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PubMed1997

Reference to psychiatric consultation in the discharge letter of general hospital inpatients.

OBJECTIVE: The consultation-liaison psychiatrist is frequently confronted with the consultees' lack of adherence to the consultants' recommendations. The aim of this study was to investigate the question if and how the C-L psychiatrist's diagnoses and recommendations are mentioned in the consultee's final medical report and thus communicated to the physician responsible for the aftercare. METHOD: Psychiatric consult reports of a consecutive sample of 144 patients of the departments of neurology, internal medicine, and gynecology and obstetrics at the University Hospital of Zurich were compared to the content of the respective discharge letters. RESULTS: Some kind of information about the psychiatric consultation was found in 84 percent of the discharge letters (consultation as such: 71.5%; psychiatric diagnosis: 66.7%; recommendations: 76.2%. Length of stay, timing of the consultation, length of the consult report and type of recommendation correlated significantly with the mention of psychiatric aspects in the final medical report. Psychotropic medication and psychiatric hospitalization were the recommendations most reliably mentioned. CONCLUSIONS: Psychiatric consultation seems to be taken seriously by attending physicians and is communicated in a high percentage to the physicians responsible for the aftercare. Nevertheless, in patients where active post-discharge management is needed the C-L psychiatrist should actively manage referral to outpatient settings and/or instruct primary care providers.

Adult↗
PubMed1994

Features of good consultation in general practice: is time important?

OBJECTIVE: To relate specifically defined 'good consultations' (GC) to length of consultation, continuity, patients' age and sex, and different doctors. DESIGN: A questionnaire about consultation length, communication and problem character, given to doctors and patients immediately after consultations. MAIN OUTCOME MEASURES: The number of GCs for different doctors in relation to time, continuity, and patients' age and sex were calculated. SETTING: 581 consultations were registered with six male general practitioners working at three different health centres in Umeå, a university town in northern Sweden. RESULTS: A significant difference in the number of GCs was only found between the doctors (p < 0.01). Length of consultation, patients' age and sex, and continuity and no impact on the GC frequency. CONCLUSION: The doctor as a person and his working style is most important in achieving good consultations in general practice. Length of consultation is less influential.

Adolescent↗
PubMed1995

Getting the most benefit from information systems consultants.

Consultants are usually well-meaning people who enjoy the variety of organizations and problems they face in their work. Most do not like to get bogged down in fruitless and wasteful consulting engagement any more than managers of health care organizations like to supervise them, but at least the consultants are paid for their time. The health care organization that defines a project poorly, does not know what it wants from consultants, or does not direct consultants will pay the price in increasingly scarce resources squandered. The tips in the following article for managing an information systems consulting engagement apply to most consulting engagements and to the use of other expensive advisers, such as attorneys and engineers. But information systems is a field particularly foreign, and often threatening, to most administrators and physician executives, so the risk of wasting money on unsuccessful consulting engagements is high.

Consultants↗
PubMed1993

Physician-ordered respiratory care vs physician-ordered use of a respiratory therapy consult service: early experience at The Cleveland Clinic Foundation.

BACKGROUND: Accumulative evidence suggests that respiratory care is frequently misallocated. We report the results of a pilot study of a delivery system aimed at correcting such misallocation. METHODS: The delivery system (Respiratory Therapy Consult Service, or RTCS) allows respiratory therapists (when requested by the case-managing physician) to determine respiratory care, with decisions guided by algorithm (ie, Consult patients). In the pilot study, Therapist Evaluators responded to requests for Consults on two study wards. All staff therapists participated in implementing Evaluator-determined treatment. STUDY DESIGN: We evaluated 38 patients (20 of whom were Consult patients) randomly selected from a total of 82 patients undergoing abdominal surgery during the study period. RESULTS: Consult patients were significantly older than non-Consult patients, more likely to be heavy smokers (67 vs 43%), and sicker as suggested by a higher Triage Score. Consult patients received more types and more total respiratory care services, demonstrated a trend toward longer stay, and had significantly higher respiratory therapy charges. CONCLUSION: Our experience shows that a consult program can be successfully implemented in a large, tertiary care institution with widespread physician and nursing support. Whether the RTCS fulfills its goal of ameliorating misallocation of respiratory care has yet to be proven and awaits the completion of other studies currently under way.

Abdomen↗
PubMedDate not supplied

Should you have an internal consultant?

