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PubMed2002

Patients' perceptions of entitlement to time in general practice consultations for depression: qualitative study.

OBJECTIVE: To investigate patients' perceptions of entitlement to time in general practice consultations for depression. DESIGN: Qualitative study based on interviews with patients with mild to moderate depression. SETTING: Eight general practices in the West Midlands and the regional membership of the Depression Alliance. PARTICIPANTS: 32 general practice patients and 30 respondents from the Depression Alliance. RESULTS: An intense sense of time pressure and a self imposed rationing of time in consultations were key concerns among the interviewees. Anxiety about time affected patients' freedom to talk about their problems. Patients took upon themselves part of the responsibility for managing time in the consultation to relieve the burden they perceived their doctors to be working under. Respondents' accounts often showed a mismatch between their own sense of time entitlement and the doctors' capacity to respond flexibly and constructively in offering extended consultation time when this was necessary. Patients valued time to talk and would often have liked more, but they did not necessarily associate length of consultation with quality. The impression doctors gave in handling time in consultations sent strong messages about legitimising the patients' illness and their decision to consult. CONCLUSIONS: Patients' self imposed restraint in taking up doctors' time has important consequences for the recognition and treatment of depression. Doctors need to have a greater awareness of patients' anxieties about time and should move to allay such anxieties by pre-emptive reassurance and reinforcing patients' sense of entitlement to time. Far from acting as "consumers," patients voluntarily assume responsibility for conserving scarce resources in a health service that they regard as a collective rather than a personal resource.

Communication↗
PubMed1991

Patient education about cough: effect on the consulting behaviour of general practice patients.

The aim of this general practice study was to examine how the consulting behaviour of patients with a cough was affected when the tasks and responsibilities of patients, practice nurses and general practitioners were reorganized. In four 'average' single-handed general practices the effects on the consulting behaviour of patients of a rational practice policy on cough and the provision of systematic patient education on cough were compared with patient behaviour in four matched control practices. Changes of behaviour were measured in 548 patients who consulted for cough at least twice, in two successive autumn-winter periods. Significantly more patients in the experimental practice changed their behaviour to follow the practice guidelines than did patients in the control practices (56% versus 30%, P less than 0.001). The proportion of patients who continued to consult in the approved manner was greater among patients receiving intervention (66% versus 29%, P less than 0.001). This was equally true for patients who had suffered less than four episodes of cough or more than four episodes. The more often the patients received the education, the more effective it was. All patients who consulted the general practitioner for cough during the first autumn-winter period filled in a cough diary during the second period. From this it appeared that the intervention did not result in patients delaying consultation when they had a cough lasting longer than three weeks or one with 'serious' symptoms. It would appear that a rational practice policy and the provision of patient education can stimulate patients to modify their consulting behaviour. This could result in a reduction in the costs of health care.

Adolescent↗
PubMed1991

Assessing the effectiveness of a computerized blood order "consultation" system.

To optimize blood ordering and accurately assess transfusion practice, in 1987, an "on line" computerized, knowledge-based, blood order critiquing system was integrated into the HELP Hospital Information System (HIS) at LDS Hospital. Evaluations of the computerized ordering system demonstrated its benefits and limitations on transfusion practice. Based on this experience, a second generation blood ordering system using a consultation mode was developed. A pilot test of this blood order consultant system, using historical data in the HELP system's database, was performed. This pilot test demonstrated that the consultation system provided accurate recommendations for red blood cell (RBC) and platelet orders. Comparing the appropriateness of blood orders with the recommendations made by the director of the blood bank, the orders recommended by the computer "consultant" agreed 95.5% of the time. The computer consultation system also recommended fewer RBC units for transfusion. Preliminary results obtained using the consultant approach suggest that we may be able to simplify blood ordering practice and also reduce the number of units of blood products ordered. Based on these findings we are now preparing to compare the "critiquing" and "consultation" approaches using a clinical trial.

Artificial Intelligence↗
PubMed1988

Impact of private medical insurance on the demand for child consultations with general practitioners.

