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PubMed2002

Do patients who self-harm consult their general practitioner soon after hospital discharge? A cohort study.

BACKGROUND: Deliberate self-harm (DSH, attempted suicide) is one of the most common reasons for emergency hospital admission in Great Britain. Approximately 20 % of patients repeat self-harm in the 12 months after admission. The GP's role in DSH aftercare and the prevention of repeat episodes is unclear. METHODS: The data were obtained from a 12-month follow-up of a series of 968 consecutive patients from 49 practices who attended an accident and emergency (A&E) department in Bristol or Bath, UK, following an episode of self-harm between 26(th) May 1997 and 1(st) March 1999. RESULTS: Information on consultation patterns were available for 681 (70 %) of the patients. Two hundred and fourteen (31 %) of these consulted their GP in the week following the episode, 360 (53 %) within 4 weeks. Of the subjects, 44 % were discharged directly from A & E; these patients were more likely to consult their GP in the 4 weeks after the episode. Over the 12-month follow-up, 117 (17 %) attended hospital for a repeat episode of DSH; 9 % of these repeats occurred within 1 week and 28 % within 4 weeks of the index event. Although few (2 out of 11 patients--18 %) of those repeating in the first week after the index episode consulted their GP prior to repeating, 50 % (11/22) of those who repeated in the 1-4 weeks after an episode did so. CONCLUSIONS: Consultation patterns indicate that most people who deliberately self-harm consult their GP soon after the episode. This consultation may provide an opportunity for preventing repeat DSH and suicide.

Adolescent↗
PubMedDate not supplied

Measuring of impact of patient counseling in the outpatient pharmacy setting: development and implementation of the counseling models for the Kaiser Permanente/USC Patient Consultation Study.

The Southern California region Kaiser Permanente Medical Care Program, which serves 2.2 million patients, and the University of Southern California School of Pharmacy have designed and implemented a patient consultation study to determine the cost-effectiveness of three different approaches to providing pharmacist consultation to outpatients. This paper describes the development and implementation of these three models. A total of 107 pharmacies (approximately 600 pharmacists) participated in the study and were assigned to provide one of the models of patient consultation, designated the Kaiser Permanente (KP) model, the state model, and the control model. The KP model (20 pharmacies) provided targeted pharmaceutical care services to high-risk patients based on drug use. The state model (67 pharmacies) provided California-mandated patient consultation to patients with new or changed prescriptions, instructions for use, relevant warnings and precautions, storage requirements, and the importance of compliance. The control model (20 pharmacies) provided consultation when deemed necessary by the pharmacist and provided care similar to that provided before mandatory consultation in California. The KP and state models used the same pharmacist/technician/clerk resources, but the control pharmacies limited personnel resources to those existing before the mandatory consultation law was passed in California. The paper describes the KP model in detail and provides a literature-based rationale for targeting particular high-risk patients for expanded services. The paper also describes the training process, gives an example of a high-risk patient intervention, provides information on documenting pharmacist interventions in all models, and explains the method used for monitoring implementation of the models.

Ambulatory Care↗
PubMed2004

Therapeutic communication part 1: general approaches that enhance the quality of the consultation.

Consultations that place the patient at the centre of the interaction and actively explore their ideas, concerns, fears, cares and expectations strongly correlate with increased satisfaction, concordance, feelings of enablement and symptom resolution. Primary Care clinicians have developed these therapeutic consultation styles as a result of utilising the extensive research that has been undertaken in General Practice. In contrast, consultations in Accident and Emergency (A&E) have received little investigation and communication has a predominant bio-medical focus. This is the first of two papers which presents the results of a substantive review of the literature which explores therapeutic communication strategies appropriate to Emergency Care. This paper sets the scene by describing the current status of the Emergency Care consultation and reviews the proposed benefits of a consultation centred around the patient. The development of "Patient-Centred Communication" and its philosophical underpinnings are also discussed in order to provide further background. Finally, the general characteristics of therapeutic consultations identified in the substantive review of the literature review are analysed. The second paper describes five key communication strategies which when employed in clinical consultations in Emergency Care, could significantly enhance the therapeutic nature of the clinician-patient interaction.

