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PubMed2006

Community consultation in emergency research.

CONTEXT: Recent federal regulations allow for emergency research without prospective consent provided that additional protections for the subjects are provided. One of these is community consultation. OBJECTIVE: To determine how to feasibly consult the community and what to do with the findings. DESIGN, SETTING, AND PARTICIPANTS: In connection with an ongoing study of l-arginine for brain injury at a public hospital's trauma center, we consulted three sets of community representatives using different methods. To sample the entire population of the county, we conducted a random-digit dialing survey (456 residents). To sample individuals served by the hospital, we interviewed a convenience sample of 566 patients and individuals in the waiting area. To sample particularly interested individuals, we conducted a series of public meetings (114 participants). In each case, the same instrument was used to ascertain their attitudes toward the study in general and toward its major features (randomization, waiver of consent, location, risks/benefits). To control for framing effects, items were randomly presented in a positive or negative fashion. RESULTS: All methods proved feasible, but telephone surveys were most efficient and guaranteed the desired demography. Even for a very low-risk study, only 79.75% of respondents would be willing to participate. The rate of approval for the major features was lower, with only 67.78% approving of the risk/benefit ratio, 53.7% approving of randomization, 57.66% approving of the consent waiver, and 44.45% approving of the location. The most significant factors affecting the rate of approval were the method of consultation and the framing of items (both p < .001), age, ethnicity, and previous research participation (all p < .01). CONCLUSIONS: Community consultation is feasible, but its results depend heavily on method of consultation, framing of questions, and choice of community. It may well demonstrate unexpectedly substantial opposition. There needs to be a better definition of the process and a better understanding of how to respond to its results.

Adolescent↗
PubMed2003

Psychological consultation before living kidney donation: finding out and handling problem cases.

BACKGROUND: Since 1996, a team of medical psychologists, nephrologists, and urologists at Heidelberg University Hospital has developed a family-oriented consultation procedure for donors, recipients, and family members before living kidney transplantation. Qualitative content analyses of these consultations and their follow-up histories are presented, with particular focus on "problem cases." METHODS: Sixty-seven consultation interviews were explored by rating family interaction, consultee-consultant interaction, decision-making process, and intervention strategies in problem cases. Subsequently, 33 catamnestic interviews 1 year or more after living donation were explored by qualitative content analysis for donor and recipient quality of life, quality of relationships, and health status. RESULTS: Generally, donors show themselves to be eager; recipients appear more reluctant. Expectations focus on spontaneity and a "normal life." Fears are usually expressed not about oneself but about the partner involved. Types of confrontation with possible complications are anxious avoidance, active consideration, and optimistic fatalism. Past family experiences of medical traumata may influence content and level of anxiety. Problem cases are characterized by unilaterally dependent close relationships, unrealistic expectations, anxious avoidance of problem confrontation, and negative experiences with the medical system. At follow-up, the majority are in good medical and psychological health. Few donors and recipients are suffering from disappointed expectations or unexpected treatment side effects. CONCLUSIONS: The Heidelberg consultation setting has proven useful for allowing open discussion about critical issues. In problem cases, prescribing a moratorium instead of rejecting donation helps to relax consultation anxiety. Psychological support after transplantation seems to be indicated for a minority with typical first-year problems.

Attitude to Health↗
PubMed2004

A National Survey of ICU consultant working practices at weekends.

A questionnaire was sent to all Intensive Care Society linkmen to investigate weekend working arrangements on Intensive Care Units (ICU) in the United Kingdom. In all, 87 responses revealed that the average consultant covering ICU at weekends works a 1 in 6 rota, is responsible for 10 beds, works 8-9 h a day and receives two calls at night. Of consultants, 54% cover anaesthesia as well as ICU, 55% work a 48 h or 72 h weekend and only one in five consultants currently have fixed sessional allocation for weekend working. 83% felt that they should not cover anaesthesia as well as ICU and there was no support for consultants to be resident at night. Applying the terms and conditions of the new consultant contract for England to this average consultant would result in 6.6 Programmed Activities for the weekend and 2 days of compensatory rest.

Health Care Surveys↗
PubMed1994

Simulated patients in assessing consultation skills of trainees in general practice vocational training: a validity study.

