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PubMed1995

Computer-based interaction analysis of the cancer consultation.

There are few data available on which to base recommendations for effective communication in the cancer consultation. This paper describes a computerised interaction analysis system designed specifically for the cancer consultation and its application in a study investigating the relationship between doctor-patient behaviour and patient outcomes. One hundred and forty-two cancer patients attending their first consultation with a cancer specialist were audio taped and a copy of the tape was retained for interaction analysis. Before the consultation patient anxiety and information and involvement preferences were measured. Outcomes included recall of information, patient satisfaction with the consultation and psychological adjustment to cancer. Doctor behaviour was shown to vary significantly according to the age, sex, involvement preferences and in/out-patient status of the patient. The ratio of doctor to patient talk was related to satisfaction with communication, while patients whose questions were answered showed better psychological adjustment at follow-up. The results suggest that patient-centred consultations lead to improved satisfaction and psychological adjustment. These data provide precise information about consultation behaviour which can be used in the documentation of current practice and the evaluation of new interventions to improve communication.

Adolescent↗
PubMed1999

The consultant orthodontic service--1996 survey.

OBJECTIVE: To evaluate the working patterns and facilities of the consultant orthodontist service. DESIGN: A cross-sectional survey. SETTING: Consultant orthodontist departments in the UK. SUBJECTS AND METHODS: All consultant orthodontists in the UK were sent a questionnaire that gathered information on the individual consultant, the facilities available, the new patients referred and patients under current treatment. RESULTS: The consultant orthodontist service provided treatment to a high number of patients who were in definite need of orthodontic treatment. A marked reduction in the use of removable appliances suggests improving standards of care and provision of more complex treatment. The caseload was high and a fair proportion of patients were returned to their referring dentists with treatment plans. The consultant service has not completely evolved into a service that provides treatment at a super-specialist level alone. CONCLUSIONS: There has been little change in the consultant orthodontist service over the past ten years. Arguably, this is because of the wishes of the purchasers and the shortage of trained orthodontic manpower as a direct result of poor manpower planning and lack of funds for post-graduate training.

Cross-Sectional Studies↗
PubMed1999

Promoting patient participation in the cancer consultation: evaluation of a prompt sheet and coaching in question-asking.

Active participation in the medical consultation has been demonstrated to benefit aspects of patients' subsequent psychological well-being. We investigated two interventions promoting patient question-asking behaviour. The first was a question prompt sheet provided before the consultation, which was endorsed and worked through by the clinician. The second was a face to face coaching session exploring the benefits of, and barriers to, question-asking, followed by coaching in question-asking behaviour employing rehearsal techniques. Sixty patients with heterogeneous cancers, seeing two medical oncologists for the first time, were randomly assigned to one of three groups: two intervention groups and one control group. Sociodemographic variables and anxiety were assessed prior to the intervention which preceded the consultation. The consultations were audiotaped and subsequently analysed for question-asking behaviour. Anxiety was assessed again immediately following the consultation. Questionnaires to assess patient satisfaction, anxiety and psychological adjustment were sent by mail 2 weeks following the consultation. Presentation and discussion of the prompt sheet significantly increased the total number of questions asked and the number of questions asked regarding tests and treatment. Coaching did not add significantly to the effects of the prompt sheet. Psychological outcomes were not different among the groups. We conclude that a question prompt sheet addressed by the doctor is a simple, inexpensive and effective means of promoting patient question asking in the cancer consultation.

Adaptation, Psychological↗
PubMedDate not supplied

Impact of pediatric ethics consultations on patients, families, social workers, and physicians.

OBJECTIVE: To evaluate whether health providers and families find ethics consultations helpful in identifying, analyzing, and resolving ethical problems. STUDY DESIGN: Forty consecutive pediatric ethics consultations at the San Diego Children's Hospital and Health Center were evaluated retrospectively through chart reviews and structured interviews with physicians, social workers, and family members. RESULTS: In 23 of 40 cases, physicians or social workers were successfully interviewed. Of these 23 cases, four family interviews were completed. Over 90% of physicians and social workers found the ethics consultation to be helpful and would recommend an ethics consultation to others in the same circumstances. Two of the four families were strongly dissatisfied with the consultation and identified miscommunication of the ethics consultant's role as a major problem. CONCLUSION: The disparity observed in this study between satisfaction levels of health providers and families raises concerns. More studies that evaluate ethics consultations are needed, especially those that are designed prospectively and explore both these perspectives.