Data were collected on over 4000 consultations with general practitioners for childhood complaints. Almost half of these consultations (46%) were covered by private medical insurance. A larger proportion of consultations for respiratory conditions were covered by insurance (50%) compared to those for nonrespiratory conditions (42% insured). Amongst those with respiratory conditions larger proportions of consultations for upper respiratory tract infections were insured (50%) than was the case for the potentially more serious conditions of asthma or otitis media (46% insured). The delay in seeking consultation for respiratory conditions was examined. In consultations for followup or persisting problems there was less delay among the insured (8.7 days) than amongst the noninsured (11 days). Those consultations initiated by the patient (or parent) were more likely to be covered by insurance (50%) than those which had been initiated by the doctor or other agency (44%). The findings are discussed in terms of the implications for equity and efficiency in health care.

Adolescent↗
PubMed1995

Factors influencing mothers' decisions to consult a general practitioner about their children's illnesses.

BACKGROUND: In the management of childhood illness only a small proportion of symptoms result in a medical consultation. AIM: This pilot study set out to assess the influence of sociodemographic factors, social network, reason of choice of doctor and contact with allied health professionals on mothers' decisions to consult a general practitioner about their children's illnesses. METHOD: In one suburb of Melbourne, Australia all mothers with children aged 11 to 26 months were identified from the maternal and child health centre register. Mothers were invited for interview and if they attended were asked to keep a health diary for their child for four weeks. Logistic regression was used to test a multivariate model of factors predicting consultation with the general practitioner. RESULTS: A total of 150 mothers were identified. Interviews were carried out with 81% of target mothers and diary data collected for 72% of target children. Over the four-week diary period, consultation rates with the general practitioner were significantly higher if symptoms were recorded on 15 days or more, or the general practitioner had been recommended by a friend or was the mother's own doctor before the child's birth. Contact with a maternal and child health nurse was also a significant predictor of medical contact. Contact with friends and relatives, whether or not the study child was the first child in the family, mother's education, husband's occupational status or contact with a chemist were not significantly related to medical consultation rates. CONCLUSION: Choice of doctor (current doctor same as doctor before birth of child, or doctor recommended by a friend) resulted in significantly more consultations as did contact with a maternal and child health nurse. These factors would seem to require further study and inclusion in future models of consulting behaviour.

Child, Preschool↗
PubMed1995

[Consultation by third parties in primary care of the aged].

OBJECTIVE: To assess elderly persons' consultations by third parties, examine the elderly, to know the characteristics of those who use it exclusively and to compare their utilization of health services with the utilization by other elderly users of Primary Care. DESIGN: Cross sectional study. PATIENTS: Data are from a stratified sample of the elderly. SETTING: Leganés. MEASUREMENTS AND MAIN RESULTS: Associations between sociodemographic and health variables with consultations by third parties are identified. Odds ratios are estimated with a logistic regression model fitted to the subsample of primary care users. Consultation by third parties is frequent among elderly in Leganés: 24.4% of them have used it in the last year; 4.2% exclusively and 20% in combination with other forms of general practitioner' consultations. Those consulting exclusively through third parties tend to have functional limitations, depression, and disabilities which keeps them apart from society. Family members are intermediary between elderly and General Practitioner. CONCLUSION: Consultation by third parties can lead to diminished quality of care. People who are currently consulting through third parties could be eligible to social and health care programs.

Aged↗
PubMed1996

[No difference in frequency of family practitioner consultation by Turkish, Surinam and Moroccan 0-14-year-old children from Dutch children, but difference in reason for contact].

OBJECTIVE: To determine whether consultation behaviour of Turkish, Surinam and Moroccan children (0-14 years old) with a GP differs from that of a comparable group of Dutch children. DESIGN: Cohort study with comparison of matched groups. SETTING: 103 general practices in the Netherlands. METHODS: Data on 63.753 children collected in the Dutch National Survey were used. 161 GPs registered all contacts between patient and practice during 1 year (in 4 parts of each 3 months). Sociodemographic characteristics of all 103 practice populations were gathered. For each Turkish, Surinam and Moroccan child a Dutch child was selected with similar age, gender, socio-economic status, degree of urbanisation, season of registration and sickness insurance coverage. Consult frequency, number of encounters per episode of care, morbidity presented, duration of encounter and percentages of encounters during evening, night and weekend were registered. RESULTS: There were no significant differences in consult frequency between the three ethnic groups and their Dutch reference group, nor were there any differences in number of encounters during an episode of care. The morbidity presented did vary compared with Dutch children. Turkish children consulted the GP more often for gastrointestinal problems (relative risk (RR): 1,81) and respiratory problems (RR: 1,27), but less often for ear problems (RR: 0,54). Surinam children consulted the GP less often for musculoskeletal problems (RR: 0,65), but more often for respiratory problems (RR: 1,20). Moroccan children consulted the GP less often for ear problems (RR: 0,51). For a larger percentage of ethnic children the duration of encounter was less than ten minutes. CONCLUSION: Turkish, Surinam and Moroccan children do not consult a GP more often than a comparable group of Dutch children. The morbidity presented differed.

