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Consultant strategies for the gastroenterologist.

Effective communication skills and the ability to respond to the needs of referring physicians are critical for the maintenance and enhancement of a referral base. One challenge is to determine the reason for the consultation and to respond to the referring physician's interests. The consultation letter should be formatted effectively and the "turn-around time" should be as brief as possible, perhaps by fax as well as mail. Prioritizing the differential diagnosis and diagnostic studies can be helpful to the referring physician. Strategies should be developed to address procedural referrals you may believe are inappropriate. A decision should be made as to whether the consultant or the primary care physician informs the patient of a serious disease diagnosis. Referral guidelines should be developed to assist primary care physicians to determine when a patient should be referred to the gastroenterologist or other specialist. Receptionists should avoid turning away new patients because of a "full schedule" and must determine if other arrangements can be made. A proper response to "hallway consultations" by referring physicians is important. Consultants should make efforts to increase their visibility in the medical community, either by newsletter or lectures to the medical staff. Every effort should be made to avoid speaking disparagingly about other physicians. Consultant strategies should be taught to house staff and fellows in a formal lecture format, in the outpatient clinics, and on hospital rounds.

Communication↗

Evaluation of 294 psychiatric consultations involving in-patients above 70 years of age in somatic departments in a university hospital.

The integrated geropsychiatric service of the Psychiatric Department of the University Hospital in Linköping consists of an observation ward, a day unit and an out-patient unit. One of the main tasks of the last-mentioned unit is to provide geropsychiatric consultations for in-patients in the non-psychiatric departments of the hospital. During the first 2 years from October 1982 to October 1984 300 consultations were performed. The consultations included registration of social, medical and psychiatric data, a psychiatric examination, discussions with the staff and a psychiatric report. Out of the total number of 300 consultations 294 could be evaluated completely. They comprised 247 individuals. The evaluation was performed after the first 2 years by screening the patients' psychiatric records and reports and by computer-analysis of 89 variables covering medical as well as social data. The patients' mean age was 78 years and 52% were treated in the Department of Internal Medicine. Fifty-three percent had had previous psychiatric contacts. Many were suffering from serious somatic diseases and 22% from depressive states. Only 9% showed no signs of psychiatric disorders. Twenty-three percent of the patients were transferred to the geropsychiatric observation ward or day unit and only 3% were recommended to be certified and transferred to a mental hospital. Pertinent findings are discussed in the light of international data on geropsychiatric consultations and liaison psychiatry. The study shows the importance of providing special geropsychiatric consultations for in-patients in somatic departments as a part of an integrated geropsychiatric service.

Aged↗

Evaluation of psychiatric consultations with suicide attempters.

Diagnosis, management and disposition were evaluated in 120 psychiatric consultations with patients referred to a university hospital following an attempted suicide. Data were registered by hospital nurses and psychiatric consultants, and the patients were extensively interviewed after discharge. Many patients (43%) had been admitted to a psychiatric hospital on previous occasions or at the time of the suicide attempt. In almost one third of the cases, the consultants did not take sufficient interest in the patients' accounts of the last and previous suicide attempts. Their estimation of the reoccurrence of suicidal behaviour had a low predictive value (54%). One fourth to one half of the patients were negative about or not satisfied with the consultation. The compliance with the psychiatric consultants' referrals, however, was very high (79%). Although a large group of patients received effective care, the consultants did not pay enough attention to the group of (former) in-patients with recurrent suicidal behaviour. Possible causes and consequences of these findings are discussed.

Adolescent↗

A communication skills programme for increasing patients' satisfaction with general practice consultations.

The research literature on patient perceptions of general practice consultations shows that, while patients are generally satisfied with the treatment they receive from doctors, they report less satisfaction with the amount and clarity of information they receive and doctors' expression of caring and respect. In the surgery, inadequate information transmission during the interaction also has the effect of increasing the level of anxiety reported by patients after their consultations. A communication skills programme was developed, incorporating variables from both the emotional and cognitive domains of the consultation. A group of GPs undertook training in this programme. It was hypothesized that patients of the trained doctors would report greater satisfaction and less anxiety, compared with patients of untrained general practitioners. Subsequent randomized interviews with patients of the trained doctors showed that these patients were significantly more satisfied with their consultations. Patients of the trained doctors also reported less state anxiety immediately following their consultations, as measured using the State-Trait Anxiety Inventory. Attempts by doctors to communicate more effectively in consultations therefore increased patients' positive feelings and reduced anxiety.

Adolescent↗

Consultation for physical illnesses by patients diagnosed and treated for psychiatric disorders by a general practitioner: 20 year follow up study.