Adolescent↗
PubMed2000

Formative assessment of the consultation performance of medical students in the setting of general practice using a modified version of the leicester assessment package.

OBJECTIVE: To evaluate the use of a modified version of the Leicester Assessment Package (LAP) in the formative assessment of the consultation performance of medical students with particular reference to validity, inter-assessor reliability, acceptability, feasibility and educational impact. DESIGN: 180 third and fourth year Leicester medical students were directly observed consulting with six general practice patients and independently assessed by a pair of assessors. A total of 70 practice and 16 departmental assessors took part. Performance scores were subjected to generalizability analysis and students' views of the assessment were gathered by questionnaire. RESULTS: Four of the five categories of consultation performance (Interviewing and history taking, Patient management, Problem solving and Behaviour and relationship with patients) were assessed in over 99% of consultations and Physical examination was assessed in 94%. Seventy-six percent of assessors reported that the case mix was 'satisfactory' and 20% that it was 'borderline'; 85% of students believed it to have been satisfactory. Generalizability analysis indicates that two independent assessors assessing the performance of students across six consultations would achieve a reliability of 0.94 in making pass or fail decisions. Ninety-eight percent of students perceived that their particular strengths and weaknesses were correctly identified, 99% that they were given specific advice on how to improve their performance and 98% believed that the feedback they had received would have long-term benefit. CONCLUSIONS: The modified version of the LAP is valid, reliable and feasible in formative assessment of the consultation performance of medical students. Furthermore, almost all students found the process fair and believed it was likely to lead to improvements in their consultation performance. This approach may also be applicable to regulatory assessment as it accurately identifies students at the pass/fail margin.

Clinical Competence↗
PubMedDate not supplied

Barriers to the use of interpreters in emergency room paediatric consultations.

OBJECTIVE: To identify barriers to the use of trained interpreters in emergency department (ED) paediatric consultations. METHODS: A cross-sectional survey of non-English-speaking-background (NESB) carers who presented a child aged 14 years or less to the Fairfield Hospital ED during a 3-month period was undertaken using a multilingual postal questionnaire or a phone interview with interpreter assistance. RESULTS: Of the 1388 paediatric consultations during the study period, 406 of the carers were registered as being of NESB, with 316 being eligible for study inclusion. Of the 278 (88%) respondents who completed the questionnaires, assistance with interpretation was required by 131 (47%) respondents: 55 (20%) used ad hoc interpreters, 47 (17%) used a trained interpreter and 21 (8%) did not receive the required assistance. Fifty-four (41%) carers who required interpreter assistance were identified as having this requirement at clerical registration in the ED, but only 18 of these were provided with a trained interpreter during the consultation. Limited English proficiency was self-reported by 127 (46%) respondents, with these respondents being more likely to need interpreter assistance (odds ratio (OR) 44.2; 95% CI 21.6-90.7), to have impaired understanding of the consultation (OR 8.2; 95% CI 4.7-14.1) and to consult a language concordant general practitioner (OR 10.1; 95% CI 5.1-19.4) compared with English proficient respondents. CONCLUSIONS: Barriers to the use of interpreters in ED paediatric consultations include poor identification of the need for and provision of an interpreter in the ED, and a preference for NESB carers to use ad hoc interpreters or no interpreter. Recommendations include the implementation in the ED of strategies to improve identification of NESB carers, as well as to improve awareness, access and use of trained interpreters during paediatric consultations. There is also a need to explore the experience of ED staff in accessing and using trained interpreters.

Adolescent↗
PubMed2003

Discrepancies between patient and professionals recall and perception of an outpatient consultation.