Attitude of Health Personnel↗
PubMed2004

Is cardiology consultation required before cardiac catheterization?

Background: In many hospitals, internists have begun to directly refer patients for cardiac catheterization without a prior cardiology consultation. The purpose of this study is to compare the results of a policy of mandatory consultation prior to catheterization with one of optional consultation. Methods: One hundred seventy-five consecutive patients who underwent catheterization with a prior cardiology consultation (closed group) were compared to 175 patients who underwent the procedure without a prior mandatory consultation (open group). The primary outcomes were defined as whether significant coronary disease was found and what therapy the patient received. Results: There was no difference in the percentage of patients who were found to have coronary disease in each group (72% in the closed group and 77% in the open group, P=NS), and there was also no difference in the percentage of patients who received revascularization therapy (43% in the closed group and 44% in the open group, P=NS). Conclusions: Allowing internists to refer patients directly for catheterization resulted in equivalent results as compared to requiring cardiology consultation. This study supports the policy of allowing direct referral for catheterization, but further studies are needed to compare the outcomes of cardiac patients cared for by hospitalists without cardiology consultation.

Journal Article↗
PubMed1999

Frequent consulters in general practice: a systematic review of studies of prevalence, associations and outcome.

We conducted a systematic review of the observational literature on frequent consulters in general practice. Electronic searching identified 34 studies which met our inclusion criteria. Frequent consulters were identified in a wide range of primary health care settings, confirming that a small proportion of patients is responsible for a disproportionate number of consultations. A cutoff of 9-14 consultations per annum was used to define a frequent consulter in most studies. Studies have examined a variety of associated characteristics, and indicate that frequent consulters are highly heterogeneous, and have high rates of physical disease, psychiatric illness and social difficulties. Few are likely to conform to the "heartsink" stereotype. These patients are likely to have multiple, complex problems, often including chronic physical disease, with or without psychological and social problems. The natural history of frequent consulting behavior seems to be to persist in many cases. Implications for management are discussed.

Family Practice↗
PubMed2001

Comparison of consultation rates in primary care attenders with and without seasonal affective disorder.

BACKGROUND: There is a lack of published information about the consultation patterns of patients with seasonal affective disorder (SAD) in primary care, when compared with non-seasonal controls (NSCs). METHODS: Interview-confirmed SAD cases (n=90) were age- and sex-matched to two controls without significant seasonal morbidity on the Seasonal Pattern Assessment Questionnaire (SPAQ) (non-seasonal controls, NSCs). A comparison of their consultation rates was made using data abstracted from primary care records over 4 years. RESULTS: The monthly rate of general practice consultations for SAD cases was significantly higher than that for NSCs. There was a significant difference in the median number of consultations in winter and autumn between the two groups. The matched multivariate analysis revealed that February and April were the independent months in which cases of SAD had significantly more consultations than NSCs. LIMITATIONS: Optimal diagnostic criteria for SAD have not been determined and our criteria may have been over-inclusive. CONCLUSION: In addition to a marked difference in monthly consultation rates between SAD cases and NSCs, the data demonstrate a difference in the pattern of seasonality of these rates. It is possible that increased frequency of consultation, in particular during the winter months (in patients who score as a case SPAQ), could be used as an indication of SAD in primary care.

Adolescent↗
PubMed2004

Annual review of patients with sleep apnea/hypopnea syndrome--a pragmatic randomised trial of nurse home visit versus consultant clinic review.

