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Biomedical subjects

N Britten

Publications and source records attributed to N Britten.

At least 19 recordsLinked to original sources
PubMed2000

Patients' unvoiced agendas in general practice consultations: qualitative study.

OBJECTIVE: To investigate patients' agendas before consultation and to assess which aspects of agendas are voiced in the consultation and the effects of unvoiced agendas on outcomes. DESIGN: Qualitative study. SETTING: 20 general practices in south east England and the West Midlands. PARTICIPANTS: 35 patients consulting 20 general practitioners in appointment and emergency surgeries. RESULTS: Patients' agendas are complex and multifarious. Only four of 35 patients voiced all their agendas in consultation. Agenda items most commonly voiced were symptoms and requests for diagnoses and prescriptions. The most common unvoiced agenda items were: worries about possible diagnosis and what the future holds; patients' ideas about what is wrong; side effects; not wanting a prescription; and information relating to social context. Agenda items that were not raised in the consultation often led to specific problem outcomes (for example, major misunderstandings), unwanted prescriptions, non-use of prescriptions, and non-adherence to treatment. In all of the 14 consultations with problem outcomes at least one of the problems was related to an unvoiced agenda item. CONCLUSION: Patients have many needs and when these are not voiced they can not be addressed. Some of the poor outcomes in the case studies were related to unvoiced agenda items. This suggests that when patients and their needs are more fully articulated in the consultation better health care may be effected. Steps should be taken in both daily clinical practice and research to encourage the voicing of patients' agendas.

Adult↗
PubMed2000

Misunderstandings in prescribing decisions in general practice: qualitative study.

OBJECTIVES: To identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice. DESIGN: Qualitative study. SETTING: 20 general practices in the West Midlands and south east England. PARTICIPANTS: 20 general practitioners and 35 consulting patients. MAIN OUTCOME MEASURES: Misunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicine. RESULTS: 14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor's decision, and relationship factors. All the misunderstandings were associated with lack of patients' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients' ideas about medicines for successful prescribing. CONCLUSIONS: Patients' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.

Adult↗
PubMed2000

Menorrhagia in general practice--disease or illness.

Menorrhagia is a common presentation in primary care. The gynaecological literature defines menorrhagia, as the loss of 80 ml or more of blood per period and guidelines for treatment are based on this definition. There is extensive evidence that the majority of women who complain of heavy bleeding do not fit the medical definition. We interviewed women presenting with menorrhagia to explore their perceptions and their initial interaction with the medical profession. A distinct illness model emerged. Women had a precise understanding of their complaint, so that a change in her cycle was indicative of a problem to many women, without reference to outside criteria. Women attached particular importance to how they felt and to their ability to function and they rejected the medical emphasis on blood loss evaluation. Many women were dissatisfied with the consultation and experienced doctors as being dismissive of their problem. They were seeking an explanation for why their periods had changed and had concerns that related to their understanding of menstrual bleeding. Interviewees were unsure whether period problems could be described as illness, and what range of disturbance was normal. It is suggested that the disease model of menorrhagia is not relevant to the majority of women with this complaint. It is proposed that the disease model be replaced with illness models.

Adult↗
PubMed2000

Doctor-patient communication about drugs: the evidence for shared decision making.

The traditional paternalistic model of medical decision-making, in which doctors make decisions on behalf of their patients, has increasingly come to be seen as outdated. Moreover, the role of the patient in the consultation has been emphasised, notably through the adoption of 'patient-centred' strategies. Models that promote patients' active involvement in the decision-making process about treatment have been developed. We examine one particular model of shared decision making [Charles, C., Gafni, A., Whelan, T, 1997. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science & Medicine 44, 681-692.]. The model has four main characteristics. These are that (1) both the patient and the doctor are involved, (2) both parties share information, (3) both parties take steps to build a consensus about the preferred treatment and (4) an agreement is reached on the treatment to implement. Focusing on the first two of the four characteristics of the model, we use the findings from a study of 62 consultations, together with interviews conducted with patients and general practitioners, to consider participation in the consultation in terms of sharing information about, and views of, medicines. We found little evidence that doctors and patients both participate in the consultation in this way. As a consequence there was no basis upon which to build a consensus about the preferred treatment and reach an agreement on which treatment to implement. Thus even the first two of the four conditions said to be necessary for shared decision making were not generally present in the consultations we studied. These findings were presented in feedback sessions with participating GPs, who identified a number of barriers to shared decision making, as well as expressing an interest in developing strategies to overcome these barriers.

Decision Making↗
PubMed2000

In pursuit of patient-centred outcomes: a qualitative evaluation of the 'Measure Yourself Medical Outcome Profile'.