AIMS: To explore the degree of agreement between patient and health care professional's perceptions of consultations. METHODS: Immediately after 141 dietitian/nurse specialist consultations, patients and professional's completed the Health Care Climate questionnaire (HCC), Medical Interview Satisfaction Scale (MISS) and the Treatment Self-Regulation Questionnaire (TSRQ) In addition, both parties were asked about any key points or issues discussed in the consultation; any decisions that were made about their diabetes treatment today; any goals that were set as a result of today's consultation. RESULTS: Patient and professional's scores on the HCC and MISS were not correlated (r=0.3 and 0.16). Patient and professionals disagreed on the issues discussed 19.6% of the time, on the decisions made 20.7% of the time and goals set 44.3% of the time. More autonomy support in the consultation was associated with greater autonomous motivation for self-care (r=0.31; P<0.001) more controlled motivation was associated with less agreement on issues discussed and goals set (r=-0.20; r= -0.24; P<0.05). CONCLUSION: There is significant disagreement between patients and professionals perceptions and recollection of the content of consultations. Professional's communications skills need to be developed to ensure these discrepancies are minimized. Skills to provide greater autonomy support in the consultation would help to enhance this process and improve outcomes.

Decision Making↗
PubMed2001

Frequency and predictors of physician consultations for headache.

We conducted a population-based headache questionnaire survey including questions on physician consultation for headache in Taipei, Taiwan from August 1997 to June 1998. The participants comprised 3377 subjects aged > or = 15 years, of whom 328 (9.7%) had a diagnosis of migraine and 1754 (52%) had a diagnosis of non-migraine headache. Migraineurs had a higher physician consultation rate (once or more in the past year) than the subjects with non-migraine headache (54% vs. 31%, P < 0.0001). When frequency > or = 10 times was taken as 10 times, the analysis showed that migraineurs consulted physicians more often than non-migraine headache subjects (2.36 vs. 0.96, P = 0.04). A small proportion of the subjects with either migraine (12%) or non-migraine headache (6%) accounted for 50% of total consultations within their groups. In addition to old age, low education levels, living in a rural area, migrainous features (nausea and photophobia), and work day loss, predictors of physician consultations also included 'having been troubled with headache' (odds ratio (OR) = 1.7) and co-morbidity with hypertension (OR = 1.8) or heart disease (OR = 2.2). Low copayment and unrestricted access to medical care, as well as cultural factors played an important role in the high consultation rates in our headache subjects. Moreover, this study found self-perception of headache impact and co-morbid illnesses were important factors affecting the decision to consult physicians about headache.

Data Collection↗
PubMed1998

Informal consultations provided to general internists by the gastroenterology department of an HMO.

OBJECTIVE: To study the process, outcomes, and time spent on informal consultations provided by gastroenterologists to the primary care general internists of an HMO. DESIGN: Observational study. SETTING: A large, urban staff-model HMO. PATIENTS/PARTICIPANTS: Seven gastroenterologists constituting the total workforce of the gastroenterology department of the HMO. MEASUREMENTS AND MAIN RESULTS: Data on 91 informal consultations were obtained, of which 55 (60%) involved the acute management of a patient with new symptoms or test results, and 36 (40%) were for questions related to nonacute diagnostic test selection or medical therapy. Questions regarding patients previously unknown to the gastroenterology department accounted for 74 (81%) of the consultations. Formal referral was recommended in only 16 (22%) of these cases. As judged by the time data gathered on the 91 consultations, the gastroenterologists spent approximately 7.2 hours per week to provide informal consultation for the entire HMO. CONCLUSIONS: Gastroenterologists spend a significant amount of time providing informal consultation to their general internist colleagues in this HMO. The role informal consultation plays in the workload of physicians and in the clinical care of populations is an important question for health care system design, policy, and research.

Boston↗
PubMed2002

[Gerontopsychiatric consultation service].

