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PubMed1982

Subspecialty consultations in a teaching hospital.

A chart review of 60 consultations by the nephrology service of a teaching hospital was carried out to determine their diagnostic and therapeutic utility. General medicine residents on elective rotations in nephrology performed 72% of the consultations, only 26% being written by residents in the subspecialty. Consultants made an average of 2.2 diagnoses per patient, of which 57% confirmed the working diagnosis already in the medical record. They made an average of 3.0 recommendations for further investigation per patient, but referring physicians implemented only 58% of these. An average of 1.6 recommendations for therapy were made per patient, of which 64% were implemented. The apparent neglect of the consultant's advice for investigation and therapy suggests that the written consultation to some extent fails to convey information useful for the referring physician and the patient. Further study is needed to determine if this failure reflects inadequate training of house officers as consultants.

Hospitals, Teaching↗
PubMed1995

[Psychiatric consultation service in a university clinic. An empirical study of characteristic performance].

In Germany, there is growing interest in consultant psychiatry on a scientific and practical level. On the other hand, very few results have been reported concerning the tasks and functions of consultant services. This study was conducted in the Lübeck University Hospital to evaluate psychiatric consultant interventions by assessing referral rates, reasons for referrals, psychiatric diagnoses and recommendations. A total of 5334 consultations from 7 years (1983-1989) was analyzed, and a sample of 1000 consultations was taken. Over the years, a continuous increase in the consultation rates can be observed, with suicide and alcoholism as important focuses. The most frequent diagnoses were adjustment disorders, organic disorders and alcoholism. Psychopharmacological intervention, referral to the psychiatric/psychosomatic ward, and short practical advice were the most frequent recommendations. The results are discussed in the context of the international literature.

Adult↗
PubMed1995

Use of videotaped consultations in summative assessment of trainees in general practice.

BACKGROUND: There are many different methods by which trainees may be assessed summatively. AIM: The objective of the study was to determine if videotaped consultations could be used to identify reliably those general practitioner trainees who have not yet reached acceptable levels of competence. METHOD: Videotapes of 10 trainees carrying out normal consultations were assessed by 20 assessors for acceptable competence using a rating scale specifically developed for the purpose. RESULTS: A principal components analysis showed a strong correlation among the items in the rating scale used, indicating that a single underlying factor accounted for 76% of the overall scores. Agreement between assessors on the scoring of individual consultations was limited. There was much greater consistency with regard to the decision on overall competence, examined for the first consultation. A non-competent trainee would have a 95% probability of being identified by the process as described using two assessors for each videotape. The assessors had reached firm judgements on each trainee by the time four consultations had been viewed. CONCLUSION: The workload involved in producing and analysing the tapes is discussed. Considerations of patient consent are addressed. It is concluded that the use of videotaped consultations appears to offer a feasible and reliable method of summative assessment of general practitioner trainees.

Education, Medical, Graduate↗
PubMed1994

[Evaluation of the use of an environmental medicine consulting center].

At the Environmental Medical Consulting Centre 1677 consultations were carried out in 1991. The centre is established at the Medical Institute of Environmental Hygiene in Düsseldorf. There were 1129 (68%) short questions and 309 (18%) detailed consultations by phone or by letter. The most of the questions were asked by the general population. Other questions came from people at health offices, from general practitioners and from hospitals. No detail information about some socio-demographic data of this group was taken. The overwhelming topics of the questions were toxicological problems of harmful substances in indoor air or about the use of some products containing harmful substances. 239 (14%) people of the whole group got an appointment for a detailed medical consultation. Only data from 158 patients--visiting the office during January and September 1991--were evaluated in detail. On average the patients examined were 40 years old and mostly with a higher school degree. The most of the people complained about permanent polysomatic symptoms. A defined exposure was diagnosed for 31 (20%) patients, which resulted from pollution at work, at home or from the environment. The term Sick-Building-Syndrome were used for further 16 (10%) patients. In conclusion, the results of the study reveal a need of consultation with a specific orientation in Environmental Medicine. But, because of lack of data from other consulting offices in order to compare the results, no quantification of the need could be estimated.

Adolescent↗
PubMed1994

Consultants' complaints about the quality of referrals from primary care physicians: tempest in a teapot?