During the past 10 years, quietly, without much fanfare, between 250 and 500 organizations have developed an internal consultant function. Many of these consultants play similar roles to the ones traditionally played by external consultants such as troubleshooting, advising the CEO, analyzing research, and implementing new programs. Because the internal consultants can respond rapidly to organizational needs and are immediately accountable to the CEO, these functions have been successful so far. There are, however, according to this author, who has surveyed 200 internal consultants and personally interviewed many of them, areas where an external consultant still works out better. In the main these are the politically sensitive areas where an internal consultant's credibility can be too easily damaged. The author discusses other aspects of the problems that surround the internal consultant, the controversy about the merits of the outsider versus the insider, and ends his article with some guidelines for developing an in-house function.

Administrative Personnel↗
PubMed1999

Concerns and confidence of general practitioners in providing telephone consultations.

BACKGROUND: In recent years the number of telephone consultations provided out of hours has increased. However, most general practitioners (GPs) have received little training in this area despite the specific skills needed to compensate for lack of visual information. Moreover, there has been no research exploring GPs' concerns and training needs in telephone consulting. AIM: To assess GPs' concerns and levels of confidence in providing telephone consultations in order to inform the development of a new training course. METHOD: Prior to attending the course, GPs were surveyed by interview or self-completion questionnaire to explore their confidence in providing telephone consultations. RESULTS: Thirty-eight GPs participated, and the sample was highly skewed towards females. The average age of participants was 42 years, 5 years less than the mean for GPs in the area. Low levels of confidence were reported by GPs in providing telephone consultations out of hours. A number of characteristics were common to telephone consultations described as difficult. The most important were lack of visual clues and lack of information about the patient, both of these were heightened in the out-of-hours period. Organizational factors leading to reduced confidence levels were also identified. CONCLUSIONS: This study demonstrates low levels of confidence among GPs conducting telephone consultations, and highlights contributing factors. Although it is not clear how far these results can be generalized, they demonstrate the need to consider telephone consulting skills training in the context of new out-of-hours arrangements. The results have been used to develop a two-day course.

Adult↗
PubMed2002

Physician-to-physician consultation via electronic mail: the Walter Reed Army Medical Center Ask a Doc system.

INTRODUCTION: Physician-to-physician consultation and discussion have traditionally been conducted by telephone, paper, and "curbside" (face to face meetings). The implementation and use of physician-to-physician consultation via electronic mail in a military health care system has not been reported previously. METHODS: The group mail function of the Composite Health Care System, the main outpatient medical automation system for the Department of Defense, was modified to create mailgroups for every specialty of the Walter Reed Army Medical Center to facilitate ease of physician-to-physician consultation. This modification was called the "Ask a Doc" system. The system was deployed to a 21-state health care network among triservice participants. RESULTS: There were 3,121 consultations logged from April 22, 1998, to December 31, 2000. Growth in use expanded initially and was sustained during a 3-year period. Average response time to consultations was less than 1 day (11.93 hours). Additional training and maintenance requirements were minimal. In general, the use of electronic consultation mirrored that of clinical practice. Most specialty consultations involved the disciplines of internal medicine. CONCLUSIONS: Use of the Ask a Doc system was representative of total clinical workload and increased access to specialty medical care over a wide geographic area. The distribution of use indicated that user statistics were legitimate, and quality improvement programs could easily troubleshoot the system. Ask a Doc was inserted into a regional health care network with minimal cost to support and implement and was sustained with very little effort for 3 years. Barriers to even wider use currently include lack of secure communications and the difficulty in assigning workload credit for electronic consultations.

Computer Communication Networks↗
PubMed2002

Neck and upper limb pain: more pain is associated with psychological distress and consultation rate in primary care.

OBJECTIVE: To investigate the association between the extent of pain and the severity of psychological distress in neck and upper limb pain, and to establish whether extent of pain is associated with consultation frequency in primary care. METHODS: The study population was selected from responders to a general health survey conducted in a general practice in North Staffordshire, UK. Responders indicating pain in the neck or upper limb area were included. The survey included the Hospital Anxiety and Depression Scale (HADS). Consultation data were retrieved for a period of 12 months following the survey. RESULTS: A total of 867 responders had experienced neck-upper limb pain in the month preceding the survey (33% of all responders). Responders with more generalized pain within the neck-upper limb area had significantly higher HADS scores compared to responders with pain in one area only, particularly for depression (median scores 5 vs 3 points). Annual consultation frequency was also higher among responders with generalized pain [adjusted OR for high consultation frequency (> or = 7 visits vs 0-2 visits) 1.6, 95% CI 1.1 to 2.4]. When the analysis was restricted to consultations specifically related to neck-upper limb pain, the association between extent of pain and consultation frequency was weak and not statistically significant. CONCLUSION: Our survey revealed a significant association between extent of pain in the neck-upper limb area and psychological distress, although scores for anxiety and depression were generally low, with only a small proportion of responders reporting moderate or severe symptoms. Responders with both generalized pain and depressive symptoms were more likely to consult their family doctor, but not specifically for musculoskeletal pain. These results confirm the hypothesis that general psychological well being rather than specific somatic symptoms predict consultation frequency.