Patterns of consultation for physical illness were analysed in a body of consultation data covering a continuous 20 year period from a single general practitioner in south London. Three groups of adult patients were identified: patients with a psychiatric disorder and a new prescription for a psychotropic drug; patients with a psychiatric disorder but no new prescription for a psychotropic drug; and a control group without psychiatric disorder. The percentages of patients having one or more consultation for physical illnesses were stable over the years studied, being roughly 90%, 85%, and 60% respectively. For groups identified in 1972 their patterns of consultation for physical illness were examined in 1957, 1962, and annually from 1967 to 1976. In every year studied except 1957 the group with a psychiatric disorder and a new prescription for a psychotropic drug exceeded both other groups in the percentage of patients having one or more consultations for physical illnesses. Both groups with psychiatric disorders had an excess of consultations over the control group; this excess halved in about four years for the group with a new prescription and in about one year for the group without a new prescription. Mental health care by general practitioners for patients with psychiatric disorders does not seem to have an offset effect on general health care of these patients.

Adult↗

Continuity of care: influence of general practitioners' knowledge about their patients on use of resources in consultations.

OBJECTIVE: To examine the relation between general practitioners' knowledge about their patients and the use of resources in consultations. DESIGN: A cross sectional evaluation of consultations. SETTING AND SUBJECTS: A representative sample of 133 Norwegian general practitioners were each asked to record 30 consecutive consultations. 131 did so, and of 3990 possible registrations, 3918 (98%) were evaluated. MAIN OUTCOME MEASURES: The influence, as assessed by the doctor, of accumulated knowledge on the use of laboratory tests, expectant management, prescriptions, sickness certification, referrals, and time spent in the consultation. RESULTS: Accumulated knowledge was a substantial factor in saving time, especially in consultations with children, the elderly, patients with psychosocial problems, and those with chronic diseases. It also influenced the overall use of laboratory tests, expectant management, sickness certification, and referrals, and to a lesser degree the use of medication. CONCLUSION: The findings imply strong but complex associations between accumulated knowledge and the use of resources in the consultation.

Adolescent↗

Communication between general practitioners and consultants: what should their letters contain?

OBJECTIVE: To canvass the views of all general practitioners and consultants working in Newcastle upon Tyne on the content of referral letters and replies, the feasibility of standardising certain aspects of referral letters, and the use of communications data for audit purposes. DESIGN: A postal questionnaire was sent to all general practitioners and consultants in Newcastle upon Tyne in May 1991. Questions were asked about the clinical and administrative content of letters, the utility of standard categories to state the reason for referral, the idea of using letters for feedback purposes, and communications as a potential topic for professionally led audit. SETTING: Area served by Newcastle upon Tyne Family Health Services Authority and District Health Authority. RESULTS: Replies were received from 274 (77%) doctors (115 general practitioners and 159 consultants). A majority (225; 82%) were in favour of items defined as "always important" forming a minimum requirement for referral letters and for consultants' replies. Using standardised categories to state the reason for referral was not endorsed: 102 (89%) general practitioners and 132 (83%) consultants preferred referrers to use their own words. Using referral communications to provide feedback was less popular with consultants (54; 34%) than general practitioners (72; 63%). Finally, a majority of doctors (179; 65%) were in favour of using written communications as a topic for professionally led audit. CONCLUSIONS: A high degree of consensus exists among clinicians about the content of referral communications. Although doctors may still reject the concept of standardised communications, they have unambiguously endorsed a standard for communication that they can aspire to, and they are prepared to use it as a yardstick for their actual performance.

Communication↗

Options for change in the NHS consultant contract.

The lead negotiators for the management and consultant sides in an NHS trust in northern England responded to debate in their trust about consultant contracts by offering to research the attitudes of their peers towards a variety of contract options. The options tested included the current contract; models already examined in the trust and elsewhere, such as time sensitive and mild performance related contracts; and some more radical and speculative possibilities, including consultants franchising their services to the trust. Beyond the predictable conclusion that consultants would prefer no change while managers desired it, a time sensitive contract emerged as having potential for successful negotiation. On the other hand, neither consultants nor managers favoured a strict performance related contract or a fee for service contract. There was a strong similarity of opinion between the two groups on the relative salary values of the options, though the consultants consistently priced these higher than the managers.

Consultants↗

Comparison of patient questionnaire, medical record, and audio tape in assessment of health promotion in general practice consultations.