OBJECTIVE: To determine whether consultants' general impressions of the quality of referrals from family physicians are consistent with their evaluations of the quality of specific referrals. METHODS: Data were gathered using two questionnaires, completed separately by the same group of consultants working in a Health Maintenance Organization (HMO). Both questionnaires contained the same items and were designed to cover the following topics: (a) the general impression of the consultants about the quality of referrals received from family physicians; (b) their specific evaluation of all consecutive patient referrals by family physicians over a one-week period. Forty consultants employed in an outpatient regional multidisciplinary clinic of the largest HMO in Israel participated in the study. Of the 3136 referrals received over a one-week period, 1466 fulfilled the inclusion criteria, and 1416 were evaluated (response rate, 97%). RESULTS: Most of the estimates of the number of unnecessary/inappropriate referrals obtained in the general impression questionnaire were 2 to 5 times higher (p < or = 0.001) than those obtained in the consultants' evaluation questionnaire about specific referrals. CONCLUSIONS: This study suggests that consultants' complaints of unjustified and inappropriate referrals from family physicians must be taken with great reservation, at least within the framework of health systems that do not encourage physicians to produce a large number of services.

Family Practice↗
PubMed1994

Consultations for women's health problems: factors influencing women's choice of sex of general practitioner.

AIM: This study set out to examine the degree to which women choose to visit a woman doctor for women's health problems and the determinants of this choice. The differences between women and men doctors with regard to treating women's health problems were also studied. METHOD: Data from the Dutch national survey of general practice were used. All group practices with both women and men general practitioners were selected. Analyses were restricted to consultations among women aged 15-65 years about menstruation, the menopause, vaginal discharge, breast examination and cervical smear tests. RESULts. Given the size of their female practice population, women doctors saw considerably more women with women's health problems than did their male colleagues. Women were more likely to consult a woman general practitioner if she was more available (that is, working longer hours), and younger women were more likely than older women to choose women general practitioners. Sex differences in the treatment of women's health problems were small and mainly related to the verbal part of the consultation: counselling and providing information. The doctors' availability and their certainty about the working diagnosis explained differences in the verbal aspects of consultations. Women general practitioners had longer consultations than their male colleagues mainly because more health problems were presented per consultation. CONCLUSION: In order to increase the possibility of patients choosing women general practitioners, policy should be directed towards the education of more women general practitioners and women general practitioners should be encouraged to work more days a week.

Adult↗
PubMed1977

The consultation process and its effects on therapeutic outcome.

There is little in the literature dealing with consultation from the point of view of patient care. Since one of the major elements in the definition of family practice deals with the synthesizing role and the responsiblity of the family physician to help guide patients through the complex health-care system, it is entirely appropriate to take a critical look at the consultation process. This will allow more appropriate teaching of the family practice resident, so that he may use consultation and referral in a more productive manner in the future. This paper defines and discusses six common problems in the consultation process. Classification of pitfalls in the consutative process can serve as a starting point from which a more critical and systematic study of the consultation can be made, to the end of making the consultant and the referring physician both more skilled and more comfortable with their coordinated tasks.

Adult↗
PubMed1995

Creating a computer-aided intellectual environment for a consultative center of intensive care.

A consultative centre for intensive pediatrics (cip) is a center for rendering aid to children in urgent conditions who are hundreds kilometers from specialized help. Such aid is typically rendered by: 1)moving the patient to the another hospital, 2) the specialized team going out by plane, or 3) consulting the local physician by phone. The complexities of the cip dispatcher-consultation of the local physician entail a real-time system that provides a consultant with simultaneous operation with a computer and a local doctor over a phone. In 1987, a computer program, DINAR-1, was used. The core of this program was the scale of a patient's state severity "FHD-5.4" and essential elements of informative services: both a reference subsystem and one accumulating and analyzing data about cip activities, treated patients, and faults in the system of medical care. Two years of DINAR-usage showed the necessity of strengthening the decision support system for cip consultant. In 1989, a new program variant, DINAR-2, was completed. During the new variant's creation, we developed a model of decision making under conditions of information distortion (e.G., as a result of the subconscious influence of diagnostical hypotheses). This model was necessary for DINAR-2, because the most part of all information for decision making had subjective issue. Distinctions between levels of medical aid at the spot (in local hospitals) demanded the special assessment of a patient's state severity in order to adequately choose between tactical activities of the CIP. The severity of a patient's state original index depended on necessary therapy type; volume was developed. Special methodological interaction expedients between the user and the decision making system were verified in DINAR-2. The following improvements were also developed: subsystem of tuning on a definite area (1990); block of analytical final instructions on a patient's treatment (1991); visualization of introduced information (1991); determination of factors causing aggravation of a patient state (1992); and specialized subsystem of consultation of neonatals (1993). During the work, CIP got a new important function. CIP became a methodical center of the medical children aid. In keeping with this, a collection and analysis of information for regional health ministry became important part of DINAR-2. It is especially connected with touched discovery and analysis of medical defects. A system of child's death-rate analysis was especially created to make impartial decisions (1990). Expert subsystems had also an original continuation. This subsystem became a basis of the new system DINAR-created for the common pediatric physician who is attending a severely ill child. A principle addition to this system is a more complicated method of tactic solution choice. The technology of CIP supported by DINAR-systems had been bought by 35 different regions of the former USSR by 1994 (1989: one region; 1990: 2; 1991: 5; 1992: 10; 1993: 17 regions). The total population of all these regions is more than 59,000,000 people, and the total area is more than 11 million square kilometers. The main direction of DINAR's development is the creation of a regional computer network, allowing DINAR-to communicate with DINAR-in local hospitals. The first place for the usage of such a network is going to be the Big Urals Region. Big Ural consists of eight states. The total population of this territory is 28 million people and total area is 3.1 million square km. Computer networks will link eight regional CIPs to one another and the medical analytical center. The CIPs will have to be connected with 259 local hospitals. At present, the DINAR-2-CIP is installed in six states of the Big Ural, and DINAR-H is installed in four hospitals of the Sverdlovsk state.