OBJECTIVES: To ascertain the ability of a patient-generated outcome measure, the 'Measure Yourself Medical Outcome Profile' (MYMOP), to reflect the outcomes of consultations which patients consider are most important, as derived from qualitative interviews. METHODS: A qualitative study using a constant comparative method to analyse semistructured interviews which were then compared with the results of MYMOP questionnaires. A variable-orientated analysis was used to develop themes and a case-orientated analysis was used to develop narrative summaries called vignettes from the interviews. The MYMOP questionnaire was completed by the interviewees (n = 20), a minimum to twice and a maximum of nine times over a four-month period. The scores were displayed on individual MYMOP charts. For each individual, the outcome as measured by MYMOP was compared with the outcome data from the qualitative interviews. The interviewees were attending a variety of complementary practitioners in primary care. RESULTS: The treatment effects which people described were encompassed by five themes: reduction in symptoms; reduction in disability; reduction in, or avoidance of, medication; gaining control and improving coping skills; and securing support and hope through the patient-practitioner relationship. The vignettes demonstrated how individuals identified and valued these various effects and weighed them up in evaluating the overall benefit of the treatment. Their MYMOP charts were able to measure some effects better than others. CONCLUSIONS: The treatment effects, as quantified using MYMOP, accorded with those described by most patients at interview, but some important limitations were identified with MYMOP, particularly an underplaying of the importance of medication avoidance or medication reduction in this patient group. This dimension is lacking in most outcome questionnaires and has been included in a new version of MYMOP. This study also showed that qualitative interview data can help in evaluating the ability of outcome questionnaires to measure the treatment effects that particular patient groups consider most important.

Adolescent↗
PubMed2000

Organising primary health care for people with asthma: the patient's perspective.

BACKGROUND: The 1993 chronic disease management contract encourages United Kingdom general practices to implement a standardised package of care with an emphasis on regular visits to an asthma clinic. AIM: To explore the views of people with asthma about the organisation of asthma care in general practice. METHOD: Semi-structured interviews with 20 patients registered with one practice with a nurse-run asthma clinic. The sample was selected to provide people with a wide range of ages and disease severity, and included parents of children. RESULTS: The age range of the interviewees was five to 87 years (parents of children were interviewed) and half of the interviewees had attended the asthma clinic at some time. In describing how they managed their asthma, people identified their medical care alongside other important factors, such as avoiding smoking and pollution, and a decision to seek medical help was made in the context of all of life's other priorities. People expressed diverse views about the organisation of care, describing how their needs changed over time and how they balanced up several factors in deciding what was best for them. These factors were encompassed by four themes: the accessibility of care, severity of asthma and dealing with uncertainty, self-knowledge and self-management, and expert knowledge and therapeutic relationships. Interviewees were evenly split between wishing to be seen regularly in the clinic and wishing only to attend when needing help. CONCLUSION: Patients required asthma services that allow individual choice and flexibility, and eight service objectives were identified that would cover most people's needs.

Adolescent↗
PubMed1999

Doctors talking

Explore the source record for details and available documents.

Journal Article↗
PubMed1999

The United Medical and Dental School of Guy's and St Thomas' Hospitals' MSc in general practice: graduates' perspectives.

AIM: Higher degrees have been proposed as one means whereby general practitioners can continue their professional development and avoid a slow decline into professional isolation and burnout. The United Medical and Dental School of Guy's and St Thomas' Hospitals' MSc in general practice has been available to experienced general practitioners for over a decade. This study reports some of the outcomes of participation for the 76 graduates of the first nine cohorts. METHOD: As part of an ongoing programme of evaluation the graduates were sent a questionnaire which, in addition to seeking information about attainment of intended outcomes, gave respondents the opportunity to write freely about the contribution made by the course to their own professional and personal development. Seventy-one graduates completed the questionnaire, a response rate of 93%. RESULTS AND CONCLUSIONS: An increased confidence that arises not only from a broadened knowledge base and increased skills but also from a sense of having been enabled to explore more deeply into their discipline, is the most frequently and highly valued outcome of participation. Graduates appreciated having additional protected time and demonstrated an ability to use it productively. A further significant outcome was the ability of the course to confront those habitual assumptions of doctors which inform their practice in a manner that was both challenging and supportive. Tendencies to professional isolation and burnout appear to have been reversed with a greater sense of connectedness to their discipline. Doctors seeking to diversify their general practice careers beyond the task of providing medical services have found the MSc an important route for change.

Attitude of Health Personnel↗
PubMed1999

Using reflexivity to optimize teamwork in qualitative research.

Reflexivity is often described as an individual activity. The authors propose that reflexivity employed as a team activity, through the sharing of reflexive writing (accounts of personal agendas, hidden assumptions, and theoretical definitions) and group discussions about arising issues, can improve the productivity and functioning of qualitative teams and the rigor and quality of the research. The authors review the literature on teamwork, highlighting benefits and pitfalls, and define and discuss the role for reflexivity. They describe their own team and detail how they work together on a project investigating doctor-patient communication about prescribing. The authors present two reflexive tools they have used and show through examples how they have influenced the effectiveness of their team in terms of process, quality, and outcome.

Communication↗
PubMed1999

What do general practice receptionists think and feel about their work?

