centred model of health
care
1. exploring both the disease and the illness
experience
2. understanding the whole person
3. finding common grounds regarding
management
4. incorporating prevention and health promotion
5. enhancing the doctor–patient relationship
6. being realistic regarding time and resources
 Neighbour’s model (1987)

• 'where shall we make for next and how shall we get there?'
1. Connecting - establishing rapport with the patient
2. Summarising - getting to the point of why the patient has come
using eliciting skills to discover their ideas, concerns, expectations
and summarising back to the patient.
3. Handing over - doctor and patient formulate a management plan
together. This will involve giving patients options, checking their
understanding and may involve some negotiation skills.
4. Safety-netting - ensure a contingency plan has been made for the
worst scenario - "What if?"
5. Housekeeping - clear the mind of the psychological remains of
one’s consultation to ensure it has no detrimental effect on the
next - "Am I in good enough shape for the next
patient?"
 The Calgary-Cambridge approach to
communication skills teaching (1996)
• Building the Relationship developing rapport involving the patient, and
‘Providing structure’ - ensuring the consultation flows well, and that the
doctor and patient are clear about what will happen during it.
1. Initiating the Session establishing initial rapport identifying the
reason(s) for the consultation
2. Gathering Information exploration of problems understanding the
patient's perspective providing structure to the consultation
3. Diagnostic Phase/Physical Examination
4. Explanation and Planning
1. providing the correct amount and type of information , Establish the
patient’s knowledge of the diagnosis, attitude
2. Development a management plan
3. achieving a shared understanding: incorporating the patient's perspective
5. Closing the Session
 Counselling
• • The therapy should be patient-centred.
• • Use gentle, clever, probing questions.
• • Facilitate the discussion to draw out relevant
• areas.
• • It is important to be non-judgmental.
• • Counsel through intuition and base it on
• common sense.
• • Do not tell the patient what to do.
• • Do not try to rush patients into achieving a
• happy ending.
• • Provide guidance to allow the patient to gain
• insight.
 Counselling (cont.)
• Ask key searching questions, such as:
• — ‘What would be different in your life if you
• were well?’
• — ‘Who are you mad at?’
• — ‘If I understand you correctly you are telling
• me that . . .’
• — ‘You seem to be telling me that . . .’
• — ‘Correct me if I’m on the wrong track, but you
• are saying that . . .’
• — ‘What do you think deep down is the cause of
• your problem?’
• — ‘What does your illness do to you?’
• — ‘Do you really worry about any things in
• particular?’
• — ‘How do you think your problem should be
• treated?’
• — ‘If you could change anything in your life,
• what would it be?’
• Avoid:
• • telling patients what they must do/offering
• solutions
• • giving advice based on your own personal
• experiences and beliefs
• • bringing up problems that the patient does not
• produce voluntarily
• Key rules to counselling
• Effective counselling comes from commitment,
experience and a genuine caring compassionate feeling
for patients and their ethos
• • The patient must leave feeling better.
• • Provide insight into their illness and/or behaviour.
• • Address any feelings of guilt (people must feel
okay or forgiven about any perceived
transgression).
The diagnostic model for a presenting
problem
1. What is the probability diagnosis?
2. What serious disorders must not be missed?
3. What conditions are often missed (the
pitfalls)?
4. Could this patient have one of the
‘masquerades’ in medical practice?
5. Is this patient trying to tell me something
else?
• DSM-5 diagnostic criteria for major
• depressive disorder
• At least five of the following symptoms nearly every
• day for 2 weeks (criterion 1 or 2 essential):
• 1 depressed mood (subjective or objective)
• 2 loss of interest or pleasure
• 3 change in weight (5% change over 1 month) or
• appetite
• 4 insomnia or hypersomnia
• 5 psychomotor agitation or retardation
• 6 loss of energy or fatigue
• 7 worthlessness or guilt
• 8 impaired concentration or indecisiveness
• 9 recurrent thoughts of death or suicide ideation or
• any suicide attempt