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PubMedDate not supplied

Patients' perceptions of "uncertainty" in nurse practitioner consultations.

The aim of this qualitative study was to explore patients' perceptions of consulting with a nurse practitioner in situations of clinical uncertainty. Uncertainty in this context is defined as one where there is no obvious diagnosis, treatment or where the outcome of the consultation is not definite. Three general practice sites were recruited to participate. 43 patients who consulted with one of three nurse practitioners were interviewed using a semistructured schedule. The nurse practitioners identified uncertainty in 30 of these consultations; only two patients expressed any awareness of uncertainty with the consultation. The results showed that patients appear to accept that there will be a level of uncertainty in some consultations. Recognition of uncertainty within the consultation does not appear to have a negative effect on patients' perception of the nurse practitioner as they feel that the nurse will refer to a doctor if necessary.

Adolescent↗
PubMedDate not supplied

Pharmacotherapy consultation on polypharmacy patients in ambulatory care.

OBJECTIVE: To investigate actual cost and adverse effect outcomes associated with a phamacotherapy consultation in ambulatory care patients receiving polypharmacy. METHODS: Patients receiving five or more chronic medications were randomized to receive pharmacotherapy consultation or usual medical care. Outcomes measured were changes in drug costs, medical costs, and drug-related symptoms six months after the consultation. Data were analyzed with unpaired Student's t-test for continuous data. Chi2 Analysis was used for categorical data. Patients and physicians were surveyed about their perceptions of the consultations after the study period. RESULTS: Drug and medical costs did not differ before and after the consultation. More patients in the consultation group had adverse symptom scores improve by two or more points, and fewer had symptom scores worsen by two or more points than in the control group. Seventy percent of patients and 76% of physicians believed that the consult was beneficial. CONCLUSIONS: Polypharmacy patients are the most likely to have drug-related problems and require intervention. Of all the interventions performed in this study, 73% of the original problems were recognized only through a patient interview, suggesting that an interpersonal relationship remains critical to the provision of pharmaceutical care. Although patients and physicians see intuitive value in pharmaceutical care, pharmacists need to exert more energy in the direction of marketing the profession. Finally, there are numerous difficulties in measuring the benefits of these interventions, possibly making broad-based interventions in complicated patients too difficult to assess accurately. Future studies should focus on patients with limited, specific problems or on interventions with narrow goals.

Ambulatory Care↗
PubMed2004

Primary care physicians' experiences of carrying out consultations on the internet.

BACKGROUND: The internet is increasingly used for health matters, including consulting a doctor. Primary care physicians (general practitioners) will probably be involved in performing text-based consultations on the internet as a complement to physical meetings. In the present study, we explored the experiences of GPs already performing consultations on the internet: the challenges, worries and educational demands of the task. MATERIALS AND METHODS: A questionnaire was given to 21 GPs performing consultations on the internet for a public, non-commercial 'ask the doctor' service. The questionnaire was carried out at a meeting or sent by mail. The doctors answered a total of 28 questions, 12 of which included graded alternatives. RESULTS: The participating GPs were stimulated and challenged by performing consultations on the internet with previously unknown enquirers, in spite of limitations caused by the lack of personal meetings and physical examinations. The participants experienced a high educational value as a result of the problem-based learning situation induced by unfamiliar questions. The asynchronous feature was appreciated as it allowed time to reflect and perform relevant information searches before replying. Prior training and long-term experience as a family doctor were recommended before embarking on this method of consultation. CONCLUSIONS: We conclude that the GPs studied experienced their new role as internet doctors mainly in a positive way, with some limitations. With the increase in consultations on the internet, training in this technique should be integrated into the curricula of medical schools and of continuous professional development (CPD).

Adult↗
PubMed2006

Consultation in adolescence: hurried, terminable, interminable.