BACKGROUND: Although there is some published work acknowledging that the general practice receptionist's role is both important and difficult, receptionists' own views have rarely been sought. AIM: To explore general practice receptionists' ideas and feelings about their work. METHOD: A questionnaire was distributed to all 150 receptionists in a representative sample of 26 practices in the area covered by Leeds family health services authority. Semi-structured interviews were conducted with a representative group of 20 receptionists selected from the questionnaire sample. RESULTS: All responders were women, 60% were over 40 years old, and about half had been in the post for more than five years; four-fifths worked part-time. They had chosen the job because it dovetailed with the rest of their lives. Responders derived satisfaction from helping patients, meeting people, having good relationships with colleagues, and doing varied work. Sources of stress included difficult patients, work pressure, problems finding appointments for patients, and feeling caught between doctors' and patients' demands. Responders' experiences and views of training were diverse. Practice managers were important in making them feel consulted and supported. All had a sense of teamwork with colleagues, but many did not perceive the whole practice as a team. Many felt doctors failed to appreciate the pressure and complexity of their work. CONCLUSIONS: Receptionists' work is complex, demanding and intense, involving a high level of commitment to patients, colleagues, and the practice. Recommendations include improved appointment systems, a positive role for practice managers in relation to reception staff, and individual planning of receptionists' training. Effective teamwork among receptionists should be recognized and developed. General practitioners (GPs) are recommended to develop a greater understanding of receptionists' work.

Adult↗
PubMed1998

A kinematic and kinetic analysis of the sit-to-stand transfer using an ejector chair: implications for elderly rheumatoid arthritic patients.

Twelve elderly female rheumatoid arthritis patients (mean age = 65.5 +/- 8.6 yr) were assessed rising from an instrumented Eser Ejector chair under four conditions: high seat (540 mm), low seat (450 mm), with and without the ejector mechanism operating. Sagittal plane motion, ground reaction forces, and vertical chair arm rest forces were recorded during each trial with the signals synchronised at initial subject head movement. When rising from a high seat, subjects displayed significantly (p < 0.05) greater time to seat off; greater trunk, knee and ankle angles at seat off; increased ankle angular displacement; decreased knee angular displacement; and decreased total net and normalised arm rest forces compared to rising from a low seat. When rising using the ejector mechanism, time to seat off and trunk and knee angle at seat off significantly increased, whereas trunk and knee angular displacement, and total net and normalised arm rest forces significantly decreased compared to rising unassisted. Regardless of seat height or ejector mechanism use, there were no significant differences in the peak, or time to peak horizontal velocity of the subjects' total body centre of mass, or net knee and ankle moments. It was concluded that increased seat height and use of the ejector mechanism facilitated sit-to-stand transfers performed by elderly female rheumatoid arthritic patients. However, using the ejector chair may be preferred by these patients compared to merely raising seat height because it does not necessitate the use of a footstool, a possible obstacle contributing to falls.

Activities of Daily Living↗
PubMed1998

The UMDS MSc in general practice: attainment of intended outcomes.

BACKGROUND: The United Medical and Dental School's (UMDS's) MSc in general practice is one of the longest running courses of its kind. Although descriptive accounts of such courses have been published, little is known about their outcomes. AIM: To measure the extent to which graduates feel they have personally achieved 16 intended outcomes derived from the course objectives, and to record current academic activities, particularly teaching and research. METHOD: A postal questionnaire to graduates of the UMDS MSc in General Practice. RESULTS: The response rate was 93%. Of the 71 responders, 23 have gone on to register for or complete other degrees or diplomas. Over two-thirds of responders had an academic commitment following the MSc. Two-thirds were currently engaged in research and over half reported having had work accepted for publication. The majority of graduates confirmed the attainment of all 16 outcomes, although outcomes related to personal achievements were endorsed more strongly than those related to service delivery. CONCLUSION: UMDS graduates are making a significant contribution to their discipline and are unanimous in describing the course as an important event in their personal development. As a result of this study, the course organizers are seeking to increase the links between academic study and everyday practice.

Adult↗
PubMed1998

Why do some patients not cash their prescriptions?

BACKGROUND: A small number of studies have used different methodologies to measure primary non-compliance, but they have not established the reasons for patients not cashing their prescriptions. It has been suggested that the number of uncashed prescriptions is a measure of the quality of doctor-patient communication, but this hypothesis remains untested. AIM: To establish the feasibility of obtaining data on a sensitive subject from patients by interview and to seek patients' reasons for not cashing prescriptions using qualitative data. METHOD: Questionnaire administered to 1000 consecutive patients attending surgery, followed by interview with those patients who indicated that they had not cashed the index prescription. RESULTS: The response rate was 93.5%. Twenty-two patients were included in the study. There was wide variation in the number of uncashed prescriptions issued by each doctor (1-13). A total of nine out of 22 patients reported that their medication was cheaper over the counter and obtained it in this way; 13 out of 22 did not obtain their medication. Five patients indicated that cost was a factor in not obtaining their medication. Other factors included the doctor's permission not to cash the prescription, poor understanding of the illness, and the wish to maintain control. CONCLUSION: It is feasible to ask patients about aspects of their behaviour that may indicate, or cause, difficulties in the doctor-patient relationship. Prescribing behaviour varies widely between doctors and, although cost is a factor in determining whether a prescription will be cashed, other variables, such as the patient's desire to maintain control over the illness, may be more important.

Adolescent↗