In the discussion of the increasing costs of health care in Germany the frequent and often times long inpatient treatments of elderly patients are pointed out. Since these patients also suffer from psychiatric disorders very frequently, a psychiatric consultation is required rather often. This study was aimed to evaluate the requirements of a consultation service for elder inpatients. For this purpose all 9363 consultation reports from 1994 to 1998 were evaluated retrospectively. 2152 (31.4 %) of the patients visited by the psychiatric consultation service were over 64 years old. The most frequent diagnoses were organic brain syndrome (ICD-10: F0), particularly senile dementia (ICD-10: F00 - 03), adjustment disorder (ICD-10: F43) and affective disorders, particularly depressive disorders (ICD-10: F3). In 139 patients (6,5 %) a consultation was requested because of a suicidal attempt prior to admission. Our results suggest that in a gerontopsychiatric consultation service predominantly old patients with internal diseases and with the need of psychosocial help are visited and that the specific knowledge of psychopharmacological treatment in multimorbid patients as well as the psychosocial help and legal advice is requested. These aspects should therefore be a special focus in educational programs for a gerontopsychiatric consultation service.

Adjustment Disorders↗
PubMed2006

[Travel medicine and vaccination as a task of infection prevention--data of the special consultation hours of the public health department Frankfurt on the Main, Germany, 2002-2004].

UNLABELLED: Infection prevention is one of the main tasks of the Public Health authorities. Because of hundreds of travel associated infections imported by travellers every year and considering increasing travel activities to tropical countries, travel medicine and consultation on the correct prevention measures including vaccination is becoming more and more important. Hence the data of the special consultation hours of the public health department of Frankfurt am Main are reported and discussed with regard to possible improvements. MATERIAL AND METHODS: The public health department of Frankfurt am Main has been offering special consultation hours for travel medicine for many years. Here, data derived from the anamneses of the clients from 2002 - 2004 are reported: personal data such as age, sex, travel destination as well as medical data such as vaccination and malaria prevention. RESULTS: 2002 - 2004, more than 14,000 persons were seen in the consultation hours, more than 66% of them asked for travel health advice, about 25% of them asked for standard vaccination (such as influenza), some others asked for attestation or certification. More than 20,000 doses of vaccines were given, the most important vaccination against hepatitis A (n = 5791), hepatitis B (n = 4064), typhoid fever (n = 2718) and yellow fever (n = 2473). 2814 were informed with regard to malaria prevention, including recipes. 7814 persons with complete data on their reason for travel were subjected to more detailed analysis: 75% of them were holiday tourists, 18% travelled as "hikers", 7% were business travellers and less than 1% of them planned a round-the-world tour. The most frequent travel destinations were: Asian or African countries about 33% each, 25% Middle or South America. Thailand, South Africa with Namibia, Brazil and India were the most important countries. The time from health consultation to the beginning of the journey was too short for full vaccine protection against typhoid fever and meningococcal disease in 10% and against rabies in 44% of the consultants. There were no significant differences between holiday tourists, business and "hikers" travellers. CONCLUSION: According to many studies, only one-third of the travellers going abroad, especially to developing countries, obtain travel health information. Hence, the clients of our consultation hours are a positive selection. Nevertheless, great need for improvement could be seen as well. In many of the clients the time from getting health information and vaccination was too short for obtaining complete vaccination protection. People travelling to countries where most hepatitis A infections are obtained and re-imported home, such as Turkey and Tunisia and other Mediterranean countries almost never came for health advice and vaccination. Therefore, public health authorities should improve and increase their publicity campaigns for travel health and vaccination in order to prevent travel-associated infections and re-importation of such diseases.

Communicable Disease Control↗
PubMed1975

Comparison of television and telephone for remote medical consultation.

Television and telephone communications were randomly used to compare their effectiveness in allowing consultation between a hospital-based physician and remote nurse practitioners. Visits using television for consultation averaged 50 minutes as compared with 40 minutes for telephone. This difference was caused by longer work-ups before the consultation, longer delays after it was requested, and longer consultations, themselves, on television. However, television consultations resulted in significantly fewer immediate referrals of patients to hospital physicians: 6 plus or minus 1 as compared to 12 plus or minus 1 per cent (mean plus or minus S.E.M) OF ALL TELEPHONE CONSULTATIONS (P SMALLER THAN 0.005). Although no overall difference in satisfaction was documented between the results of television and telephone consultations, participants preferred the former for medical decision making and cited it for allowing more social interaction than telephone. These findings suggest that television may have its greatest value in remote sites where the sense of isolation is great and the need to reduce long-distance referrals offsets the costs of the system.