The physiological ambivalence displayed by adolescents towards dependence on adults is an obstacle, at least initially, to a course of psychotherapy. A consultation is often the only thing that can be offered to start with, and constitutes an essential stage even for those teenagers who go on to prove themselves able to benefit from therapy or analysis. The way this first meeting is handled is therefore crucial. The author investigates the difficulties and paradoxes of this consultation, the particular nature of the 'time' of the consultation compared to that of therapy, and the different internal attitude this requires of the analyst. She thus identifies two separate configurations--a hurried consultation and an interminable consultation--which can result when the consultation fails in its primary objectives. Both are connected with possible collusive elements in the professional linked to specific adolescent angst. The very detailed account of a consultation shows the 'journey' made by a 14 yearold starting from her urgent request to be freed from a symptom experienced as an incomprehensible obstacle, to her gradual development of curiosity towards herself and towards her own mental and emotional make-up, resulting in her acceptance of therapeutic treatment, which would initially have been impossible.

Adolescent↗
PubMedDate not supplied

Who gets referred? Child psychiatric consultation in a pediatric hospital.

The authors approach the question, "Who receives a child psychiatry consultation?" in several ways. First, by reviewing the consultation patterns in a pediatric hospital over a five year period as a new array of liaison services were being provided, they found the overall consultation rate decreased. Yet in absolute numbers the referral rate for consultation around diagnostic issues remained relatively constant. This underlines the core importance of the child psychiatry consultant as diagnostician. Second, in matching a group of children receiving a psychiatric consultation against a group of children who did not, the authors found somewhat more psychosocial information recorded in the charts of the former group. However, it is doubtful that this played any direct role in the generation of the referral per se. The authors stress the finding that the pediatric hospital is a medical setting and unless the child's psychological problems impinge directly on that system, such problems are likely to remain hidden and beyond the scope of the consultation process.

Awareness↗
PubMedDate not supplied

Predictors of pretravel consultation in tourists from Quebec (Canada).

BACKGROUND: Although many tourists from Quebec (Canada) each year visit destinations at risk for infectious diseases, only a few of them seek travel health advice. To identify the determinants of travel health consultation, we conducted a study among Quebec's tourists visiting two popular sun destinations. METHODS: A conceptual model based on psychosocial determinants of human behavior was constructed. A cross-sectional survey was carried out, from January to April 1999, on two samples of travelers planning to visit Mexico and the Dominican Republic. One sample was composed of people who did not consult a travel clinic (cluster sampling in seven flights), and the other sample was one of clients of travel clinics (purposive selection of 13 specialized clinics located in Quebec). A 34-item self-administered bilingual questionnaire was distributed to travelers. Statistical analysis included a multivariate approach (logistic regression). RESULTS: A total of 2,242 travelers were surveyed (response rate in flight 75% and in clinics 99%). We present only results reported by French-speaking tourists: 1,152 who did not consult a travel clinic and were reached in flight, and 449 who were reached in clinics. Multivariate analyses indicated that travel agent recommendation was the most important predictor of consultation among travelers (OR 8.0, 95% CI 5.1-13), especially among those under 45 years of age and those who never sought pretravel consultation before (OR 21, 95% CI 11-41). Other important predictors were: traveling for the first time, traveling with children, previous consultation, perception about efficacy of immunization, risk perception, and information from travel agent, family doctor, and pharmacist. CONCLUSIONS: Despite its limitations, this study provides data that should help improve public health interventions aimed at encouraging travelers to get a pretravel consultation.

Adolescent↗
PubMed1996

Supervision and consultation services for pediatric occupational therapists.

OBJECTIVE: Occupational therapists with advanced experience or expertise provide supervision and consultation services in a variety of settings. This pilot study examined the use of such supervision and consultation services by pediatric occupational therapists. METHOD: Special education administrators and pediatric occupational therapists from Massachusetts, a state often regarded as a leader in special education, responded to surveys designed especially for this study. These surveys asked about current supervision and consultation use, satisfaction with present services, and the need for additional resources in this area. Opinions regarding practice areas that would best be addressed by supervision and consultation were also obtained. RESULTS: Both administrator and therapist respondents agreed that expert occupational therapy supervision and consultation are needed. Identified areas of interest were classroom supervision and consultation strategies, service delivery decisions, and evaluation methods. CONCLUSION: Pediatric occupational therapists need expert supervision and consultation from occupational therapists with advanced experience or expertise in addition to traditional management, education, and training methods.

Administrative Personnel↗
PubMed1999

[Study of consultation in an Internal Medicine Department].