Adolescent↗
PubMed2005

The influence of outreach in the development of the nurse consultant role in critical care: cause or effect?

BACKGROUND: Critical care nurse consultant roles have evolved against a background of service innovation that has resulted in the development of critical care outreach services. Despite compelling evidence that there was a serious problem with the management of critically ill patients in the ward environment, there is little evidence to support outreach as a concept or as a role for nurse consultants. AIMS: The aims for this part of the study were to: METHODS: A national postal survey of all 72 critical care nurse consultants in post in England by August 2003; response rate 72% (n = 52). All data was entered on to a computer anonymously and analysed using SPSS version 11.5. A factor analysis revealed a sub-set of nurse consultants who had a significantly greater involvement in outreach activity. RESULTS: Critical care nurse consultants have a high involvement in the development of care for critically ill patients outside the traditional boundaries of critical care. A sub-set emerged that has a significantly greater involvement in outreach activity. This includes roles such as working with an individual or team to develop their practice (whole group mean involvement score M = 4.45, outreach M = 4.88, p < 0.001); developing education outside the ICU/HDU (whole group M = 4.13, outreach M = 4.88, p < 0.001) and receiving nurse led referrals from the wards (whole group M = 3.92, outreach M = 4.81, p < 0.001). CONCLUSIONS: Given the lack of evidence for outreach, organisations should consider the high level of involvement of the nurse consultant outside the traditional boundaries of the ICU/HDU.

Attitude of Health Personnel↗
PubMed2005

Infectious disease consultations and antibiotic usage in a Turkish university hospital.

OBJECTIVES: The aim of this study was to investigate the various features of infectious disease (ID) consultations and the usage of antibiotics in a Turkish university hospital. METHODS: A total of 395 consultation requests were recorded during a three-year period. RESULTS: The departments most frequently requesting the consultation services of the ID department were Orthopedics (29.6%), Neurology (18.5%), Cardiology (11.8%) and Internal Medicine (10.4%). The main reasons were for diagnosis of unexplained fever (42.3%) and for antibiotic modification according to culture results (18%). Diagnoses made by the ID consultant were pneumonia (16.7%), urinary tract infections (9.3%), bone and joint prosthesis infections (9.1%) and in 15.7% of the investigated patients, no infectious focus was determined. It was recognized that the use of antibiotics had already been initiated in the great majority of patients (67.1%) before the consultation request. While the current therapy was changed in 57.4% of these patients, antibiotics were not necessary for 9.8%. CONCLUSIONS: Since the most common diagnoses were respiratory and urinary tract or bone and joint prosthesis infections, the ID specialists should have detailed knowledge of these problems. Usage of antibiotics without ID consultation was prevalent, therefore a continuous educational program is a necessity for healthcare workers in the hospital.

Anti-Bacterial Agents↗
PubMedDate not supplied

Expansion of the consultation-liaison psychiatry paradigm at a university medical center: integration of diversified clinical and funding models.

The perspective of the contemporary Consultation-Liason Service (CLS) psychiatrist is increasingly one of consultant to medical and surgical colleagues in models other than inpatient medical and surgical units. Simultaneously, the need for a clinically and educationally robust inpatient CLS persists despite funding pressures. The University of California, Davis Medical Center Department of Psychiatry has made use of creative organizational and financial models to accomplish the inpatient CLS clinical and educational missions in a fiscally responsible manner. In addition, the department has in recent years expanded the delivery of psychiatry consultation-liaison clinical and educational services to other models of care delivery, broadening the role and influence of the CLS. Several of the initiatives described in this paper parallel an overall evolution of the practice of consultation-liaison psychiatry in response to managed care influences and other systems pressures. This consultation-liaison paradigm expansion with diversified sources of funding support facilitates the development of consultation-liaison psychiatry along additional clinical, administrative, research, and educational dimensions. Other university medical centers may consider adaptation of some of the initiatives described here to their institutions.

