USOS POR ZONAS CONSTRUCCION Y INDICES DE OCUPACION

The medical consultation is a two-way interaction between doctor and patient which is contextually and temporally defined and which has a high degree of specificity. It is the main forum for the exchange of ideas and information between patient and doctor, and this communication forms the basis for subsequent medical decision-making and treatment plans (General Medical Council, 2009b).

Traditionally, in the medical consultation, there was a perceived competence gap between doctor and patient (Stimson and Webb, 1975). Medical decision- making within consultations was physician-led, medically-driven and patient participation was discouraged. However, over the last 50 years, a shift from a doctor- centred, biomedical consultation style to a more patient-centred orientation, integrating biomedical history taking and psychosocial discussion, has occurred gradually. The medical consultation began to be seen as a meeting between two equally competent experts, each with a different area of expertise; the patient being competent in their ‘illness world’ and the doctor being expert in the ‘disease world’ (Stewart and Roter, 1989). This shift in emphasis is reflected in the development of a number of progressive models of medical consultations, which draw on several

different disciplines including psychology, sociology and anthropology (De Haes, 2006, Silverman et al., 2005, Stewart and Roter, 1989, Engel, 1977). The historical background to PPC within the medical consultation will now be discussed briefly in order to contextualise the research reported within this thesis.

Changing attitudes to the medical consultation began in 1969 with the work of Enid Balint. Balint coined the term ‘patient-centred medicine’ in a published address to the Royal College of General Practitioners (Balint, 1969). In this address, she proposed an alternative to the traditional ‘illness-orientated’ model of care by conceptualising a model of care whereby decision-making in medical consultations should be dependent on the needs of the individual patient. She discussed the importance of doctors examining “the whole person” in order to understand the patient as “a unique human being” (Balint, 1969). In short, her address highlighted the importance of effective PPC in understanding and treating each patient’s medical complaint as a unique illness.

Despite active patient participation in the medical consultation being advocated and encouraged by Balint (1969), later research revealed a continued discrepancy between patient behaviour during consultations (characterised by passive and polite conduct) and attitudes expressed during post-consultation briefings (characterised by critical appraisal of consultations) (Stimson and Webb, 1975). Indeed, the majority of consultations were still heavily doctor-dominated, with active patient participation or attempts by the doctor to elicit patients’ concerns about their illness rare (Byrne and Long, 1976). Doctors dictated the level of patient involvement in the consultation by exhibiting predominantly closed information- gathering behaviours, resulting in minimal patient contribution. Rarely did doctors display non-directive counselling behaviours, thus allowing patients to talk unimpeded (Byrne and Long, 1976).

In response to this, Engel (1977) proposed a biopsychosocial model of illness, in which the contribution of both organic and psychological factors towards illnesses was stressed. The importance of treating the patient as a whole person was emphasised, thus encouraging doctors to treat both physical and psychological presenting complaints as one. Despite this, subsequent research in junior doctors consulting in General Practice found that the majority still did not take account of

patients’ feelings, concerns or expectations regarding treatment plans whilst delivering information (Maguire et al., 1986), indicating incongruence between researchers’ recommendations for clinical practice and providers’ actual clinical behaviour.

Stewart and Roter (1989) subsequently proposed their disease-illness model of medical consultations, based on an analysis of over 100 GPs consulting with over 500 patients. In this model, they outlined that an effective consultation should combine two parallel pathways, simultaneously pursued and given equal importance. One pathway should follow a ‘disease’ framework. This should be characterised by biomedical information seeking, in which the doctor sets the agenda, explores symptoms, signs and investigations and considers the underlying pathology of the patient’s presenting complaint to produce a differential diagnosis6

. The other should follow an ‘illness’ framework. In this framework, the psychosocial and emotional aspects of illness should be discussed and the patient should be treated as an individual experiencing unique symptoms of illness. A shared understanding of the illness between patient and doctor should be sought through discussion of the patient’s concerns, ideas, thoughts, feelings and expectations. They proposed that an effective consultation should successfully ‘weave’ the two frameworks together, in a way that maintains their integrity, in order to give a shared understanding of the presenting complaint. Stewart and Roter (1989) discussed how successful adoption of this approach should allow for collaborative explanation, planning and decision making.

