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PubMed1984

How good is communication between primary care physicians and subspecialty consultants?

We prospectively studied the communication between 27 referring practitioners and their consultants for 464 consecutive patient referrals from a general internal medicine group practice at a university medical center. The rates of referral among practitioners varied from 0 to 28.1 per 100 patients visits. Though referring physicians provided patient background information in 98% of the cases, they made explicit the purpose of the referral in only 76% of the cases. They contacted consultants directly in only 9% of the cases. In return, consultants communicated their findings to referring practitioners in only 55% of the consultations. Referring physicians who personally contacted consultants or who supplied them with more clinical information were more likely to learn the results of the consultation. While communication between the referring physicians and consultants in this setting is limited, it may be improved if referring physicians supply more clinical information to consultants and contact them directly.

California↗
PubMed1984

A continuity model for research consultation in family medicine.

This paper describes a model of individualized research consultation designed to assist family physician faculty members to develop research skills. The consultative relationship described here is a one-to-one helping relationship between a client (a family physician researcher) and a research consultant that is directed toward enabling the client to complete a research project and ultimately to function as an independent researcher. The continuity model stresses a relatively longterm, intensive relationship--a departure from the typical consultation in which the consultant renders advice and then exits. Within this continuity model, the consultant is involved at regular intervals throughout the duration of the research project and is committed to its completion. The principal role of the consultant is that of educator, within which the consultant may at various times act as reflective listener, agent of change, role model, "linker" to resources, and informational expert.

Consultants↗
PubMed1982

Evaluating performance in writing drug information consultations.

A form for evaluating written drug information consultations was used to measure the performance of pharmacy students in a drug information service clerkship; the reliability of the evaluation process was also assessed. Drug consultations were written by 74 clerks during a four- or five-week rotation. A total of 147 consultations were written: Nine clerks wrote one consultation, 57 clerks wrote two, and eight clerks wrote three. The consultations were evaluated on 11 criteria by 18 different preceptors using an evaluation form. Performance on each criterion was rated on a four-level scale. Clerk improvement over time, reliability of the instrument, and inter-rater reliability for preceptors were analyzed statistically. The overall mean score for all consultations was 84 7%. Some improvement was observed between the first and second consultations completed by clerks, but the difference was not significant. Reliability of the evaluation process was good (coefficient of alpha = 0.666). There as no significant difference among preceptors. The authors concluded that the written drug information consultation evaluation form was a valid and reliable method for measuring individual and program competence.

Clinical Competence↗
PubMed1980

The referral process: a study of one method for improving communication between rural practitioners and consultants.

Communication between referring physicians and consultants, essential for successful completion of the consultative-referral process, was inadequate in a rural clinic. This finding prompted the authors to conduct a randomized prospective trial of a referral form and return mailer in three rural primary care clinics associated with a university medical center. The use of a return mailer increased the percentage of consultant feedback from 39 percent to 60 percent, a highly significant increase. An added benefit was a decrease in the median time interval between a patient's contact with a consultant and receipt of that consultant's report by the rural clinics. The positive effect of the return mailer was consistent among various consultant categories, with the greatest improvement coming from a teaching hospital Emergency Room. The type of referring provider or the emergency status of the patient did not affect the percentage of communications returned. The use of a referral form accompanied by a request for feedback and a return mailer is an inexpensive method of increasing communication between primary care providers and consultants, thereby enhancing the value of the consultative-referral process.

Ambulatory Care Facilities↗
PubMed1995

Factors that influence the patient centredness of a consultation.

BACKGROUND: Research suggests that patients are more satisfied with patient-centred consultations than with doctor-centred consultations and that some health measures are positively influenced by this type of consultation. Research on the factors that influence the patient centredness of the consultation is sparse but suggests that women doctors are more patient centred than men doctors. AIM: A study was designed, first, to confirm or reject the suggestion that women general practitioners are more patient centred than men general practitioners and, secondly, to determine some of the factors that might influence the patient centredness of a general practitioner. METHOD: The audiotaped consultations of 41 general practitioners were analysed using an instrument designed to measure patient centredness. The general practitioners were selected from a group of volunteers to represent both sexes as well as a wide range of age and experience. RESULTS: The results of the analysis showed that women general practitioners, particularly trainers, had higher patient-centredness scores than men general practitioners. This behaviour is characterized by an increased frequency of open questions and greater attention to patient offers (anything of potential significance that a patient brings to the general practitioner consultation). Additionally, the combination of sexes in a consultation seemed to have an effect on the interaction, with woman general practitioner/female patient dyads (pairings) having the highest median patient-centredness score, woman general practitioner/male patient and man general practitioner/male patient dyads scoring the same as each other and man general practitioner/female patient dyads having the lowest median scores. CONCLUSION: The results suggest that women general practitioners, in this sample, were more patient centred than men general practitioners. The results also suggest that inherent inequalities exist, with female patients receiving a more patient-centred service from general practitioners of their own sex than from general practitioners of the opposite sex. Male patients, on the other hand, seemed to fare equally well, irrespective of the sex of their general practitioner. Training is required to address these inequalities and to improve the level of patient centredness in the consultation.