Consultation in Internal Medicine is a common task of the attending labor of the internist in a general hospital and is a relevant link for intrahospital cohesion. In the present work the characteristics of 738 consultations, which represented all consultation request forms received at our Department during a nine-month period, were studied. A 55.4 percentage of consultation forms were requested urgently and 93.6% of them were answered on the same day. Most consultation parts received came from General Surgery and traumatology, with a predominance of cardiologic, pneumologic, infectious and multiple causes. The assessment of the urgency made by the internist coincided with the urgent request only in 38.3% of cases. A clinical follow-up was made for 33.3% of patients and 2% of them were transferred to the Internal Medicine Department. The consultation was repeated for 22.5% of the total of patients. Only in 23.1% of cases an oral link with the referring physician occurred. To remark the relevance of the consultation for the optimization of care quality to our patients and its influence on the inter-relationship between specialists in different fields of medicine.

Adult↗
PubMed1986

A consultant pharmacist's use of a portable microcomputer at several skilled nursing facilities.

A consultant pharmacist used a portable microcomputer and a private on-line host system in order to produce drug regimen review letters more efficiently. The portable computer was a Tandy Radio Shack Model-100, and the host system was a Sperry-PC running the MIST+ telecommunications software. The portable computer stored three letter templates used by the consultant pharmacist to prepare letters sent to physicians. After doing a drug regimen review, the consultant pharmacist edited one of the random access memory resident letter templates corresponding to the type of letter which needed to be sent to a patient's physician. The letters consisted of information concerning the drugs and diagnoses of patients at various skilled nursing facilities. The consultant pharmacist personalized the letter templates by editing the physician's name and address, patient's name, skilled care facility name, patient's room number, diagnosis, medications, and pharmacist's recommendations. After the letters were edited at the facility, the letters were then "telecomputed to" and archived on the host system. Personalized letters were then printed and sent to the consultant pharmacist, patient's physician, skilled care facility administrator, skilled nursing facility medical director, and charge nurse. The consultant pharmacist, facility administrators, physicians, and nurses have responded favorably to this computerized practice innovation for consultant pharmacists.

Computers↗
PubMed1986

The impact of a geriatric assessment unit on a psychiatric consultation service in a general hospital.

The opening of a geriatric assessment unit (GAU) in a large general hospital has affected the number of elderly patients referred for psychiatric consultation, the type of psychopathology seen, and the training provided for psychiatric residents and interns on the consultation-liaison service. To examine these changes, the six months prior to the opening of the GAU are compared to the six months immediately following its opening. The number of patients age 65 or older referred and diagnoses made by the consulting psychiatrists were studied. The opening of the GAU significantly increased the number of elderly patients referred for psychiatric consultation. It was found that the GAU offered unique advantages in the assessment and treatment of elderly patients with certain psychiatric problems, and the advantages and limitations of different facilities within the general hospital for the psychiatric assessment and treatment of elderly patients are discussed. A case is presented which illustrates the interplay between the consultation-liaison psychiatrist and the geriatric service in the management of an elderly patient referred for consultation. The experience of this hospital in providing psychogeriatric training for residents and interns on the psychiatric consultation service is reviewed.

Aged↗
PubMed1998

[The role of diet consultation on improvement of the diet nutrition in pregnant women].

OBJECTIVE: To study the improvement of the intakes of various nutrients including protein, fat, carbohydrate, fibers, calcium, iron, zinc et al, in pregnant women after appropriate diet consultation by doctors. METHODS: 100 cases of pregnant women coming to our diet consultation clinic were randomly selected, in which 50 cases (control group) came for the first time and another 50 cases (study group) were for the third visit at least. The diet nutrition of the study group after the second consultation were compared with that before consultation and with concurrent control group. RESULTS: After diet consultation, except for retinol, the intake of various nutrients, including calorie intake, protein, fibers, magnesium, calcium, phosphorus, iron, zinc, vitamin E, riboflavin, thiamine, nicotinic acid, in study group were significantly improved compared with that of the study group before diet consultation and of the control group (P < 0.01). CONCLUSION: Diet consultation plays excellent role in promoting scientific and appropriate nutrients intake of pregnant women.