In the 1990s, moves in perceptions towards the patient-provider relationship and in medical education began to occur. Factors influencing these moves in the UK included social, economic and political environmental changes (Salmon and Young, 2005); the political influences of neo-liberalism, in which both the structure of the NHS and the views of society changed, transformed the patient from a passive element to an active consumer of services, with a responsibility to manage their own care and lifestyle (Brown, 2008). Awareness of the therapeutic benefits of effective PPC for both patients and providers emerged (Kaplan et al., 1989, Rost et al., 1989, Roter and Hall, 1993, Hickson et al., 1994, Stewart, 1995, Levinson and Chaumeton,

1999, Stewart et al., 1999a, Street, 2001). Simultaneously, rather than being a forum to solely produce graduates who were competent for independent medical practice, undergraduate medical education began to be viewed as a platform to prepare students for the transition to their first post-graduate year as practising doctors (Watmough, 2008).

This shift in UK undergraduate medical education became formalised in 1993 with the publication of Tomorrow’s Doctors (General Medical Council, 1993). This document called for a major reform of UK undergraduate medical curricula, including the mandatory integration of PPC teaching and assessment and the introduction of other professions other than clinical medicine in the teaching of PPC (Brown, 2008, Taylor, 2009). This marked a cornerstone in PPC skills’ teaching and assessment; prior to the publication of Tomorrow’s Doctors, formal teaching or assessment of ‘soft’ skills such as PPC skills during undergraduate or postgraduate medical education was optional and rarely included (Frederikson and Bull, 1992) and PPC skills were not seen as distinct from diagnostic and management skills. Formal PPC education was restricted to psychiatry and general practice clinical placements and was limited or absent from medical curricula (Hargie et al., 2010). Assessment, when conducted, was in short and long cases7, which primarily focused on the medical aspects of patient care rather than communication processes.

Medical curricula were reformed in the UK following the publication of Tomorrow’s Doctors (General Medical Council, 1993), with curricula placing the patient and their clinical picture at the starting point of students’ learning rather than the end, as had traditionally been accepted and taught (De Haes, 2006). The general move was towards more active learning, developing a more favourable balance between biomedical learning and more socially focused clinical learning, and being more respectful of patients’ autonomy. Emphasis was placed on the teaching and learning of PPC within a clinical context and PPC began to be seen as a skill that

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In a ‘short case’, candidates are given approximately 8-12 minutes to examine a patient’s body system or anatomical area and are then asked to give a brief summary of the findings of the examination, the patient’s likely differential diagnosis and the probable causes and severity of the patient’s condition. Generally, candidates are asked to complete four to five short cases in sequence. In a ‘long case’, candidates are given a varying amount of uninterrupted and unexamined time (usually between 30-50 minutes) to interview and examine a real patient, untrained for examinations. Candidates are then required to present their findings to the examiner(s) as in an unstructured oral assessment, and are further examined on their findings, diagnosis, management and related knowledge of the patient’s presenting complaint.

could be acquired, measured and developed over the course of an individual’s medical education (Aspegren, 1999, Brown, 2008, Salmon and Young, 2005). Problem-based learning (PBL)8 was introduced as a means of both reducing the factual burden of didactic science knowledge and promoting effective PPC skill development (Aspegren, 1999). Emphasis was placed on cultural, social, emotional and psychological outcomes of illnesses, as well as the impact of illnesses on patients’ families. Attitudinal elements of medical education were also stressed; showing respect for patients and colleagues, being aware of uncertainties and limitations, ability to cope with uncertainty and knowing when to ask for help were emphasised. A shift from hospital-based teaching to more General Practice teaching was advocated in order to teach students about the social and emotional contexts of illness.

Furthermore, Objective Structured Clinical Examinations (OSCEs) were introduced as means of objectively assessing both PPC and clinical skills during undergraduate medical education. Although OSCEs differ between institutions, students generally interact with a simulated patient in any number of different timed interactions. In each interaction (or station), students are assessed on their ability to respond to the simulated patient’s presenting problem by an examiner who rates their performance using a standardised mark sheet (Cherry, 2010). The simulated patient may or may not also provide feedback on the students’ performance. Whilst the use of short and long cases had been widely criticised on the basis of their reliability and lack of objectivity and standardisation between candidates (Wass and Van Der Vleuten, 2004), the introduction of OSCEs went some way to address these issues because of their standardised nature (Epstein and Hundert, 2002). The word standardised reflects the main objective of the OSCE; simulated patients receive the same scripts and training to ensure minimal variation in their performances across examiners and students, and checklists and rating scales are also standard across students and examiners (Mazor et al., 2005). With the introduction of PBL and OSCEs, and the need to obtain new skills, attributes and psychosocial knowledge, medical education began to change from a didactic process towards a problem-

8 _{A student-centred pedagogy in which students learn about a subject through the experience of}

solving process, with a more collaborative relationship between teacher and student (Dornan, 2006, Philips, 2008).