Child↗
PubMed1996

Telesurgical consultation.

PURPOSE: We evaluated the feasibility of "telesurgical" consultation during laparoscopic surgery. Telesurgical consultation is a distinct application of telemedicine in which a surgeon at a primary operating site can consult another experienced surgeon or colleague for complex and/or unexpected problems encountered during surgery. MATERIALS AND METHODS: Telesurgical consultation was used in 6 complex laparoscopic cases, including upper pole nephrectomy, diagnostic laparoscopy with inguinal hernia repair, orchiectomy, gastric augmentation with bladder suspension, bladder reconstruction and ureteral lithotomy. RESULTS: In each case an experienced laparoscopic surgeon at the primary operative site consulted a surgical specialist at the remote site who had expertise in the particular procedure being performed. All procedures were accomplished successfully without intraoperative or post-operative complications. CONCLUSIONS: Complex laparoscopic procedures that normally require a surgical specialist can be performed successfully by an experienced laparoscopic surgeon consulting a remote specialist via the tele-operative system.

Adolescent↗
PubMed1996

[Psychiatric emergency consultation in a general hospital].

Inpatients in general hospital often presented with psychological problems and some of them need emergent psychiatric interventions. However, there have been little attention on the psychiatric emergency consultation. The purpose of this paper is to review the psychiatric emergency service in a general hospital over 3-year period. During this period, there were 88 psychiatric emergency consultations that represented 2.3% of all psychiatric consultations. The emergency group showed no difference in sex and age, but received more diagnoses of delirium (58.0%) than the other referrals. About one fourth of these patients had psychiatric history. Stated requests for "agitation and irritability", "psychiatric symptoms" and "uncooperation with treatment" were the most frequent reasons. Sixty-five percent of the patients receive recommendations of medication treatment. Among them, neuroleptics and anxiolytics were most common used. About one half of the patients needed further medical tests. After psychiatric interventions, most of the patients got improved within 2 days but 15 patients died during hospitalization. These findings indicated that psychiatric emergency consultation though the request rate is low. When making diagnoses in emergency consultation, past psychiatric history is important and organic mental disorders should be ruled out first. After psychiatric interventions, most of the psychiatric emergency could be improved. It suggested that the setting of psychiatric emergency consultation could improve the quality of patient care in a ageneral hospital.

Adolescent↗
PubMed1997

[The reason for medical consultations in patients with psychiatric diseases: somatization phenomena and suicide attempts].

BACKGROUND: The objectives of the study are to document the frequency of use of the general medical services by psychiatric patients, to measure how many consultations are due to somatization and suicide attempts and to know the existence of possible differences between psychiatric inpatients and outpatients in relation to the reason of medical consultation. MATERIAL AND METHODS DESIGN: retrospective study. Site: Manchester Royal Infirmary, a university third level hospital in Manchester (United Kingdom). PATIENTS: patients from the psychiatric department seen during the period from July 1st to December 31st in 1992 (n = 1,012 patients). RESULTS: The percentage of patients that consults a medical/surgical department in one year is 27.5%, 25.2% of outpatients and 36.3% of inpatients. Non-medical reasons are 42.3% of these consultations: 30.4% somatization phenomena and 10.8% suicide attempts. The frequency of somatization in psychiatric patients (30.4%) is similar to that described in non-psychiatric patients. The psychiatric inpatients that are referred to a medical department as inpatients show a significant lower rate of somatization (2.2%) and a higher rate of suicide (35.5%). CONCLUSIONS: On fourth of psychiatric patients consult a medical department in one year and more than 40% of these consultations are not due to somatic diseases. The frequency of somatization in psychiatric patients is similar to the observed in other patients. Psychiatric inpatients that are also medical inpatients in one year constitute a specific high risk group.