Although simulated patients are increasingly used in medical education, little research has been carried out on their validity. Validity in this case defines the relationship between performance with a simulated patient and performance with a real patient. One of the objectives of this study was to determine the validity of the use of simulated patients in assessing the consultation skills of trainees in vocational training at the Department of General Practice, University of Utrecht, The Netherlands. A check-list with a rating scale was used to assess the consultation skills of trainees at the department with simulated patients as well as in their training practices with real patients. The simulated and the selected practice cases were patients with complex multi-conditional problems like low back pain, headache and chest pain. The consultation skills were subdivided into four groups: the patient-centered approach, the non-somatic approach, communication skills and interpersonal skills. The measurement of skills, in particular of consultation skills, is very difficult. A description is given of the way the research group solved this problem. The analysis was performed by determining the sensitivity and predictive value of the assessment of a simulated encounter with a routine practice encounter. A difference existed in the assessed level of consultation skills in the simulated encounter compared to the level in the training practice. In simulation the level of consultation skills was higher than in day-to-day practice. This difference can reflect the difference between competence and performance. Competence is defined as what a doctor is capable of doing and performance as what a doctor actually does in day-to-day practice.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Competence↗
PubMed2004

Effect of medical students' ethnicity on their attitudes towards consultation skills and final year examination performance.

AIM: The study had two aims. The first aim was to examine the relationship between final year medical students' ethnicity and their attitudes towards consultation skills. The second aim was to investigate the relationship between ethnicity and final year performance. METHOD: A cross-sectional study was undertaken of all final year medical students in 1995 and 1996, both before and after their attachment through the Department of General Practice at Monash University, Australia. A questionnaire was designed to assess students' attitudes (views of importance and confidence) towards consultation skills. Also, records of final year performance were obtained from the University. RESULTS: Five clusters of consultation skills were formed through factor analysis: communication skills, difficult consultations, traditional diagnostic methods, routine management and life threatening conditions. There were no significant differences in students' attitudes towards these consultation skills based on country of birth, language, or student status preattachment. The only significant postattachment difference was that students born in non-Western countries placed a significantly higher importance on communication skills and the traditional diagnostic method than students born in Western countries. There were significant differences in final year performance between students across all three parameters of ethnic diversity. Non-Western born students performed worse than Western born students. Students who preferred using a language other than English also performed worse than those students preferring English. International students performed worse than students with Australian citizenship or permanent residency., CONCLUSIONS: The only significant difference regarding attitudes to consultation skills was that non-Western born students placed significantly greater importance on communication skills and the traditional diagnostic method postattachment than Western born students. No significant differences were found in attitudes preattachment. There were significant differences in performance, with students of ethnic background performing consistently poorer in all the final year assessment parameters analysed.

Adult↗
PubMed2005

Explanations in consultations: the combined effectiveness of doctors' and nurses' communication with patients.

BACKGROUND: Multidisciplinary and interprofessional working is currently a priority in health care policy, in caring for patients and in health professional education. Realising multidisciplinary approaches presents challenges in the context of changes in doctors' and nurses' roles and the increased emphasis placed on communication with patients. In communication in consultations, explanations are employed in the service of numerous activities, including decision making, diagnosis and physical examination, but they have been little studied. SETTING: This paper presents findings from a comparative study of doctors' and nurses' communication with patients in multidisciplinary health care, focusing on diabetes in primary care. METHODS: Video- and audio-recorded consultations were subjected to conversation analysis. Output from discussion groups with patient representatives and health professionals underwent qualitative analysis. FINDINGS: Distinctive features of explanations in nurses' and doctors' consultations with patients were identified. These can be understood by reference to patterns of communication. Nurses' communication was mediated by patients' contributions; doctors' communication gave an overarching direction to the consultation as a whole. While nurses' explanations began from the viewpoint of a patient's responsibility and behaviour, doctors' explanations began from the viewpoint of biomedical intervention. Their consultations lent different opportunities for patients' involvement. CONCLUSION: Nurses' and doctors' communications each exhibit their own distinct features. Specification of these features, when considered in the context of a particular consultation activity such as explanations, allows both recognition of the distinct contributions each profession can offer and identification of ways of combining these to maximum effect. This has implications for policy, for practice and for interprofessional education.

Blood Glucose↗
PubMed1984

Seasonal variation of asthma and allergic rhinitis. Consultation pattern in general practice related to pollen and spore counts and to five indicators of air pollution.