Adult↗
PubMed1995

The impact of a pharmacotherapy consultation on the cost and outcome of medical therapy.

BACKGROUND: One important task for physicians is to optimize their patients' medication regimen. Involvement of clinical pharmacists who have specific training in drug regimen design has been associated with improved patient outcomes for specific medical conditions, eg, hypertension and anticoagulation. This prospective, randomized trial investigated whether a single consultation by a clinical pharmacist with high-risk patients and their primary physicians would result in improved prescribing outcomes. METHODS: Patients at risk for medication-related problems were identified and randomized to receive a pharmacotherapy consultation (consult group) or usual medical care (control group). Outcomes, including the number of drugs, number of doses per day, cost of medications, and patient reports of adverse effects, were recorded at baseline and at 6 months following the intervention. RESULTS: Fifty-six subjects were evaluable: 29 in the control group, and 27 in the consult group. Six months after the consultation, the number of drugs, the number of doses, and the 6-month drug costs all decreased in the consult group and increased in the control group; the net difference was 1.1 drugs (P = .004), 2.15 doses per day (P = .007), $586 per year (P = .008). The side effects score improved by 1.8 points more in the consult group compared with the control group (P = NS). Similarly, the prescribing convenience score in the consult group improved by 1.4 points more than that of the control group (P = NS). CONCLUSIONS: This study demonstrates several important benefits of integration of a clinical pharmacist into a primary care setting, including improvement in cost and simplification of the medication regimen with no reduction in quality of care.

Ambulatory Care↗
PubMed1994

Dermatologic consultations in the hospital setting.

BACKGROUND AND DESIGN: Dermatologic practice occurs mainly in the outpatient setting. The reasons for, frequency, and impact of inpatient dermatologic consultation are largely unstudied. In this report, we prospectively studied dermatologic consultation in the major teaching hospital complex of a medical school. Over a period of 8 months, we prospectively recorded the demographics of the patients for whom consultation was requested, the provisional dermatologic diagnosis of the referring service, the final diagnosis of the dermatologic service, and the tests necessary to arrive at a final diagnosis. RESULTS: During a period of slightly over 8 months, dermatologic consultation was requested and delivered to 591 patients who were either hospitalized or being evaluated in the emergency department or other urgent care settings. The services requesting consultation most frequently were medicine (39%), pediatrics (14%), surgery (12%), psychiatry (6%), and neurology (3%). In 51% of consultations, the patients were younger than 45 years of age. Diagnostic tests, including Tzanck smear and potassium hydroxide preparation, confirmed the clinical diagnosis in up to 50% of cases. Dermatologic consultation changed dermatologic diagnosis and treatment in more than 60% of the patients. Generally, the dermatologic diagnoses most frequently missed by the referring service were common conditions with established treatment. CONCLUSIONS: Dermatologic consultation in the hospital setting improves dermatologic diagnosis and has an impact on treatment.

Adolescent↗
PubMed1995

Effective use of the research consultant.

A principal investigator (PI) often includes a consultant in a proposal for a research project either at the request of the funding agency or because a consultant may add expertise to the research team. The most effective use of the consultant may vary according to the needs and gaps in areas of expertise of the team. Lippitt and Lippitt (1978) developed a model for guiding consultation that has been adapted in this article to guide not only the consultant but also the researcher in how to effectively use a consultant. The model is adaptable whether the principal investigator is new to designing and implementing research projects and needs a consultant expert in the research process or the PI has much research experience and needs a clinically expert consultant. The six phases of this model from contact and entry through contract completion is a step-by-step guide that is adaptable to the needs of the PI and research team.