BACKGROUND: This pragmatic randomised, controlled trial investigated annual review of patients with sleep apnea/hypopnea syndrome (SAHS). Clinical outcomes and costs were compared for consultant clinic review versus specialist nurse home visit. METHOD: One hundred and seventy-four patients were randomised to annual review by consultant clinic appointment or by specialist nurse home visit. SAHS symptoms, Epworth score, hospital anxiety and depression scale (HADS), Short Form-36 (SF-36) and hours of use of constant positive airway pressure (CPAP) were measured before and 3 months after review. The costs and patient preference for review were determined. RESULTS: After review, both groups significantly increased CPAP use (mean (SD) increase: nurse, 0.66 (1.71) h; consultant, 0.45 (1.69) h) and reduced symptom scores (nurse, -2 (7); consultant, -3 (9)), compared to baseline. There were no differences between groups in these improvements, or in HADS or SF-36 scores. Average duration of a nurse home visit, excluding travel time, was 26 (6) min. Total NHS cost per visit was 52.26 UK pounds (49.85) ($83.62 (79.76)), of which 6.57 UK pounds (1.43) ($10.51 (2.29)) reflected time spent with the patient and the remainder was travel cost. Average duration of consultant review was 10 (6) min, total NHS cost 6.21 UK pounds (3.99) ($9.94 (6.38)). However, the cost to the patient of attending the clinic was 23.63 UK pounds (23.21) ($37.81 (37.13)). Patient preference for review was nurse 16%, consultant 19%, and no preference 65%. CONCLUSION: Following annual review, use of CPAP increased and symptoms improved. Outcomes were similar for consultant and nurse led review. Home visits were expensive for the healthcare provider, whereas clinic attendance incurred substantial costs to the patient. The majority of patients would accept nurse review for their sleep apnea management.

Annual Reports as Topic↗
PubMed2003

Joining the team: ethics consultation at the Cleveland Clinic.

In this paper, I describe the development of ethics consultation services and their operation at the Cleveland Clinic; my own educational experiences and background and how I came to see the importance of setting and collaboration for successfully doing clinical ethics; the unique culture of the Cleveland Clinic and its influence on the ethics consultation services provided there; and, finally, the place of personal commitments and values on the conduct of ethics consultations. I stress the point that although philosophers (and perhaps other bioethicists without health professions training) are socialized and educated to do solitary work, successfully conducting ethics consultations requires relatively high levels of collaboration and cooperation that have not been sufficiently discussed. Although this paper is more a description than an analysis of the influence of institutional setting on ethics consultation, I would claim that attention to setting, either as the local scene of the consultation or the institutional and social framework, deserves more attention by bioethicists intent on understanding ethics consultation.

Ambulatory Care Facilities↗
PubMed2001

Evaluation of the chemotherapy patient monitor: an interactive tool for facilitating communication between patients and oncologists during the cancer consultation.

Effective communication between oncologists and patients with cancer is of paramount importance. The Chemotherapy Patient Monitor (CPM) is a novel tool designed to assist doctor-patient communication regarding patient concerns and side-effects. Initially, the CPM was assessed in a primary evaluation study of its use during consultations with 26 patients with advanced colorectal cancer (one consultation without, followed by two with, the CPM per patient). This led to a further dissemination/audit of 34 patients attending oncology centres in the UK, who had completed the survey prior to three consultations. The CPM contains a checklist of common side-effects of chemotherapy regimens used in advanced colorectal cancer, and other common concerns of patients with advanced colorectal cancer. The CPM records the presence of side-effects/concerns, the distress caused, whether patients wish to discuss them further, and actions taken as a result. Questionnaires explored the views of patients and oncologists in the UK and Spain regarding the effectiveness of consultations during a baseline visit conducted without the CPM, and then with the CPM in subsequent visits. These data were then complemented by the dissemination/audit study of the CPM across nine centres in the UK. All patients understood the CPM. The CPM was rated as useful by oncologists in 83% of consultations, and did not lengthen 82% of visits. Patients felt it had improved the visit in 95% of cases. Responses from patients (100%) and oncologists (84%) indicated willingness to use the CPM for at least some consultations in the future. The results of the dissemination/audit study supported these conclusions. We conclude that the CPM appears to be a useful new tool for improving patient-doctor communication during cancer consultations.