Adult↗
PubMed2003

Training GPs in parent consultation skills. An evaluation of training for the Triple P-Positive Parenting Program.

BACKGROUND: The Triple P-Positive Parenting Program is a behavioural family intervention program that aims to prevent severe behavioral, emotional and developmental problems in children by enhancing the knowledge, skills, and confidence of parents. OBJECTIVE: This study evaluated the effect of training general practitioners in the use of the primary care version of the TPP on their consultation skills, satisfaction and confidence in conducting consultations with parents. STUDY DESIGN: Participants were assigned to an experimental condition that involved a brief behaviorally oriented parent consultation skills training program or to a wait-list comparison group. Thirty-two GPs participated in the training. Fifteen participants attended the first workshop (intervention group) and 17 attended the second (wait-list comparison group). RESULTS: GPs who participated in the training reported greater satisfaction with the outcomes of their parent consultations and showed significantly greater use of targeted parent consultation skills than GPs in the wait-list comparison group. Observations of GP consultation skills during simulated patient interviews with parents showed there was a significant overall improvement in their interactional skills during parent consultations. There was a high level of satisfaction with the quality of training received by the GPs. CONCLUSION: This was a brief, cost effective program that had significant effects on participating GPs' skills, confidence and satisfaction with child consultations involving behavioral problems. Implications for public health approaches to the prevention of child psychopathology are discussed.

Adult↗
PubMed2003

Consultation and the outcome of shoulder-neck pain: a cohort study in the population.

OBJECTIVE: Despite the high prevalence of shoulder-neck pain in the community, and the fact that it is commonly a persistent and disabling condition, only a minority of sufferers seek medical help. We investigated the association between primary care consultation and subsequent outcome in a cohort of shoulder-neck pain sufferers. METHODS: A population with unilateral shoulder-neck pain was identified by a questionnaire mailed to 4002 adults randomly selected from the register of one family practice. Subjects were asked to shade areas of pain on a blank manikin, and give demographic details and scales of pain, anxiety, and depression. For the following 2 years, general practitioner (GP) consultations for shoulder and neck problems were determined using the practice database. The persistence of pain and degree of shoulder-specific disability, as well as general health status using the Medical Outcome Study Short Form-36 (SF-36), were assessed by means of a second postal survey at 2 years' followup. RESULTS: Three hundred four subjects (11.7% of questionnaire responders) had unilateral shoulder-neck pain at baseline, and 224 were included in the study analyses. Of these, 47 (21%) consulted their GP for shoulder-neck problems over the 2 years. Of the 47 consulters, 36 (77%) reported shoulder-neck pain at followup; this was a higher percentage than that for nonconsulters (RRadjusted = 1.3). Among all subjects with persistent shoulder-neck pain, consulters were more likely than nonconsulters to have shoulder related disability at followup (RRadjusted = 1.6). On average, consulters had more pain and lower levels of physical functioning at followup than nonconsulters as measured by the SF-36. CONCLUSION: The minority of shoulder-neck pain sufferers who consult a primary care practitioner do not have better subsequent pain and disability outcomes than those who do not consult. Our findings raise questions about the current influence of medical care on the natural history of this condition.

Adolescent↗
PubMed1992

[An analysis of the interruptions in general medicine consultations].

AIM: To find out the number and nature of the interruptions which occur in general medical consultations. DESIGN: Prospective study lasting two months. SITE. Two representative primary care consulting rooms in an urban health centre (a family and community medicine teaching centre). PATIENTS AND OTHER PARTICIPANTS: All the interruptions which occurred on the days chosen within the period of study were analysed. MEASUREMENTS AND MAIN RESULTS: The two consulting rooms had an average of 10 and 6.8 interruptions a day: which suggests that, in 91% and 54% respectively of the consultations that took place, some type of interruption occurred. The average length of the interruptions was 35 and 16 seconds, which represented 3.2% and 1.1% of the total time of the consultations. The members of staff who caused most interruptions were janitors (30.6% and 37%), followed by clerks (24.1% and 22.5%). However those who took the most time in their interruptions were clerks (25.4% of the total time in one consulting room) and nurses (30.3% of the total time in the other consulting room). The majority of the interruptions (63% and 53%) were considered unjustified. The handling over of analyses and further tests (15.8% and 21.4%); the bringing-in of certificates stating inability to work (16.5% and 18.1%); and the bringing-in or taking-out of clinical notes (15.1% and 11.2%) accounted for the most common causes of interruption. CONCLUSIONS: There is a need to organise the health centre's infrastructure so that as few interruptions as possible take piece actually during a consultation, given the bad effect they have on the doctor-patient relationship.