OBJECTIVE: To determine what proportion of health promotion activities reported by the patient is recorded in the general practice notes and to compare these methods of assessing health promotion with audio tape analysis. DESIGN: Secondary analysis of data obtained in a controlled trial of differing appointment lengths. After each consultation the medical record was examined and the patient invited to completed a questionnaire. A subsample of consultations was audio taped. SETTING: Nottinghamshire. SUBJECTS: 16 general practitioners from 10 practices. This report includes 3324 consultations with patients aged > or = 17, with data on measurement of blood pressure and advice about smoking and alcohol. RESULTS: Data from questionnaire and medical notes were available for 2281 consultations. Advice on smoking was recorded in the notes in 30.9% of cases in which a patient reported it (for alcohol and measurement of blood pressure, 44.4% and 82.7% of cases respectively). In 516 cases analysis of audio tape and review of records was performed. Advice on smoking was recorded in the patient's notes in 28.6% of cases in which it was detected on audio tape (for alcohol, 31.1% of cases). In 335 consultations data from audio tape and questionnaire were available. Advice on smoking was reported by patients in 73.9% of cases in which it was detected on audio tape (for alcohol, 75.0% of cases). CONCLUSIONS: Review of the medical record is a reasonably accurate method of assessing measurement of blood pressure in the consultation but would lead to significant underestimation of advice about smoking and alcohol.

Adult↗

Doctors as patients: postal survey examining consultants and general practitioners adherence to guidelines.

OBJECTIVES: To examine the adherence by senior NHS medical staff to the BMA guidelines on the ethical responsibilities of doctors towards themselves and their families. DESIGN: Postal semistructured questionnaire. SETTING: Four randomly selected NHS trusts and three local medical committees in South Thames region. SUBJECTS: Consultants and principals in general practice. MAIN OUTCOME MEASURES: Personal use of health services. RESULTS: The response rate was 64% (724) for general practitioners and 72% (427) for consultants after three mailings. Most (1106, 96%) respondents were registered with a general practitioner, although little use was made of their services. 159 (26%) general practitioners were registered with a general practitioner in their own practice and 80 (11%) admitted to looking after members of their family. 73 (24%) consultants would never see their general practitioner before obtaining consultant advice. Most consultants and general practitioners admitted to prescribing for themselves and their family. Responses to vignettes for different health problems indicated a general reluctance to take time off, but there were differences between consultants and general practitioners and by sex. Views on improvements needed included the possibility of a "doctor's doctor," access to out of area secondary care, an occupational health service for general practitioners, and regular health check ups. CONCLUSION: The guidelines are largely not being followed, perhaps because of the difficulties of obtaining access to general practitioners outside working hours. The occupational health service should be expanded and a general practitioner service for NHS staff piloted.

Attitude of Health Personnel↗

Making an IMPACT on emergency department flow: improving patient processing assisted by consultant at triage.

OBJECTIVES: To assess whether initial patient consult by senior clinicians reduces numbers of patients waiting to be seen as an indirect measure of waiting time throughout the emergency department (ED). METHODS: An emergency medicine consultant and a senior ED nurse (G or F grade), known as the IMPACT team, staffed the triage area for four periods of four hours per week, Monday to Friday between 9 am to 5 pm for three months between December 2001 and February 2002 when staffing levels permitted. Patients normally triaged by a nurse in this area instead had an early consultation with the IMPACT team. Data were collected prospectively on all patients seen by the IMPACT team. The number of patients waiting to be seen (for triage, in majors and in minors) was assessed every two hours during the IMPACT sessions and at corresponding times when no IMPACT team was operational. RESULTS: There was an overall reduction in the number of patients waiting to be seen in the department from 18.3 to 5.5 (p<0.0001) at formal two hourly assessments. The largest difference was seen in minors. Of the patients seen at triage by the IMPACT team, 48.9% were discharged home immediately after assessment and treatment. With the IMPACT team present, no patient waited more than four hours for initial clinical consult. CONCLUSIONS: By using a senior clinical team for initial patient consultation, the numbers of patients waiting fell dramatically throughout the ED. Many patients can be effectively treated and discharged after initial consult by the IMPACT team.

Appointments and Schedules↗

Ability of a nurse specialist to diagnose simple headache disorders compared with consultant neurologists.

OBJECTIVE: To compare the ability of a headache nurse specialist and consultant neurologists in diagnosing tension-type headache and migraine. METHODS: An experienced neurology ward sister was trained in the differential diagnosis of headache disorders. Over six months, patients with non-acute headache disorders and role players trained to present with benign or sinister headaches were seen by both the nurse and a consultant neurologist. Both reached independent diagnoses of various headache disorders. RESULTS: Consultants diagnosed 239 patients with tension-type headache (47%), migraine (39%), or other headache disorders (14%). The nurse agreed with the consultant in 92% of cases of tension-type headache, 91% of migraine, and 61% of other diagnoses. Where the nurse did not agree with the diagnosis, most would have been referred for a consultant opinion. Both the nurse and the doctors misdiagnosed the same three of 13 role players. The investigation rate of the consultants varied between 18% and 59%. Only one clinically relevant abnormality was found on head scans and this was strongly suspected clinically. CONCLUSIONS: A headache nurse specialist can be trained to diagnose tension-type headache and migraine. A nationwide nurse led diagnostic headache service could lead to substantial reduction in neurology waiting times.