The seasonal variation of consultations on account of asthma and allergic rhinitis, and the relationship with air concentrations of pollen, spores, and lead, cadmium, dust, soot and sulfur dioxide was investigated in Danish general practice during a 1-year period 1977-78. A population of about 500,000 was studied. Among about 3000 asthmatics there were less consultations during spring than the rest of the year, but the seasonal variation of consultations with symptoms was rather small. The highest rate of consultations was in week 24, which is close to the peak of the grass pollen period. No relationship was found between asthma symptoms and concentrations of pollution indicators. Among about 5000 patients with allergic rhinitis the rate of consultations with symptoms increased at the start of the tree pollen season, still more at the start of the birch pollen season, and was very high during weeks 21-26 in the grass pollen season. Two thirds of all consultations for symptomatic allergic rhinitis took place within 10 weeks (Nos. 18-27). During the grass pollen season there was a relative preponderance of young patients, while during the birch pollen season older patients dominated. No connection was seen between rhinitis symptoms and pollution indicators. The different seasonal variation of asthma and allergic rhinitis indicates that the two patient categories differ as regards symptom-provoking factors. Allergic rhinitis is mainly precipitated by grass and birch pollen. The precipitating factors of asthma were not disclosed in this study, with the exception perhaps of some influence from pollen, and - among 0-4-year-old children - respiratory infections.

Asthma↗
PubMedDate not supplied

Consultative intervention to improve outcomes of high utilizers in a public mental health system.

PURPOSE: To examine the effectiveness of an academic consultation on outcomes among consumers in a public mental health system and to compare outcomes between high-cost/high-utilizer and midcost consumers. METHODS: Participants (N = 36) completed all questionnaires during three semistructured interviews. Using a repeated-measures experimental design, the outcomes of global functioning, quality of life, service use and need, costs, and consumer satisfaction were examined. FINDINGS: The hypothesis that consultation would change medication practices and reduce costs was supported. CONCLUSIONS: Consultation with a senior clinician helped change medication practices and reduced costs. Consultation may lead to recognition of a new diagnosis (medical, neurologic, or psychiatric) or suggestions for modifying a treatment regimen that could improve functioning and QOL. In a busy public mental health system, there is often little time for consultation and little thought to second opinions. For clients who cost the system the greatest amount, the small additional cost of a consultation is a good potential investment.

Adult↗
PubMed2004

Clinical comorbidity in patients with osteoarthritis: a case-control study of general practice consulters in England and Wales.

OBJECTIVES: To determine patterns of clinical comorbidity in general practice consulters with OA and compare them with comorbidity in consulters without OA. METHODS: A case-control study nested in a one-year prevalence survey of consultations in 60 general practices in England and Wales. Cases were 11 375 subjects aged 50 and over who had consulted with OA during the study year. Controls were 11 780 subjects matched for age and sex who had consulted during the study year, but not for OA. Morbidity outcomes were based on a standard clinical classification system. RESULTS: After adjusting for age, sex, and social class, cases were significantly more likely to have high levels of comorbidity than controls (2.35; 2.16 to 2.55). Significant OA comorbid associations with other musculoskeletal conditions included arthropathies (OR 2.26; 99% CI 1.50 to 3.41), upper limb sprain (2.04; 1.38 to 3.00), synovial and tendon disorders (2.03; 1.54 to 2.68), and other joint disorders (2.00; 1.71 to 2.32). OA non-musculoskeletal associations were with obesity (2.25; 1.73 to 2.92), gastritis (1.98; 1.46 to 2.68), phlebitis (1.80; 1.28 to 2.52), diaphragmatic hernia (1.80; 1.29 to 2.51), ischaemic heart disease (1.73; 1.13 to 2.66) and intestinal diverticula (1.63; 1.20 to 2.23). CONCLUSIONS: Comorbidity for OA was extensive, with musculoskeletal as well as non-musculoskeletal conditions. Age, sex, and social class did not explain this comorbidity but propensity to consult may be a part explanation. An important question remains as to whether comorbidity in general practice significantly adds to the disability or further impairs the health of patients with OA.

Aged↗
PubMed1985

Reactions of patients to video recording of consultations in general practice.

The potential value of video recording for examining medical consultations depends on the extent to which recordings are representative of unfilmed consultations. This paper examines the views of 295 patients in two general practices whose consultations were filmed and compares them with the views of a control group of 185 patients. Most of those who were filmed reported that the consultation was not directly affected, and no overall effect of filming was discovered when patients rated their stress after the consultations, their rapport with the doctor, or other aspects of the consultation. At one practice, however, filming was significantly associated with lower ratings of rapport between doctor and patient among those patients who reported some direct effect of filming. Patient refusal rates from other studies are also examined and shown to vary systematically--the more opportunity patients are given to decline the more likely they are to take it. Consideration of doctors' responses to being filmed would usefully complement the emphasis on the views of patients.

Adult↗
PubMed1992

Health promotion in the general practice consultation: a minute makes a difference.