Academic Medical Centers↗
PubMed1992

Consultants' views of a district's services.

A postal questionnaire survey of consultants in the Bath Health District was conducted to establish a means for individual consultants to express their views about the provision of health services in the district, so that by working together a new relationship between the District Health Authority (DHA) as purchaser and the clinicians as providers of services could commence. A response rate of 84 per cent was achieved. The survey sought views on clinical and management issues to be used in the development of service agreements (contracts) and views on topics identified by general practitioners (GPs) as areas in need of improvement. Detail is given of results relating to out-patient services, issues of communication and the continuing role of community hospitals. Most consultants sanctioned the appropriateness of referrals by GPs to out-patient services but they identified some out-patient referrals as inappropriate. This justifies a further review of the out-patient services to be purchased by the DHA. Consultants were in agreement that there was scope for review of out-patient follow-ups. They agreed with GPs that discharge summaries could be provided within 24 hours of patient discharge to improve communication with GPs and that consultants should be available by pager to be contacted by GPs, but disagreed with GPs about the feasibility of giving patients on waiting lists a firm admission date at the time of going on the waiting lists. The majority of consultants were in favour of continuing support for community hospitals. They identified overall social value of community hospitals and greater clinical value of out-patient services than in-patient services in community hospitals.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory Care↗
PubMedDate not supplied

The effective use of consultants.

Successful consultation between nurse administrators and management consultants requires developing a good working relationship and effectively managing the consultation process. The authors describe a four-phase consultation process from the perspective of both the manager and the consultant, identifying the critical steps and behaviors at each phase that promote a successful consultation.

Consultants↗
PubMedDate not supplied

Referral and consultation in emergency medicine practice.

Since emergency physicians (EPs) frequently initiate referrals and consultations, accept patients in referral, and may provide consultation services, it is imperative that EPs fully understand these processes. Such an understanding improves communication and facilitates professional interactions and patient care. There is little published information concerning the significance and practice of referrals and consultations as they pertain to the EP. This article addresses referrals and consultations in relation to EPs. Specific recommendations are made for consultation initiation and execution. The dynamics and ethical/legal issues associated with initiating and accepting referrals and consultations are discussed.

Consultants↗
PubMed1997

Profiling outpatient workload: practice variations between consultant firms and hospitals in south west England.

OBJECTIVES: To describe the variation in outpatient new to old ratios between consultants and between providers for seven high volume specialties (four surgical, three medical). DESIGN: This was a descriptive study at consultant and provider unit level based upon patient administration system data from the South and West Regional Health Authority for the financial year 1992-93. Additional components of variance analysis was used to distinguish individual consultant effects from host institution effects. SETTING: The former South Western Regional Health Authority area from Gloucestershire to Cornwall. SUBJECTS: Altogether 345 consultant firms in seven specialties grouped into 13 provider unit groups. MAIN MEASURES: New to old ratio, omitting elective inpatients followed up as outpatients. RESULTS: Variation between consultants is greater in surgical than in medical specialties, while absolute levels of new to old ratios tend to be higher in surgical specialties than in medical. Variation between provider unit groups is also greater in surgical specialties. Analysis of variance shows that more total variance is attributable to provider unit group in gynaecology than in other specialties. CONCLUSIONS: Within individual specialties there is evidence of substantial variation that is not attributable to underlying differences in morbidity patterns. There is evidence of marked variation in terms of both individual consultants and institutions, a finding that provides the springboard for further analytical work. Published routine outpatient activity statistics should distinguish between new referrals, inpatient follow up, and clinic rebookings.

Analysis of Variance↗
PubMed2006

Email teleconsultations: well formulated clinical referrals reduce the need for clinic consultation.