Adult↗

Psychiatric consultation: concepts and controversies.

There are two major models of consultation in the field of psychiatry, differing in their goals, participants, settings, and methods. The psychiatric-therapeutic model entails provision of optimal care for the individual patient; the community mental health model involves provision of assistance to mental health caregivers. The author believes that to enhance the value of consultation the consultation should restrict his or her role to that for which he or she has been trained. Current social needs, coupled with a limited supply of consultants, suggest that psychiatric consultation should be provided within comprehensive health care systems. There is a pressing need to clarify the concepts of formulations concerning the criteria of outcome of psychiatric consultation so that evaluation of its effectiveness can be advanced.

Canada↗

Consultation in psychotherapy.

The value of consultation in good medical practice is equally relevant in the practice of psychiatry including psychotherapy. It is one important example of the need for collaboration in medicine, in clinical, educational, and administrative spheres. Excessive protection of the patient's privacy and the psychotherapist's autonomy can lead to lost opportunity for both participants. Appropriate introduction of the opinion of a respected colleague can have facilitating and creative effects upon the psychotherapy. Difficulty in ongoing psychotherapy often occurs when imbalance develops, and consultation can lead to restoration of an appropriate balance. Long-standing respectful professional association between consulting colleagues can make consultation more comfortable and profitable. It is our opinion that increased readiness to seek appropriate consultations in psychotherapy can be of considerable benefit to psychotherapists, to their patients, and to the consultants with whom they share their concerns.

Female↗

Creating a mental health consultation package for community agencies.

The author designed a consultation package for a community mental health center consultant to present to the relevant agencies and organizations in the community. The consultation package is designed to create a series of regularly scheduled voluntary group meetings that center on the discussion of a case or a particular topic. The package also includes a written agreement, an evaluation procedure, and a six- to eight-month free trial period. The steps for establishing a new consultative relationship and developing a consultation network are also outlined. By using those steps and the package, the author and his colleagues have successfully established consultation services with schools, with the welfare, probation, and police departments, and with organizations of physicians, nurses, and clergy.

Attitude of Health Personnel↗

Psychiatric nursing consultation in a university medical center.

A program of psychiatric nursing consultation was established at a large university medical center in response to requests from nonpsychiatric nurses; they generally felt that patient evaluations provided by the psychiatry liaison service did not have specific application to nursing care. The program is operated by two part-time coordinators who train and supervise the nurse-consultants through monthly group sessions and individual supervision. One aim is to set up ongoing consultative meetings with nursing staffs who request help rather than providing only one-time or crisis consultation. During the program's first year, 146 consultations were given, and an average of 9.5 nursing units received consultation services each month.

Affective Symptoms↗

Psychotherapy consultation in an inpatient setting.

Evaluation of an ongoing psychotherapy by a consultant is a demanding and important task. In many cases consultation is best carried out in a hospital setting; the patient benefits by the structured environment, and the therapist gains the support of the inpatient consultative team. Close cooperation between patient, therapist, and inpatient staff can help revitalize a psychotherapy by renewing the commitment of therapist and patient to work together again on an outpatient basis. Consultation can also lead to a decision to terminate therapy. Psychotherapy consultation should be viewed not as a failure of either therapist or patient, but as a commonly occurring need in some psychotherapies, especially with difficult patients. A consultative team sensitive to the nature of the patient-therapist relationship and careful to avoid devaluing the therapist can make a significant contribution to a psychotherapy.

Adolescent↗

Predictors of missed appointments for psychiatric consultations in a primary care clinic.

OBJECTIVE: The purpose of the study was to determine predictors of missed appointments for psychiatric consultations among patients in a general medical clinic. METHODS: The charts of 180 patients consecutively referred for psychiatric consultations at a university-affiliated primary care clinic were reviewed. Ninety patients missed appointments for these consultations. Parametric and nonparametric tests were used to compare patients who missed and did not miss appointments on demographic and clinical variables, as well as measures related to patients' interactions with the clinic and the referring clinician. RESULTS: Logistic regression analysis revealed three significant predictors of missed appointments. Patients with mild distress and those with significant resistance to seeing a psychiatrist were more likely to miss appointments, as were those who had to wait longer between the referral and the appointment date. CONCLUSIONS: The results suggest that shortening the wait for a psychiatric consultation, reserving consultation for more severe cases, and working to reduce patients' resistance to consultation will reduce the number of missed appointments.

Adolescent↗