OBJECTIVE: To see whether extending appointment length from seven and a half minutes or less to 10 minutes per patient would increase health promotion in general practice consultations. DESIGN: Controlled trial of 10 minute appointments. Consultations were compared with control surgeries in which the same doctors booked patients at their normal rate (median six minutes per patient). SETTING: 10 general practices in Nottinghamshire. SUBJECTS: 16 general practitioners were recruited. Entry criteria were a booking rate of eight or more patients an hour, a wish for longer consultations, and plans to increase appointment length. MAIN OUTCOME MEASURES: Duration of consultations; recording of blood pressure, weight, and cervical cytology in the medical record; recording of advice about smoking, alcohol, diet, exercise, and immunisation in the medical record; reporting of the above activities by patients. RESULTS: Mean consultation times were 8.25 minutes in the experimental sessions and 7.04 and 7.16 minutes in the control sessions. Recording of blood pressure, smoking, alcohol consumption, and advice about immunisation was significantly more frequent in the experimental sessions, and the proportion of consultations in which one or more items of health education were recorded in the medical notes increased by an average of over 6% in these sessions. Patients more often reported discussion of smoking and alcohol consumption and coverage of previous health problems in the experimental sessions. There was little change in discussion of exercise, diet, and weight or cervical cytology activity. CONCLUSIONS: Shortage of time is a major factor in general practitioners' failure to realise their potential in health promotion. General practice should be organised so that doctors can run 10 minute appointment sessions.

Adult↗
PubMed1993

Education and training of preregistration house officers: the consultants' viewpoint.

OBJECTIVE: To determine the opinions, attitudes, and requirements of consultants responsible for preregistration house officers in the light of the General Medical Council's Recommendations on General Clinical Training. DESIGN: A questionnaire was piloted asking 28 questions under the headings professional details, present training arrangements, effectiveness of current training, and perceived help required for implementing the recommendations. SETTING: Two teaching hospitals and nine district general hospitals in the Yorkshire region. SUBJECTS: 33 consultants (19 physicians, 14 surgeons) responded to an hour long interview. RESULTS: The traditional teaching ward round, with clinical meetings, was the main educational provision for house officers. Under a quarter of respondents provided specific teaching, which rarely exceeded 30 minutes weekly. Many delegated teaching to other junior or non-medical staff. Few consultants assessed the effectiveness of teaching, and feedback to juniors was rudimentary. There was strong support for the apprenticeship system and concern that it should not be downgraded. Appointing educational supervisors and introducing a structured educational programme were approved theoretically. Pressure on consultants to work faster, participate in audit and management, and accept financial responsibility for their clinical work, coupled with the reduction in junior doctors' hours, were considered to militate against educational developments. Many respondents felt frustrated and powerless. They would welcome an increased educational role but considered there must be conceptual, contractual, and financial changes. CONCLUSIONS: Fundamental changes are required by both consultants and management before the preregistration year can have proper educational value. Training in educational methods for consultants and a structured curriculum and formative assessment for trainees require recognition and financial support.

Attitude of Health Personnel↗
PubMed2000

Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care.

OBJECTIVE: To ascertain any differences between care from nurse practitioners and that from general practitioners for patients seeking "same day" consultations in primary care. DESIGN: Randomised controlled trial with patients allocated by one of two randomisation schemes (by day or within day). SETTING: 10 general practices in south Wales and south west England. SUBJECTS: 1368 patients requesting same day consultations. MAIN OUTCOME MEASURES: Patient satisfaction, resolution of symptoms and concerns, care provided (prescriptions, investigations, referrals, recall, and length of consultation), information provided to patients, and patients' intentions for seeking care in the future. RESULTS: Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices. For children, the mean difference between general and nurse practitioner in percentage satisfaction score was -4.8 (95% confidence interval -6.8 to -2.8), and for adults the differences ranged from -8.8 (-13.6 to -3.9) to 3.8 (-3.3 to 10.8) across the practices. Resolution of symptoms and concerns did not differ between the two groups (odds ratio 1.2 (95% confidence interval 0.8 to 1.8) for symptoms and 1.03 (0.8 to 1.4) for concerns). The number of prescriptions issued, investigations ordered, referrals to secondary care, and reattendances were similar between the two groups. However, patients managed by nurse practitioners reported receiving significantly more information about their illnesses and, in all but one practice, their consultations were significantly longer. CONCLUSION: This study supports the wider acceptance of the role of nurse practitioners in providing care to patients requesting same day consultations.