Consultants↗
PubMed1996

Should consultant surgeons see new or follow-up patients? A prospective audit of a change in clinic organisation.

In the traditional surgical clinic consultants assess new referrals (NP) and trainees follow-up patients (FP). To improve the management of FP and to increase trainee teaching a clinic was changed so trainees assessed NP (under supervision) and the consultant FP. A prospective audit was conducted two months before and two and six months after the change. A further audit four years later included a questionnaire to trainees, patients, General Practitioners (GP) and nurses. Before the change the proportion of NP to FP was 1:1.9. Six months later FP were reduced by 28 per cent. Four years later the proportion of NP to FP was 1:1.6. The consultant was more likely to discharge follow-up patients and shortened the interval between follow-up appointments. Questionnaires revealed that many GPs (59 per cent) would accept less consultant involvement with NP if this increased FP discharges. All trainees and most nurses (83 per cent) preferred the rearranged clinic. NP found initial assessment by trainees acceptable and FP noted the greater consultant input. This study suggests that consultant surgeons should review more FP and this can be achieved without reducing NP consultations. This arrangement is acceptable to patients and improves training. Guidelines recommending that consultants see all NP should be reconsidered.

Attitude of Health Personnel↗
PubMed1998

The consultation and referral process. A report from NEON. Northeastern Ohio Network Research Group.

BACKGROUND: Consultation and referral are essential components of the practice of primary care. Despite this, little is known about the factors that contribute to the success of a referral. We examined the short-term outcomes of communication between family physicians and consultants during the referral process. METHODS: The study setting was six family practice centers in northeastern Ohio. All eligible physicians at each center participated in data collection by means of a card study. Data was recorded on any patient who received a referral to a physician or nonphysician provider during the month of July 1994. One year later, referrals were followed up by physician questionnaire. RESULTS: Three hundred nine of 5172 total patients were referred (5.97 referrals per 100 office visits). At follow-up, the family physicians reported that 63% of patients had visited the consultant, 14% had not, and the physician had no knowledge of the actions taken by the other 23%. The referring physician received feedback from the consultant regarding 55% of the patients referred. Receipt of feedback was strongly related to communication by the family physician to the consultant at the time of referral. Physicians who received feedback were the most satisfied with communication from the consultant and the care their patient had received. CONCLUSIONS: Primary care physicians can influence the likelihood of receiving feedback from a consultant by initiating communication with the consultant. A referral wherein the physicians involved do not communicate with one another results in physician dissatisfaction. Primary care physicians must practice strategies to improve the referral process.

Adolescent↗
PubMed1998

Consultancy in nursing: roles and opportunities.

This paper considers the development of consultancy roles within nursing, specifically examining internal and external approaches to consultation. As consultancy in nursing develops there appear to be two major trends: external or independent consultancy where the incumbents focus purely upon this role as their 'job', and internal consultation where consultancy is seen as an integral part of their role and is a subrole of the advanced practitioner. In promoting consultancy as a means of developing and enhancing advanced practice, suggestions are made for future opportunities for consultancy in nursing and its role in the development of nursing practice.

Career Mobility↗
PubMed2006

Effects of interventions aimed at changing the length of primary care physicians' consultation.

BACKGROUND: Observational studies have shown differences in process and outcome between the consultations of primary care physicians whose average consultation lengths differ. These differences may be due to self selection. OBJECTIVES: To assess the effectiveness and efficiency of interventions to alter the length of primary care physicians' consultations. SEARCH STRATEGY: The following electronic databases were searched: Cochrane Effective Practice and Organisation of Care Group (EPOC) Specialised Register (October 2002); CENTRAL (The Cochrane Library June 2003); MEDLINE (1966 to October 2002);EMBASE (1981 to October 2002); NHS National Research Register (June 2003). The search strategies combined subject terms for 'general practice', 'consultation' and 'length' with methodological filters. SELECTION CRITERIA: Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of interventions to alter the length of primary care physicians' consultations. DATA COLLECTION AND ANALYSIS: Data were extracted independently by two authors using agreed criteria. Disagreements were resolved by discussion. Where data were missing attempts were made to contact authors. Given the heterogeneity of studies meta-analysis was not attempted, and results are presented as a narrative summary. MAIN RESULTS: Six articles describing four UK trials met the inclusion criteria. All tested short term changes in the consultation time allocated to each patient and all had methodological weaknesses, particularly due to non-random allocation of patients. Altering appointment length resulted in modest changes in average length of consultation. There were no consistent differences in problem recognition, examination, prescribing, referral or investigation rates. There was some evidence that blood pressure was checked and smoking discussed more often when more time was available. None of the interventions were associated with differences in patient satisfaction. No trials examined efficiency. AUTHORS' CONCLUSIONS: The findings of this review do not provide sufficient evidence to support or resist a policy of altering the lengths of primary care physicians' consultations. Further trials are needed that focus on health outcomes and cost effectiveness.