Antineoplastic Agents↗
PubMed2003

Traditional finals and OSCEs in predicting consultant and self-reported clinical skills of PRHOs: a pilot study.

INTRODUCTION: As we move from standard 'long case' final examinations to new objective structured formats, we need to ensure the new is at least as good as the old. Furthermore, knowledge of which examination format best predicts medical student progression and clinical skills development would be of value. METHODS: A group of medical students sat both the standard long case examination and the new objective structured clinical examination (OSCE) to introduce this latter examination to our Medical School for final MB. At the end of their pre-registration year, the group and their supervising consultants submitted performance evaluation questionnaires. RESULTS: Thirty medical students sat both examinations and 20 returned evaluation questionnaires. Of the 72 consultants approached, 60 (83%) returned completed questionnaires. No correlation existed between self- and consultant reported performance. The traditional finals examination was inversely associated with consultant assessment. Better performing students were not rated as better doctors. The OSCE (and its components) was more consistent and showed positive associations with consultant ratings across the board. DISCUSSION: Major discrepancies exist between the 2 examination formats, in data interpretation and practical skills, which are explicitly tested in OSCEs but less so in traditional finals. Standardised marking schemes may reduce examiner variability and discretion and weaken correlations across the 2 examinations. This pilot provides empirical evidence that OSCEs assess different clinical domains than do traditional finals. Additionally, OSCEs improve prediction of clinical performance as assessed by independent consultants. CONCLUSION: Traditional finals and OSCEs correlate poorly with one another. Objective structured clinical examinations appear to correlate well with consultant assessment at the end of the pre-registration house officer year.

Clinical Competence↗
PubMed1999

Is 'shared decision-making' feasible in consultations for upper respiratory tract infections? Assessing the influence of antibiotic expectations using discourse analysis.

OBJECTIVES: To examine the discourse of consultations in which conflict occurs between parents and clinicians about the necessity of antibiotics to treat an upper respiratory tract infection. To appraise the feasibility of shared decision-making in such consultations. DESIGN: A qualitative study using discourse analysis techniques. SETTING: A general practice with 12 500 patients in an urban area of Cardiff, Wales. PARTICIPANTS: Two consultations were purposively selected from a number of audiotaped sessions. The consultations took place during normal clinics in which appointments are booked at 7-minute intervals. The practitioner is known to be interested in involving patients in treatment decisions. METHOD: Discourse analysis was employed to examine the consultation transcripts. This analysis was then compared with the theoretical competencies proposed for 'shared decision-making'. RESULTS: The consultations exhibit less rational strategies than those suggested by the shared decision-making model. Strong parental views are expressed (overtly and covertly) which seem derived from prior experiences of similar illnesses and prescribing behaviours. The clinician responds by emphasizing the 'normality' of upper respiratory tract infections and their recurrence, accompanied by expressions that antibiotic treatment is ineffective in 'viral' illness - the suggested diagnosis. The competencies of 'shared decision-making' are not exhibited. CONCLUSIONS: The current understanding of shared decision-making needs to be developed for those situations where there are dis-agreements due to the strongly held views of the participants. Clinicians have limited strategies in situations where patient treatment preferences are opposed to professional views. Dispelling 'misconceptions' by sharing information and negotiating agreed management plans are recommended. But it seems that communication skills, information content and consultation length have to receive attention if such strategies are to be employed successfully.

Journal Article↗
PubMed2002

Internet teleconferencing method for telepathology consultations from lung and heart transplant patients.