Adult↗
PubMed1998

[Clinical applications of computer system for diet consultation of pregnant women].

OBJECTIVE: To investigate nutritional status of women in different gestational ages and seasons and the role of diet consultation by a computer system on the improvement of intakes of nutrients of pregnant women. METHODS: 712 women in different gestational ages and 747 cases in different seasons received diet consultation by the computer system. A comparison was done for nutritional status between pregnant women with consultation and the women without consultation. RESULTS: Major pregnant women in various gestational ages and seasons was deficient in nutrient intake. However, the nutritional status was significantly improved in women following diet consultation in comparison with the women not received diet consultation. CONCLUSION: Computer system really plays an excellent role in promoting diet consultation and improvement of diet condition of pregnant women.

Diet Surveys↗
PubMed2001

A retrospective view of school mental health consultation.

General principles of mental health consultation as written about by Coleman and Maddux are enumerated. Historically, the refinement of these principles for school consultation was described in detail in the literature by Gerald Caplan and Irving Berlin. Common methods define the consultees' problems as work problems; the consultant views the consultees' difficulties as due to intrapsychic conflicts. Resolution of the consultees' difficulties requires the consultant to use methods that enhance the consultee's self-esteem and indirectly provide the consultee insight into the genesis of his or her problems. Thus, consultees are gradually better able to help the client with his or her difficulties. Training of child psychiatry residents in school consultation historically occurred in three divisions of child psychiatry. Training methods were quite similar. The history of consultation to school administrators at various levels, the issues that emerged, and methods of helping administrators to deal with these problems are elucidated. Special problems in dealing with school consultation on two American Indian reservations, especially that of gaining entrance into the school, are discussed.

Adolescent↗
PubMed2002

[Psychiatric consultation in the nursing home. An inquiry among Amsterdam nursing home physicians].

Psychiatric disorders are common among nursing home residents. However, little is known about psychiatric consultation in Dutch nursing homes. As an exploration of the topic, Amsterdam-based nursing home physicians were asked to rate a number of aspects of psychiatric consultation as performed in their nursing home. Striking differences are reported between 14 participating nursing homes with regard to the intensity of psychiatric consultation and the number of consultation requests, which seems low compared with the perceived psychiatric problems. Somatically ill and psychogeriatric residents are estimated to generate an equal number of consultation requests. Psychiatric consultation appears to be characterized by diagnostic clarification, medication recommendations and behavioral management advice whereas staff-directed activities are scarce. Physicians report shortcomings in psychiatric skills among care staff. Research is necessary concerning the psychiatric care delivered to nursing home residents, as well as with regard to the optimal model for psychiatric consultation services. Integration of psychiatric care in nursing homes with mental health care services appears to be desirable.

Aged↗
PubMed2003

A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care.

BACKGROUND: Joint consultation sessions of a small group of general practitioners (GPs) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients. Cardiac complaints comprise an important category of health problems with high referral rates. AIMS: To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints. DESIGN OF STUDY: Randomised controlled trial. SETTING: Forty-nine GPs participated in 16 consultation groups, each with one of 13 cardiologists, in monthly joint consultations over a period of about 18 months. METHOD: The GPs selected patients about whom they were uncertain, and those needing urgent referral were excluded. Patients were randomly assigned to joint consultation or to usual care. After a follow-up period all patients had a joint consultation for outcome assessment. Referral data were provided by two regional health insurance companies and questionnaires were given to the patients, GPs, and cardiologists to gauge their opinion of the trial. RESULTS: One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol. The quality of care was similar in both groups. In the intervention group, 34% of the patients were referred, compared with 55% in the control group (P = 0.001), and fewer patients underwent further diagnostic procedures (7% compared with 16%, P = 0.013). Referrals to cardiology as a proportion of all referrals decreased in the practices of the participating GPs, compared with their reference districts (P = 0.024). CONCLUSION: Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care.

Adult↗
PubMed1992

[The content of the nursing consultation at a health center].