Age Factors↗
PubMed2005

[Caring for teenage girls: from the perspective of establishing women's health consultations on campuses].

Women's health problems are increasing among teenage girls in modern society. However, there are only a few programs related to women's health consultation on campuses. Three issues are explored in this paper - the health rights of teenage girls, women's health consultations, and teenage girls' subjective views about the establishment of a women's health consultation service on their campus. In the course of our research of teenage girls' subjective views, three hundred and eighty-seven young girl students responded to questionnaires and seven volunteer students among them were invited to do in-depth interviews. Most students (98.2%) thought that it was necessary to set up a women's health consultation service on campus, because they hoped to get personal health information that could not be found in a textbook. Three hundred and five (78.8%) students perceived that they had women's health problems. Their health problems are ranked as follows: dysmenorrhea, irregularity of menstrual periods, unusual vaginal secretions and questions of contraception and urinary system health. They suggested that campus consultation centers should have the following characteristics: protection of students' privacy, provision of multiple channels for consultation, strict limitation on numbers of people in the consulting office, and a non-discriminatory policy towards all clients. Hopefully, an information database can provide a good reference for establishing a women's health consultation service on campus in the near future.

Adolescent↗
PubMed2005

An audit of anticoagulation practice among UK cardiothoracic consultant surgeons following valve replacement/repair.

BACKGROUND AND AIM OF THE STUDY: In 1998, the American College of Cardiology and The American Heart Association (ACC/AHA) published guidelines for the postoperative anticoagulation of patients who have undergone heart valve replacement. The American College of Chest Physicians made similar recommendations in 2001. The present survey was conducted to review anticoagulation practice among UK consultant cardiac surgeons, and to assess compliance with these guidelines. METHODS: An anonymous postal questionnaire was distributed to 185 adult cardiac surgeons identified from the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS). RESULTS: The analysis was based upon 97 replies. All consultants use lifelong warfarin after mechanical valve replacement. In general, target INR ranges were lower for aortic valves compared with mitral valves. Some 53% (51/97) of consultants never use warfarin after bioprosthetic aortic valve replacement (AVR), compared with 33% (28/86) after bioprosthetic mitral valve replacement (MVR). Temporary (< or = 3 months) warfarin is used by 47% (46/97) of consultants after bioprosthetic AVR and by 63% (54/86) after bioprosthetic MVR. Some 64% (52/81) of consultants use warfarin after mitral valve repair, when an annuloplasty ring is inserted. This was always temporary (< or = 6 months). Aspirin is used long term by 54% (44/82) of consultants after mitral valve repair. CONCLUSION: All consultant cardiac surgeons adequately anticoagulate their patients after mechanical valve replacement. Only 16% (16/97) of cardiac surgeons follow current guidelines for the postoperative anticoagulation of bioprosthetic AVR. Only 28% (24/86) of consultant cardiac surgeons comply with guidelines for bioprosthetic MVR. No guidelines exist for the anticoagulation of patients after mitral valve repair. Guidelines need to be reviewed for the anticoagulation of patients undergoing bioprosthetic valve replacement and formulated for patients undergoing mitral valve repair.

Adult↗
PubMed2006

Consultations for middle ear disease, antibiotic prescribing and risk factors for reattendance: a case-linked cohort study.