Appointments and Schedules↗
PubMed2002

Family physicians' selection of informal peer consultants: implications for continuing education.

INTRODUCTION: Studies of physicians' preferred sources of clinical information suggest that many rely heavily on advice from colleagues. This study examines the criteria that a sample of physicians used to select informal educational consultants, the characteristics of participants adhering to these criteria and those of the peers they consult, and the participants' approaches toward evaluating information gathered from peers. METHOD: In-depth interviews were conducted with 45 family physicians from three mid-sized Ontario cities. A typology of participants' approaches for selecting informal peer consultants was developed from participants' selection criteria. Seven themes emerged from analysis across the interviews, and three types of approaches to selecting peer consultants are characterized with respect to these themes. RESULTS: When seeking clinical information, most participants reported that their first resource was informal consultation with peers. Fifty-four percent turned to readily available and approachable peers, and 24% asked only those peers they considered to be experts. The remaining participants (22%) searched the literature before or in conjunction with consulting expert specialists or innovators. Participants who sought advice from their most readily accessible peers asked for advice most frequently, rarely consulted innovators, and were least critical of the advice they received. DISCUSSION: The profiles of those who sought clinical information from their most accessible peers suggested that the quality of informal peer consultations could be improved through explicit guidelines within formal continuing education programs. Longitudinal studies are needed to examine the effectiveness of this strategy in increasing the translation of research into family physicians' clinical practices and patient outcomes.

Diffusion of Innovation↗
PubMed2006

Relationship between climate, pollen concentrations of Ambrosia and medical consultations for allergic rhinitis in Montreal, 1994-2002.

The aim of this study is to evaluate the influence of meteorological factors on Ambrosia pollen concentrations and its impact on medical consultations for allergic rhinitis of residents from various socio-economic levels in Montréal (Québec, Canada) between 1994 and 2002. The study was conducted to recognize the sensitivity of pollen productivity to daily climate variability in order to estimate the consequences on human health vulnerability in the context of global climate change. Information related to medical consultations for allergic rhinitis due to pollen comes from the Quebec Health Insurance Board (Régie de l'assurance-maladie du Québec). Ambrosia pollen concentration was measured by the Aerobiology Research Laboratories (Nepean, Ontario). Daily temperature (maximum, minimum, and mean) and precipitation data were obtained from the Meteorological Service of Canada. Socio-economic data come from the 1996 and 2001 census data of Statistics Canada. Between 1994 and 2002, during the Ambrosia pollen season, 7667 consultations for allergic rhinitis due to pollen were recorded. We found a significant association between the number of medical consultations and pollen levels. Significant associations were detected for over-consultation the day of exposure, 1, 2, 3 and 5 days after exposure to high levels of pollen. The consultation rate is higher from low-income residents (3.10 consultations per 10,000 inhabitants) than for high-income (1.65 consultations per 10,000 inhabitants). Considering the demonstrated impact of pollen levels on health, it has become critical to ensure adequate monitoring of Ambrosia and its meteorological sensivity in the context of the anticipated climate change and its potential consequences on human health.

Air Pollutants↗
PubMed2003

The ethics of public consultation in health care: an Orthodox Jewish perspective.

New Zealand and United Kingdom governments have set new directives for increased consultation with the public about health care. Set against a legacy of modest success with past engagement with public consultations, this paper considers potentially adverse ethical implications of the new directives. Drawing on experiences from New Zealand and the United Kingdom, and on an Orthodox Jewish perspective, the paper seeks to answer two questions: What conditions can compromise the ethics of public consultation? How can the public respond ethically to consultation? In answering these questions, the paper considers how Orthodox Judaism, as a specific positive morality, can aid the development of public policy. It is suggested that an Orthodox Jewish perspective does not require limiting the content of public consultations and helps to define a common procedural morality binding Jews and non-Jews. This procedural morality requires avoiding two conditions that, as shown from Jewish texts, make public consultation unethical. These are "overpreparation" and "underpreparation." Members of the public who deem a consultation unethical should give feedback not on the proposal but on the conditions they perceive to prevent the consulting party from considering their viewpoints on the proposal.