Current Internet-based teleconferencing techniques allow a referring pathologist to transmit real-time images from a microscope to a consultant, while maintaining a verbal conversation using Internet telephony. In our study, 50 randomly selected transbronchial biopsies from lung allograft recipients and 58 randomly selected endomyocardial biopsies from heart transplant patients were diagnosed by consultant pathologists using Internet-based teleconferencing methods. The referring pathologists acquired the real-time video images from the biopsies using a light microscope equipped with a phototube adapter and a video camera. The consultant pathologists viewed the processed images on a video monitor at 800 x 600 resolution, using a standard microcomputer equipped with Netmeeting software, and directed the referring pathologist to move the slide under the microscopy and/or change image magnification. The validity of telepathology diagnoses was assessed with kappa coefficients. Consultations were completed in 5 to 15 minutes per case. Sound transmission was unreliable, and in approximately 25% of consultations the referring pathologist needed to "call back" to reestablish verbal communication. In all but 2 transbronchial biopsies there was agreement between the original diagnosis and the diagnosis by telepathology (kappa = 0.92). In 48 of 58 endomyocardial biopsies there was concordance between the 2 diagnoses (kappa = 0.692). Only 3 out of 10 of these discrepancies were clinically significant (kappa = 0.897). Internet-based teleconferencing techniques provide effective and relatively inexpensive tools for real time telepathology consultations. The technology is probably best suited for the study of small specimens from patients that require rapid diagnosis by a consultant.

Biopsy↗
PubMed2005

The tobacco industry's worldwide ETS consultants project: European and Asian components.

BACKGROUND: The tobacco industry has formed regional environmental tobacco smoke (ETS) consultants programs in order to generate controversy on the issue of secondhand smoke (SHS) in Europe, Asia and Latin America. Only those countries in which the industry foresaw SHS restrictions were included. This paper describes the European and Asian components of the tobacco industry's worldwide ETS consultants program. METHODS: A systematic search was carried out of tobacco industry documents available on the Internet between October 2002 and February 2004. RESULTS: Beginning in 1987, Philip Morris assembled an international ETS consultants program in collaboration with other tobacco companies based on their market shares in different regions of the world. The law firm Covington & Burling contacted and hired consultants with a wide range of expertise, usually affiliated with an academic institution, in order to avoid direct contact with the industry. The objective of the program was to influence policy makers, media and the public by providing, through their consultants, 'accurate' (pro-industry) information concerning smoking regulations in public places and workplaces, indoor air quality and ventilation standards, and scientific claims regarding SHS. Consultants also conducted research related to SHS and organized and attended regional and international symposiums related to SHS without acknowledging industry funding. CONCLUSIONS: Despite evidence that the issue of smoke-free environments was close to emerging within the general public throughout the world in the late 1980s, the tobacco industry used its well-organized network of consultants to avoid SHS regulations in most of the world.

Asia↗
PubMed1994

Is there a link between the consulting patterns of premenopausal women and the menstrual cycle?

Menstrual cycle hormonal changes have been reported to be responsible for a number of physical and behavioural changes. A number of studies have suggested that both physical and mental disorders occur in the premenstrual part of the cycle. The object of this study was to discover whether the frequency with which women of childbearing age seek medical advice is affected by the 'time of the month'. It was hypothesized that because of an increase in symptomatology there would be an increase in the number of requests for consultations to see the doctor in the premenstrual phase of the cycle. Women between the ages of 18 and 45, in two practices, answered a questionnaire when they arrived at the surgery for a consultation. The women were later telephoned to discover the exact first day of their next period. Four hundred and thirty-two questionnaires were analysed. The number of requests for a surgery consultation did appear to vary according to the phase of the cycle. There were fewer than anticipated requests for consultations in the few days prior to the onset of menstruation; however the rate of requests for a consultation during menstruation was significantly increased. These differences from the expected were particularly significant if the appointment had been made within 24 hours of the consultation (that is for urgent consultations) and among women who had high scores on a premenstrual syndrome checklist.

Adolescent↗
PubMed1989

Length of consultations in general practice in Sweden: views of doctors and patients.

In a study in Sweden of 160 consultations, general practitioners and patients separately assessed their satisfaction with the consultation length and the ability of the patient to explain the problem. These assessments were compared with each other and were correlated with the actual length of the consultation. The mean length of the consultations was 21 minutes with a great variation between different doctors. Consultations with psychological problems were longer than those with a physical character (mean of 28 versus 14 minutes). Elderly patients had longer consultations. The patients were on the whole more satisfied than the doctors. There was no evidence that longer consultations gave more satisfaction for either doctors or patients. The doctors not only registered more psychological problems than the patients but they were more likely to register insufficient time for discussing psychological problems.