In line with this changing view of PPC skills in undergraduate medical education, Silverman, Kurtz and Draper (2005) proposed the Calgary-Cambridge model of medical consultations. This model adopted an evidence-based approach to integrating both the ‘tasks’ of the consultation (the ‘disease’ and ‘illness’ aspects, also known as biomedical and psychosocial information gathering) through effective PPC skills. This model proposed five tasks, or competencies, which it outlined must be accomplished in order for the consultation to be effective from a communicative point of view:

 Initiating the session

 Rapport building

 Information gathering

 Information giving

 Planning and closing the session

To aid curriculum planners in the design, implementation and review of PPC skills’ curricula in order to fulfil such competencies (Silverman et al., 2005), the UK Council of Clinical Communication Skills Teaching in Undergraduate Medical Education was established (Von Fragstein et al., 2008). This group outlined that a patient-centred approach should be taken in the teaching of PPC skills and specifically highlighted the need to obtain skills such as establishing, recognising and meeting patients’ needs, and eliciting and considering patients’ agendas, as central to a patient-centred approach (Von Fragstein et al., 2008). The authors also outlined that, in addition to a patient-centred approach, skills that were readily observable, such as eye contact, were essential to promote active facilitation and emotional exploration with patients (Von Fragstein et al., 2008).

Tomorrow’s Doctors was subsequently revised in 2009 (General Medical Council, 2009b). In the revised document (hereafter referred to as Tomorrow’s Doctors: Revised for clarity), emphasis was placed on the importance of graduates’ interpersonal skills in congruence with their biomedical knowledge and clinical skill requirements (Cherry, 2010). Tomorrow’s Doctors: Revised (General Medical

Council, 2009b) further stated that, to improve graduates’ PPC skills, patient experience must be included throughout all years of undergraduate medical curricula, with an increase in duration and responsibility as students approach the end of medical school (General Medical Council, 2009b).

As a result of changing attitudes and practices regarding the importance of effective PPC, the goal of undergraduate medical education in the UK changed. Its aim is now to produce doctors who are competent to work in the National Health Service (NHS) and to continue their medical education into specialist training (General Medical Council, 2009b). Undergraduate medical education now generally consists of 5 years of training, encompassing the teaching and learning of both biomedical sciences and interpersonal skills, and the translation, application and integration of theory, knowledge and skills to the clinical workplace setting (Dornan, 2006). Newly-qualified doctors then enter a two-year Foundation programme. The Foundation Programme is a two-year generic training programme which forms the bridge between medical school and specialist/General Practice training. The aim of the Foundation Programme is to provide the graduate with an opportunity for development and enhancement of their clinical and interpersonal skills. This is achieved through workplace-based learning across a series of six closely supervised four-month placements within different specialties, including a placement in General Practice during the second Foundation year9. Following successful completion of the Foundation Programme, doctors then undertake three years of core training, followed by between three and seven years of specialist training, depending on their specialty choice (General Medical Council, 2013).

In contrast to historical practice, effective PPC is now accepted as forming the basis of an effective medical consultation (General Medical Council, 2009a, General Medical Council, 2009b). As a result, PPC skills’ training is now a core and mandatory taught and assessed component of undergraduate and postgraduate medical education in the UK (Brown, 2008, Cherry, 2010, Hargie et al., 2010, General Medical Council, 2012a) with most undergraduate curricula following the Calgary-Cambridge model of medical consultations (Silverman et al., 2005).

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In some Deaneries, General Practice placement is obligatory for successful completion of the Foundation Programme. In others, including the Mersey Deanery (the Deanery from which the junior doctors in Study 3 were recruited, see Chapter 7), General Practice placement is optional.

Undergraduate medical curricula differ slightly in how they implement the recommendations of Tomorrow’s Doctors: Revised (General Medical Council, 2009b) with respect to PPC skills’ teaching and assessment (see the Case Study on page 17). However, all UK medical schools now formally teach PPC skills and assess students on their PPC competencies throughout their undergraduate medical education, mainly in the form of OCSEs (Hargie et al., 2010). Indeed, the development and acquisition of PPC skills throughout undergraduate and postgraduate medical education is now viewed as equally important as the development of biomedical knowledge and technical skills (Brown, 2008, Cherry, 2010).