Adult↗
PubMed1997

Psychiatric referrals associated with substance use disorders: prevalence and gender differences. European Consultation-Liaison Workgroup.

A psychoactive substance use disorder (ICD-10) was diagnosed in 28% of 1222 psychiatric referrals in six general hospitals in Finland. In the age group 35 o 50 years, 53% of men and 29% of women had a substance use disorder. In the age group 35 to 50 years, sociodemographic characteristics differentiated men diagnosed with substance use disorders from other male consultation patients, but women with substance use disorders were similar to other female consultation patients. Urgency (i.e., consultation required within the same day) was accentuated in referrals associated with substance use disorders. Of attempted suicides, 65% were related to substance use disorders. Use of sedatives or hypnotics had more frequently induced disorders in women with substance use diagnosis compared to men with diagnosis (30% vs. 13%; p < 0.01). Female consultation patients with substance use disorders more often than respective male patients were current mental health outpatients. In conclusion, the proportion of substance use disorders among psychiatric consultation patients was remarkably higher in the present study (28%) compared with the average provided by the earlier literature (12%), and therefore, at least in Finland, psychiatric assessment of general hospital patients should always include assessment for the presence of substance use disorders. If substance use is only looked for in patients who have social problems typical of advanced misuse, detecting female substance use might be impeded. Relation of attempted suicides to substance use disorders was confirmed. To prevent misuse of prescribed drugs detected particularly in female consultation patients, and to prevent attempted suicides, doctors' attention is called to prescriptions of sedatives and hypnotics.

Adolescent↗
PubMed1997

Patient satisfaction with a consultation at a cranio-facial pain unit.

OBJECTIVE: Patient satisfaction is an important component of the evaluation of the quality of health care and has also been linked to therapeutic outcomes. The objective of this paper was to assess patient satisfaction with an initial consultation at a cranio-facial pain unit located in a large hospital in a major metropolitan centre. DESIGN: A case series design was used. The study population consisted of new patients referred to the unit. One month before their initial appointment patients were mailed an oro-facial pain questionnaire. Immediately following the consultation they were mailed a satisfaction questionnaire which contained a modified version of the Dental Visit Satisfaction Scale. RESULTS: Oro-facial pain data were collected from 121 patients and 78 of these returned a completed satisfaction questionnaire. While levels of satisfaction with the consultation were high overall, specific questions about consultation processes and outcomes revealed some sources of dissatisfaction. Just over half reported dissatisfaction with communications and one fifth were dissatisfied with outcomes in terms of diagnosis and treatment. Satisfaction with communication was the only dimension of the consultation process to be associated with satisfaction with outcomes, and satisfaction with outcomes was the main predictor of satisfaction overall. CONCLUSIONS: Although the relationships between patients and practitioners at the unit were favourable, improvements in communications may be necessary if the full benefits of the consultation are to be realised. This can be difficult with this patient population whose conditions are complex and often poorly understood.

Adolescent↗
PubMed1997

[Consultation system in Tenri Hospital from a physician's perspective].

Tenri hospital is a large hospital with 1,001 beds, and is famous in Japan for its unique resident system. Two doctors and more than 120 technicians work in the department of clinical pathology. In this paper, the status of the consultation system in the field of clinical pathology is described from the perspective of a physician. Most physicians do not find it inconvenient to consult about laboratory tests and they come to know whom and how to consult. However, some new doctors sometimes have difficulties with consulting. As for residents, they can rotate in clinical pathology if they wish. All residents who rotated in each of the 4 divisions of clinical pathology said that their training was very useful. They did not learn procedures in depth because the period was short. However, they came to understand the entire departmental system, became acquainted with medical technologists and laboratory physicians, and could easily consult concerning laboratory tests. Communication and mutual understanding is a very important factor in consultation.

Clinical Laboratory Information Systems↗
PubMed2001

Clinical value of postnatal autopsy and genetics consultation in fetal death.