We examined how well primary-care physicians formulated their clinical referrals when asking for help with patient-related clinical problems using an email-based teleconsultation service. Over 100 family physicians made use of the service. The specialists were medical school faculty members. The service was initiated in May 1996 with 19 specialists and expanded to 34 specialties over the next five years. A total of 1618 patient-related clinical questions were analysed, the outcome for the analysis being whether specialists recommended a clinic consultation. Specialists recommended a clinic consultation in response to 10% of their clinical questions about patients. There was a strong association between how family physicians formulated their clinical questions and whether the specialist recommended a clinic consultation. When the family physicians specified a clinical task (P < 0.001), intervention (P = 0.004) and outcome (P < 0.001) in their questions, specialists were less likely to recommend a clinic consultation. This influence was independent of the amount of clinical information included with the question (P > 0.05). About 5% of the questions that included all three question components resulted in the recommendation for a clinic consultation, compared with nearly 30% of the questions containing none of these components. How family physicians formulate their clinical questions influences whether specialists request a clinic consultation.

Electronic Mail↗
PubMed2006

Quality of written reports provided by consultants in restorative dentistry to referring general dental practitioners in the west midlands.

OBJECTIVES: The primary objective of this study was to assess the views of general dental practitioners (GDPs) on the content, style, and readability of written reports provided by restorative consultants at a dental hospital in response to referral letters from the GDPs. The secondary objective was to determine the style of the written consultant report preferred by GDPs. SETTING: Referral letters received and replied to by four consultants in the restorative department at Birmingham Dental Hospital. METHOD: The quality of written reports sent by the four consultants to 100 referring GDPs in the West Midlands area was evaluated using a postal questionnaire, which assessed 100 GDPs' satisfaction with the content, style, and readability of the reports. To assess which format they favoured a second questionnaire was subsequently sent to the same GDPs with three versions of the original report in: (a) a standard format, (b) a summary format, and (c) a bullet point format. RESULTS: The results of the initial questionnaire revealed that 79 (96%) of practitioners were satisfied with the existing style of the reports. Following a second questionnaire in which GDPs were asked to choose which format they preferred, 61 (81%) expressed a preference for a bullet point or summary style report. CONCLUSION: The GDPs who responded to the questionnaires felt that a bullet point format or summary style report from the consultants concerned would summarise cases more clearly and concisely than the conventional standard format letters which they had previously received. Opportunities may exist for improving the quality of consultant reply letters through the use of structured templates and/or a summary or bullet point format.

Attitude of Health Personnel↗
PubMed2000

Pacific Island Health Care Project: early experiences with a Web-based consultation and referral network.

The Pacific Island Health Care Project (PIHCP) has in the past provided definitive care at the Tripler Army Medical Center (TAMC) for nearly 3000 patients. To contain costs, increase access, and provide consultative and referral services to physicians in the Pacific Basin, a web-based network was established in 1997. Four sites in the Western Pacific were provided with a desktop computer, digital still and video cameras, flatbed scanners, and printers. Consultations with supporting imagery are submitted to TAMC where the consults are data-based and dynamically posted on a secure web server. TAMC consultants triage and comment on the cases and the educational significance. Unnecessary or inappropriate referrals are returned with instructions for local care. Cases are formatted to allow rapid response, image review, consultant/provider interaction, and peer review. More than 180 consults have been submitted from the island nations electronically (30 September 1998) and initial experience indicates that the Internet can be easily used as an inexpensive store and forward consultation format. There has been an overwhelming enthusiasm for this project by all participants and for the first time since the inception of the PIHCP, funding was available during the entire fiscal year, with tens of thousands of dollars saved.

Female↗
PubMed1989

Ethics consultants and ethics committees.

To address moral questions in patient care, hospitals and health care systems have enlisted the help of hospital ethicists, ethics committees, and ethics consultation services. Most physicians have not been trained in the concepts, skills, or language of clinical ethics, and few ethicists have been trained in clinical medicine, so neither group can fully identify, analyze, and resolve clinical ethical problems. Some ethics committees have undertaken clinical consultations themselves, but liability concerns and variable standards for membership hinder their efforts. An ethics consultation service comprising both physician-ethicists and nonphysician-ethicists brings complementary viewpoints to the management of particular cases. If they are to be effective consultants, however, nonphysician-ethicists need to be "clinicians": professionals who understand an individual patient's medical condition and personal situation well enough to help in managing the case. Ethics consultants and ethics committees may work together, but they have separate identities and distinct objectives: ethics consultants are responsible for patient care, while ethics committees are administrative bodies whose primary task is to advise in creating institutional policy.

Consultants↗