Community Participation↗
PubMed2001

Knowing patients and knowledge about patients: evidence of modes of reasoning in the consultation?

BACKGROUND: The idea that the patient is in some way known to the doctor is an important one in general practice. The thrust towards patient-centred medicine, the promotion of open and negotiative consultation skills and the development of a biopsychosocial model of primary care medicine all rely on the patient providing a history composed of more than a list of facts. OBJECTIVE: Our aim was to explore the nature and importance of doctors' knowledge about patients. METHODS: Fifteen GPs audio-recorded 25-30 consultations with consecutive consenting patients. They scored each consultation according to how satisfying they found it. Semi-structured interviews based on a selection of consultations were conducted to draw out the doctor's views on the factors that were important to their satisfaction. The interviews were transcribed verbatim. Qualitative analysis was inductive and iterative. RESULTS: Within doctors' narratives, we found accounts of two ways of 'knowing' the patient. The first was a deductive mode of reasoning derived from facts about the patient. The facts that were known were specific to the context of the general practice consultation and led to biomedical and biographical knowledge. The second was an inductive mode of reasoning derived from a contextual interpretation of the facts about the patient which resulted in knowledge of their behaviour and cognitions. Both modes of reasoning gave the doctor knowledge of the patient and permitted action by the doctor in the consultation but led to different interpretations of the patient and different experiences of the consultation. CONCLUSION: 'Knowing the patient' is important to the way GPs attribute meaning to their work. Doctors were more likely to identify as 'known' those patients with whom they adopted an inductive mode of reasoning. In addition, their experience of the consultation was more likely to be positive.

Adult↗
PubMed2002

Workload and stress in consultant medical microbiologists and virologists: a questionnaire survey.

AIMS: To document demography, changing workload patterns, job satisfaction, morale, and prevalence of stress and psychological morbidity among UK consultant medical microbiologists and virologists. METHOD: A questionnaire survey of all identified UK practising consultant medical microbiologists and virologists (n= 464). RESULTS: Among 367 respondents (79%), there were 33 virologists and at least 89 single handed consultants. Over half the respondents (58%) were working a 1 : 1 or 1 : 2 on call rota during the week and a similar proportion (51%) at weekends. Of all consultants (including those working part time), 56% were working more than 48 hours weekly. Working more than 48 hours weekly, and being on call 1 : 1 or 1 : 2 at weekends, were both independently associated with increased psychological morbidity. Those on call 1 : 1 or 1 : 2 at weekends were also more likely to have low or very low morale. Female consultants were more likely to have higher stress scores. More than half of the respondents (208 of 363; 57%) were making active financial provision to retire early, and 198 of 363 (55%) did not intend to work beyond the age of 60. CONCLUSIONS: The long hours worked by many consultant microbiologists and virologists are in breach of the European Working Time Directive and are associated with a higher degree of psychological morbidity. For most consultants, the frequency of on call commitments is demanding and job satisfaction and morale have deteriorated. Urgent action is needed, particularly to support those working more than 48 hours each week and those on call at weekends 1 : 1 or 1 : 2. However, a major expansion of the consultant establishment cannot be achieved rapidly, and will be slowed further if early retirements become more frequent.

Adult↗
PubMed2006

[Time and mean cost rate of a nurse's work in nursing consultation].

In this study, the author aimed at characterizing Nursing Consultation attendances according to pre-surgical patients of the Coronary Program, estimating the nurse's average time and work mean cost in performing it, and studying the existence of association/correlation between time, cost and other variables of interest. The development of the consultation followed the phases of the Assistance Systemization Nursing (ASN). The sample was comprised of 44 patients, of which 37 (84%) were attended in new consultations and 7 (16%) in follow up consultations. Results obtained from the coronary program were mean time of 48.91 minutes for new consultations and 22.14 minutes for follow ups, with a mean cost of around R dollars 18.01 for new consultations and R dollars 8.15 for follow ups. These figures show that new consultations mean time exceeds with statistical significance follow up consultations mean time and, consequently, so do costs.

Costs and Cost Analysis↗