AIMS: To describe the care process in the Nursing Station. To analyse the length of a consultation and factors which affect the length. DESIGN: Crossover study. Analysis of the length of the Consultation, using a multiple lineal regression model. SITE. Urban Health Centre. PATIENTS AND OTHERS TAKING PART: All the calls and consultations, both in the patient's home and in the Health Centre, undertaken by six nurses over a period of two weeks. MAIN MEASUREMENTS AND RESULTS: There were 879 consultations. 65.41% of them took place in the treatment room. Ten health problems represented 72% of the work-load. Health education took un the greatest proportion of time. The average time of a consultation was of 10.40 +/- 0.3 minutes. The length of the consultation depended on the professional involved, on the place where it took place, on the number of problems which the patient had and on the nature of the main problem: multiple correlation coefficient = 0.74; F = 67.52 (p < 0.00000001). CONCLUSIONS: The nurse faces a very limited number of health problems. Most of her activities are preventive or to do with prevention. The length of the Consultation in greatly conditioned by the amount of morbidity.

Community Health Centers↗
PubMedDate not supplied

Medico-legal issues in radiological consultation.

Providers increasingly use radiological services for diagnosis and treatment. Both the referring physician and the radiological consultant can contribute to efficient and effective consultation, and direct interaction may facilitate the process further. Furthermore, inadequate communication can influence poor patient outcome. We examine the roles and responsibilities of referring physicians and consultant radiologists, and present a malpractice case, Townsend v. Turk 218 Cal. App. 3d 278 (1990), to identify medico-legal issues in radiological consultation. Important issues are implied by the Townsend case. First, it is the clinician's responsibility to include clinical information that is appropriate and adequate. Further, the radiologist is a valuable resource in the selection of the optimal procedure, provided that he or she is aware of the patient's history. The second issue discussed by the court represents a possibly more pervasive problem. The interaction between a consulting radiologist--indeed any specialist--and a treating physician is subject to difficulties caused by different conceptions of professional boundaries. The position taken by the court in the Townsend case is consistent with the traditional view that a consulting radiologist has an attenuated duty to the patient. It also would seem to receive at least some support from the language contained in the current revision of the ACR Standard for Communication: Diagnostic Radiology, effective Jan. 1, 2002: ...The referring physician or healthcare provider also shares in the responsibility of obtaining results of imaging studies they have ordered. Despite the result of the Townsend case and the current formulation of the ACR Standards, however, radiologists face risks of litigation. Indeed, the emerging trend in radiological consultation is the direct communication of results to the patient. It is clear that improved communication between radiologists and referring physicians is both desirable and imperative. Clinico-radiological encounters yield additional clinical information and guide the decision-making process. In the Townsend case, direct interaction would have resolved ambiguity.

Accidents, Aviation↗
PubMed2004

[Modes of consultant employment in Israel].

BACKGROUND: One of the features of modern clinical practice is the shift of secondary care from hospitals to the community clinics. This phenomenon and the competition among health plans, has accelerated the development of secondary medicine at the community level, and increased the activity of outpatient clinics in acute-care hospitals. Consequently, many consultants are working in more than one setting within the framework of different modes of employment. AIMS: To examine the extent of consultants' employment in multiple organizational settings, and their modes of employment in each setting (i.e. weekly work hours, type of contract, mode of remuneration, and the division of time between community and hospital work). METHODS: A mail survey was conducted on a representative sample of 50% of consultants in six selected specialties: ophthalmology, dermatology, ear-nose-and-throat, gynecology, cardiology and general surgery (response rate 63%, n=890). RESULTS: Most (84%) of the consultants worked in more than one organizational setting, and more than 40% of them work in three or more settings. Nearly all the consultants (98%) work for a public sector employer in their primary job. Furthermore, in their secondary job, most consultants work for a public sector employer, usually a health fund (67% of them). When physicians' third jobs were examined, the high proportion (42%) of physicians engaged in private practice was prominent. The average number of weekly work hours of practice (including on-call hours) was 48 hours in the primary job and 63 hours in all jobs. The average duration of weekly work time was 52 hours not including on-call hours. CONCLUSIONS: The findings justify serious consideration of the proposal to reduce the number of jobs at which consultants work in order to improve both their clinical effectiveness and quality of work life.

Ambulatory Care↗