The aim of the present study was to investigate the clinical use of postnatal autopsy and genetics consultation in cases of fetal death in a teaching hospital. A retrospective analysis of medical records including pathology and genetics reports was performed in all cases of fetal death in which a woman delivered at Ben Taub General Hospital, Houston, Texas over a 2-year period. Cases were excluded when gestational age of the fetus was less than 20 weeks. Fetuses were only included when the 1- and 5-min Apgar scores were 0 and 0, respectively. There were 139 fetal deaths and 12,209 live born infants during the study period (stillbirth rate 1.125%). Although pathology services were used in 96.2%, a genetics consultation was obtained in only 12% of cases. Fetal autopsy provided a certain cause of fetal death in 19.4%, a probable cause for death in 36.3%, and was inconclusive in 44.3%. Among the cases in which a genetics consultation was obtained, a certain and probable cause for fetal death was found in 20% and 20% of cases, respectively. The utilization of genetics consultation was found to be independent of multiple clinical variables examined including ultrasound data, identification of maceration, and training level of resident. Our data show a frequent use of pathologic examination in cases of fetal death and an infrequent use of genetics consultation services. The request for genetics consultation seemed to have been made at random.

Autopsy↗
PubMed2006

Consultation of parents in actual end-of-life decision-making in neonates and infants.

The objective of this study was to assess how frequently end-of-life decisions (ELDs) with a possible or certain life-shortening effect in neonates and infants were discussed with parents, and to determine if consultation of parents was associated with the type of ELD, (clinical) characteristics of the patient, and socio-demographic characteristics of the physician. A retrospective study of all deaths of live born infants under the age of one year was conducted in Flanders, Belgium. For 292 of all 298 deaths in a 1-year period (between 1 August 1999 and 31 July 2000) the attending physician could be identified and was sent an anonymous questionnaire. All cases with an ELD and containing information regarding the consultation of parents were included. The response rate was 87% (253/292). In 136 out of 143 cases, an ELD was made and information on the consultation of parents was obtained. According to the physician, the ELD was discussed with parents in 84% (114/136) of cases. The smaller the gestational age of the infant, the more the parental request for an ELD was explicit (p=0.025). When parents were not consulted, the ELD was based more frequently on the fact that the infant had no chance to survive and less on quality-of-life considerations (p=0.001); the estimated shortening of life due to the ELD was small in all cases, but significantly smaller (p<0.001) if parents were not consulted. It is concluded that the majority of parents of children dying under the age of one year are consulted in ELD-making, especially for decisions based on quality-of-life considerations (95.1%). Parents of infants with a small gestational age more often explicitly requested an ELD.

Belgium↗
PubMed1993

The anatomy of a consultation: a teaching method.

The Anatomy of a Consultation is a teaching method useful in introducing residents to Consultation-Liaison psychiatry. It is designed to stimulate them to think actively about the process of consultation in its broadest implications, including interaction with staff. The residents are encouraged to observe, make inferences, establish hypotheses about the evolution of the consultation, and to test these hypotheses by obtaining new information. The analogy of an unfolding detective story is used. A resident is asked to present the evolution of a consultation chronologically for ongoing group discussion. A vertical and a horizontal approach to the examination of the material are used. The vertical proceeds with clarification of the consultation as it evolves toward closure. The horizontal takes as its point of departure various topics that emerge to illustrate general principles and applications in different situations. These topics are approached more systematically and in greater detail in later teaching. Emphasis is placed upon coping and adaptation and the principles of active interventions useful for people in crisis. Patient data is organized within two broad categories: 1) the diagnostic, phenomenologic, and psychopathologic; and 2) the psychodynamic, conflictual, and life historical. An illustrative example is presented.

Adaptation, Psychological↗
PubMed1995

Content and predictors of consultation experiences among Finnish primary care patients.

The study focuses on how patients' explanations of their illnesses, their own diagnoses and their expectations are related to their experience of general practice consultations. Before seeing the General Practitioner (GP) on call, 127 Finnish acute health centre patients were interviewed about their interpretation of their symptoms, their explanations for the causes of their illnesses and their expectations of the forthcoming consultations. After seeing the GP they were asked to describe what happened in the consultations and to evaluate their experiences. In the qualitative analysis, the following consultation experiences were found: (1) being treated with holistic approach; (2) enjoyment of support and consolation; (3) receipt of important information; (4) subjection to routine and ritualistic conduct; (5) experience of insecurity and helplessness; and (6) experience of indifference and neglect. Loglinear models for predicting the success of medical consultations showed that 'negative medical consultation' is more likely to happen if: (a) the patient's illness explanation integrates both biomedical and psychosocial models; and (b) there is no match between the patient's own and the doctor's diagnosis.

Adult↗