Attitude of Health Personnel↗
PubMed2005

General practice as a complex system: a novel analysis of consultation data.

BACKGROUND: Complex systems have specific properties of robustness and self organisation which arise from interacting components within the overall system and which govern the system's behaviour. These are typically associated with a power law distribution of event sizes. Commentators have suggested that health systems are complex, but there has been limited quantitative investigation of this issue. OBJECTIVES: To test the hypothesis that consultation patterns in primary care follow a power law distribution typical of a complex system. METHODS: Analysis of 142,050 episodes of non-pathological back pain in routinely collected New Zealand national data. Calculation of the distribution of the duration and number of GP consultations for each illness episode. Secondary analysis of a published UK dataset of consultation rates for 44,000 patients in four general practices. RESULTS: Number of consultations per episode of back pain demonstrated excellent fit with a power law in the full dataset (r2 = 0.96) and all but one subgroups (r2 = 0.90-0.99). The number of consultations per patient from four UK practices was suggestive of a power law distribution (r2 = 0.88-0.93). CONCLUSIONS: Consultation patterns in general practice show measurable properties of a complex system. The consistency of the distribution across different population groups suggests that attempts to manage consultation patterns should focus on the whole system of patients, rather than upon individuals or subgroups of the patient population.

Accidents↗
PubMed2003

A reliability study of an instrument for measuring general practitioner consultation skills: the LIV-MAAS scale.

OBJECTIVE: To evaluate the reliability of a new tool, the LIV-MAAS, in assessing consultation competence in UK general practice. DESIGN: These were pilot studies, with small numbers of participants. Videoed general practitioner (GP) consultations were analysed by trained lay and professional raters, using the LIV-MAAS. The inter-rater reliabilities were assessed. Four videos were assessed by five raters in a pilot study. After this, 71 consultations from eight doctors were assessed by sets of three raters. MAIN MEASURES: Inter-rater reliabilities and inter-consultation reliabilities. RESULTS: For the pilot study, the estimated inter-rater reliability ranged from 0.69 (one rater) to 0.91 (five raters). For the main study, the estimated inter-rater reliability for the LIV-MAAS checklist using two raters was 0.71, and using three raters it was 0.78. Mean differences in reliability within each series of nine consultations were 0.20 (three raters) and 0.42 (two raters). CONCLUSIONS: As a measure of 'consultation competence', administered by trained raters (medical or lay) to real GP consultations, the LIV-MAAS instrument shows adequate reliability and stability but would benefit from considerable shortening. Further development of the LIV-MAAS and testing with larger samples are required.

Adult↗
PubMed1992

Verbal consultation regarding prescription drugs: findings from a statewide study.

In 1984 the Wisconsin Division of Health showed interest in patients' receipt of verbal consultation for prescription drugs and included relevant questions in the Wisconsin Health Status survey to: 1) investigate the receipt of verbal consultation for new and refill prescriptions, 2) allow a comparison of state results with those of a national study that used similar sampling and data collection procedures, and 3) more closely examine the relationships between receipt of verbal consultation and such variables as prescription status (new or refill), age, sex, race, and education. Data were collected from 2,135 randomly selected respondents using Computer Assisted Telephone Interviewing with random digit dialing. After controlling for elapsed time since last prescription, log-linear analyses showed the importance of prescription status (new and refill) and respondent's age as correlates of consultation by pharmacy personnel, while prescription status, age, and sex were significant for prescribers. For both prescribers and pharmacy personnel, the authors found no association between client education and receipt of verbal consultation. The absence of verbal consultation cannot be entirely accounted for by client characteristics or prescription status. Based upon their experience, the authors encourage continued monitoring of prescribers' and pharmacists' provision of verbal consultation through questions contained in state and national health status surveys.

Adolescent↗