Community Health Services↗
PubMed2004

Patients' evaluation of their psychiatric consultation after attempted suicide.

Few studies have previously investigated patients' evaluation of their psychiatric consultation after attempted suicide. The aim of the present study was to examine the patients' view of their psychiatric consultation after a suicide attempt. Of a systematic sample of 114 suicide attempters in Helsinki, 73 subjects were referred to psychiatric consultation at an emergency room or department, and 53 of these evaluated the consultation received. Half of these suicide attempters considered their psychiatric consultation had occurred too soon after the attempt. Those whose prior attitude toward the consultation was indifferent had higher Hopelessness Scale (HS) and Beck Depression Inventory (BDI) scores than those who were positive. Psychiatric assessment should not take place before the patient has recovered from toxic effects caused by any overdose attempt. Suicide attempters with severe depression and hopelessness are likely to be those most indifferent to the prospect of psychiatric consultation. The presence of severe depression or hopelessness should not deter active evaluation and treatment.

Adult↗
PubMed2006

Risk communication in consultations about hormone therapy in the menopause: concordance in risk assessment and framing due to the context.

BACKGROUND: It is important for the physician and the patient to have a mutual understanding of the possible consequences of different treatment alternatives in order to achieve a partnership in decision-making. OBJECTIVE: The aim of this study was to explore to which degree first-time consultations for discussion of climacteric discomfort achieved shared understanding of the risks and benefits associated with hormone therapy in the menopausal transition. METHODS: Analysis of structure and content of transcribed consultations (n = 20), and follow-up interviews of the women (n = 19 pairs of consultations and interviews), from first-time visits for discussion of climacteric discomfort and/or HT with five physicians at three different outpatient clinics of gynecology in Sweden. RESULTS: Four distinctively different interpretations of risk, depending on whether or not benefits were discussed in the same context, emerged from the analysis. On average, five advantages (range 0-11) and two (0-3) disadvantages were mentioned during the consultations. In the interviews, the women expressed on average four advantages (0-7) and one disadvantage (0-3). There were major variations between advantages and disadvantages expressed in the consultation and the following interview. CONCLUSION: Even though the consultations scored high in patient involvement, the information in most consultations was not structured in a way that made it possible to achieve a shared or an informed decision-taking.

Communication↗
PubMed1995

Female urinary incontinence--consultation behaviour and patient experiences: an epidemiological survey in a Norwegian community.

The objective was to study explanatory factors for help-seeking among incontinent women, and what was the outcome of the treatment. A questionnaire was mailed to all 2366 women aged 20 or over in the rural community of Rissa, Norway. Women confirming incontinence gave information about duration, precipitating factors, frequency, amount of leakage, and impact. Questions about doctor consultation or planned consultation, treatment and results were included. Women with incontinence which had resolved without treatment were also recorded. A total of 77% answered the questionnaire. Twenty per cent of women with incontinence (n = 535) had consulted a doctor, 18% had planned to consult. Increasing age and duration, and urge/mixed type of incontinence were determinative factors for doctor consultation, while increasing severity and impact were determinative for planned consultation. Drugs, exercises, pads, and electrostimulation were all important treatment options: 21% were cured, 40% much better after treatment. Of all the women, 8% reported that they had been incontinent in the past, and only 18% of these had consulted a doctor.

Adult↗
PubMed1999

How should patients consult? A study of the differences in viewpoint between doctors and patients.