BACKGROUND: Otitis media is the most common reason for children to receive antibiotics, but there is no evidence about the effect of prescribing on reattendance. AIM: To evaluate the changing workload of middle ear disease in general practice, and the impact on surgery reattendance of prescribing antibiotics at first attendance. DESIGN OF STUDY: A case-linked cohort analysis for antibiotic prescribing versus no prescribing at first consultation event. SETTING: Two hundred and ninety-one practices spread throughout the UK recording for the General Practice Research Database (GPRD) and incorporating individual patient data records for 2,265,574 patients. METHOD: All middle ear disease coded events that can be classed within acute otitis media (AOM) or glue ear sub-categories (and excluding chronic suppurative otitis media) were selected for analysis when the first event was from 1991-2001. The effect of antibiotic prescription on the risk of reattendance using Cox proportional hazards regression was analysed. RESULTS: Total consultations for AOM have fallen markedly over this decade, and glue ear consultations have risen but by a much smaller extent (26,000 decrease versus 4000 increase in consultations per year), which makes relabelling an unlikely explanation of the fall in AOM consultations. In the 2-10 years age range, consultations for AOM fell from 105.3 to 34.7 per 1000 per year, with glue ear consultations unaltered (15.2 to 16.7 per 1000 per year). Antibiotic prescribing for AOM has stayed remarkably constant (80-84% of consultations), but antibiotic prescribing for glue ear has risen sharply (13 to 62%). Prescribing antibiotics increased the risk of reattendance for AOM (hazard ratio [HR] = 1.09, 95% confidence interval [CI] = 1.07 to 1.10) and has reduced the risk of reattendance for glue ear (HR = 0.92, 95% CI = 0.88 to 0.96). CONCLUSION: Prescribing antibiotics for AOM probably increased reattendance, but the opposite effect has been noted for glue ear, which suggests a treatment effect of antibiotics in glue ear. Further research is needed to clarify whether this possible benefit is worth the known harms, and if so in which subgroups of children.

Adolescent↗
PubMed2006

[Medical insurance consultation through the medical society in the PKV--a quantitative analysis].

Insurance medical consultation by a medical consultant or medical director is well established at many companies in the German private health insurance sector. Nevertheless, the field of activity of the medical consultant is hardly known to the public and even less scientifically investigated. The present study deals with a quantitative analysis of insurance medical enquiries to medical consultants. For this, the total of all insurance medical enquiries in a whole year have been checked and classified. The total of 5116 enquiries shows that a large demand for consultation refers to the medical necessity of medicaments, followed by consultation on complementary and alternative medicine (CAM). Further important fields of consultation are the assessment of out-patient and in-patient psychotherapy, the verification of the extent of physical measures, the duration of hospital treatments, the extent of laboratory testing, the examination of new medical methods and the definition of cure measures in comparison with hospital treatment. Increasing demand exists for the definition of the necessity of out-patient and in-patient operations, the definition of cosmetic surgery and medically necessary plastic surgery and for questions of reproductive medicine. There is also increasing demand for consultation regarding lifestyle drugs and anti-aging medicine.

Complementary Therapies↗
PubMed1989

Consultation rates in English general practice.

Methods of estimating the annual consulting rate per patient are reviewed. Methodological problems include the definition of consultations as opposed to problems encountered, the definition of population at risk, the reliability of data about home visits and the limitations of extrapolating data collected over a short period. Estimates of consultation rate are usually obtained from surveys which have other primary objectives. The annual consultation rate in 1981, excluding telephone contacts, was estimated at 3.5 consultations per patient. In spite of its limited sample size, the general household survey provides a reliable estimate of the national consulting rate. There is, however, a need to validate it against a survey covering a longer period in which consultation rates are measured and not just estimated from memory. The total workload of the 'average' doctor changed little between 1970 and 1981 in spite of reducing list size. Home visits accounted for approximately 15% of all consultations in 1981 and this value has been consistent over the period 1980-83.

Adolescent↗
PubMed1977

The development of a "statement of policy regarding consultations".

The use of consultations in family medicine has often been misunderstood by both the persons seeking the consultations and the persons acting as consultants. A policy regarding the use of consultants has been written by the Department of Family Medicine and Practice at the Center for Health Sciences, University of Wisconsin. The statement includes a definition of "consultation," the reasons and goals for consultation, and the manner in which consultations are obtained. The policy includes the family practice residents, faculty, and patients in the decision-making process prior to all consultations.

Family Practice↗
PubMedDate not supplied

The use of consultation in the treatment of suicidal patients.

Consultation is acknowledged to be a useful aid in the treatment of the suicidal patient. Consultation is, however, a deviation from the therapeutic framework, and there are potential dangers. A case example is used to illustrate the various phases of the consultation process--from the decision to consult, the way the consultation is arranged, the type of consultation, and the results of the consultation on the patient-therapist relationship. A brief examination of the intrapsychic and interpersonal dynamics of the suicidal patient highlights the patient's vulnerability to seeing the deviation in technique as a disruption. A preferred form of consultation for these situations is suggested.

Adult↗