BACKGROUND: Increasing pressure on limited NHS resources has led to the introduction in primary care of a skill mix which seeks to match clinical presentation to an intervention based on skills and training. There has also been increasing emphasis on the use of telephone consultations. However, outcomes on the benefits of these different approaches may be difficult to obtain and process variables such as the views of patients may be important. OBJECTIVE: The objective of the study was to answer the following questions (i) how many existing GP consultations do doctors and patients assess as being suitable for consultation with a specially trained nurse or for telephone advice from a doctor?; (ii) do doctors and patients share similar views on the suitability of individual cases?; and (iii) do these assessments differ between acute, chronic and urgent cases? METHOD: A sample of 750 patients comprising of 150 patients attending for booked consultation with each of five doctors were interviewed prior to the consultation and asked whether they would be happy to see a specially trained practice nurse or if their problem could be dealt with by a doctor on the telephone. For each case the GP gave his response. A similar study was undertaken with 150 'extras' patients who needed to be seen urgently and who could not wait for an appointment the following day. The viewpoint of the GP was compared with that of the patient. RESULTS: GPs felt that 20% of all booked cases could be seen by a nurse compared with the patients' assessment of 29%. These figures were higher for acute booked cases (30 and 34%) and for urgent extras (44 and 58%). There was a poor agreement between the viewpoints of doctor and patient especially for chronic booked cases although this agreement increased with the more acute presentations. The number of cases that could be dealt with on the telephone ranged from 5 to 9% with poor agreement between doctor and patient. CONCLUSION: This study extends the findings of a number of others which indicate that patients can be seen satisfactorily by nurses, and that both doctors and patients see scope for increasing the number of consultations dealt with by nurses. Booked patients with chronic presentations and urgent extras are more likely than their doctors to think that they could be dealt with by the nurse. This may be due to a difference in perspective between doctors and patients about the outcome they hope to achieve in the consultation. Further qualitative work is needed to explore these differences and to clarify the best approach to this expanding area.

Attitude of Health Personnel↗
PubMed2000

Developing a 'consultation quality index' (CQI) for use in general practice.

BACKGROUND: The core values of general practice include holism and patient-centredness. None of the measures of quality of care in general practice presently capture the expression of these values at routine consultations. OBJECTIVES: The aim of the present study was to construct a 'consultation quality index' (CQI) which reflects the core values of general practice, using as proxies 'consultation length' and how well patients 'know the doctor' as process measures and 'patient enablement' as an outcome measure. METHODS: The CQI was constructed from data collected from 23 799 adult English-speaking patients consulting 221 doctors in four demographically contrasting areas of the UK during 2 weeks of March/April 1998. A total of 171 doctors who entered 50 qualifying consultations were allocated scores for the three component variables, and a total CQI was calculated. RESULTS: CQI scores were in the range 4-18. Validity was examined by looking at high and low scorers in greater detail and by searching for correlates with case mix, patient age and gender, and the deprivation scores of the practices concerned. Particular attention was paid to how registrars and doctors new to their practices scored. The scores of different doctors in the same practice were also noted. The results had strong face validity and were independent of case mix and deprivation. Reliability was gauged by examining similar work from a previous study which had collected information on consultation length and enablement over three time periods. High CQI scores were associated with smaller overall practice list sizes. CONCLUSIONS: We have outlined possible uses for the CQI as part of the packages assessing quality of care by doctors and practices. The measure may also have a part to play in recognizing poorly performing doctors. We suggest how CQI scores could contribute to an incentive scheme to reward good consulting practice. Further work is in hand to compare doctors' CQI scores with scores based on performance indicators constructed from routine NHS data on prescribing and preventive medicine.

Family Practice↗
PubMed2005

The prevalence of symptoms and consultations in pre-school children in the Avon Longitudinal Study of Parents and Children (ALSPAC): a prospective cohort study.

BACKGROUND: Pre-school children are frequent users of health services, but little contemporary data are available describing their symptoms or why they consult. OBJECTIVE: To describe symptom and consultation prevalence in pre-school children and to identify the socio-demographic factor or factors associated with consultations for those symptoms. METHODS: Prospective cohort study of 13,617 pre-school children living in south-west England. Parents completed questionnaires asking about symptoms and consultations for those symptoms at six, 18, 30, 42 and 57 months. RESULTS: During the pre-school years, all children experienced one or more symptoms, most commonly cold, cough, high temperature, vomiting or diarrhoea. Ninety seven percent consulted a doctor at least once, most commonly for cough, high fever and/or earache. Lower parity was most strongly and consistently associated with higher consultation rates. CONCLUSIONS: Fever, respiratory and gastro-intestinal symptoms are a normal part of pre-school life. Research of acute conditions in young children could focus on the most common symptoms leading to consultation, namely cough, fever and earache. Efforts to support parents' help seeking decision making might usefully be targeted at first time parents.

Child, Preschool↗