Acute Disease↗
PubMedDate not supplied

Consultation patterns and provision of contraception in general practice before teenage pregnancy: case-control study.

OBJECTIVES: To determine patterns of consultation in general practice and provision of contraception before teenage pregnancy. DESIGN: Case-control study, with retrospective analysis of case notes. SETTING: 14 general practices in Trent region. SUBJECTS: 240 registered patients (cases) with a recorded conception before the age of 20. Three controls per case were matched by age and practice. MAIN OUTCOME MEASURES: Consultations in general practice and provision of contraception in the 12 months before conception and recorded provision of contraception at any time before conception. RESULTS: Overall, 223 cases (93%) had consulted a health professional at least once in the year before conception, 171 (71%) had discussed contraception in this time, and 121 (50%) had been prescribed oral contraception. Cases were more likely to have consulted in the year before conception than controls (odds ratio 2. 70, 95% confidence interval 1.56 to 4.66). Most of the difference was owing to consultation for contraception. Overall, 53 cases (22%) resulted in a termination of pregnancy. Cases whose pregnancy ended in a termination were more likely to have received emergency contraception than either their controls (3.21, 1.32 to 7.79) or cases resulting in other outcomes (3.01, 1.06 to 8.51). CONCLUSIONS: Most teenagers who became pregnant attended general practice in the year before pregnancy, and many had sought contraceptive advice. The reluctance of teenagers to attend general practice for contraception may be less than previously supposed. The association between provision of emergency contraception and pregnancy ending in termination emphasises the need for continuing follow up of teenagers consulting for this form of contraception.

Adolescent↗
PubMed2002

Engagement of patients with psychosis in the consultation: conversation analytic study.

OBJECTIVE: To investigate how doctors engage with patients with psychotic illness in routine consultations. DESIGN: Conversation analysis of 32 consultations between psychiatrists and patients with schizophrenia or schizoaffective disorder. SETTING: Two psychiatric outpatient clinics in east London and south west London. PARTICIPANTS: 7 psychiatrists and 32 patients with schizophrenia or schizoaffective disorder. MAIN OUTCOME MEASURE: Mutual engagement in communication during the consultation. RESULTS: Patients actively attempted to talk about the content of their psychotic symptoms in consultations by asking direct questions, repeating their questions and utterances, and producing these utterances in the concluding part of the consultation. In response, doctors hesitated, responded with a question rather than with an answer, and smiled or laughed (when informal carers were present), indicating that they were reluctant to engage with patients' concerns about their psychotic symptoms. CONCLUSIONS: Patients repeatedly attempted to talk about the content of their psychotic symptoms, which was a source of noticeable interactional tension and difficulty. Addressing patients' concerns about their illness may lead to a more satisfactory outcome of the consultation and improve engagement of such patients in the health services.

Adult↗
PubMedDate not supplied

Curriculum-based measurement and two models of follow-up consultation.

This investigation focused on the effects of two independent variables: (a) teacher-developed goals and monitoring systems versus a curriculum-based measurement (CBM) goal and monitoring system; and (b) individual expert versus group follow-up consultation. The dependent data were academic achievement measures. Subjects were 55 special education, elementary school students with mild and moderate disabilities randomly assigned to one of four treatment conditions: A, teacher-developed goal and progress monitoring with individual expert follow-up consultation; B, CBM goal and progress monitoring with individual expert follow-up consultation; C, teacher-developed goal and progress monitoring with group follow-up consultation; and D, CBM goal and progress monitoring with group follow-up consultation. Results showed that groups employing CBM and group consultation generally out-performed the other groups. Implications included expanded use of CBM goals and progress monitoring and continued study of collaboration as a method of CBM program implementation.

Child↗
PubMed1991

Psychiatric consultation with children in underserviced areas: lessons from experiences in northern Ontario.

There are only 350 child psychiatrists in Canada. It is therefore unrealistic to expect them to be able to provide sufficient direct treatment, even in small densely populated communities with abundant resources. Such expectations are even more unrealistic in underserviced, sparsely populated areas. A review of the literature on psychiatric consultation in underserviced areas is presented along with a description of the consultation process, taking advantage of the "multiplier effect." Some of the realities of mental health consultation in underserviced areas are discussed, stressing the importance of consultation as a way of professional life. Some guidelines for the psychiatric consultant are outlined which would enhance the "multiplier effect". It is maintained that the training of psychiatric residents should include a supervised experience consulting in underserviced areas. Finally, it is hoped that psychiatric training programs, funding bodies, hospitals, and agencies, will recognize the value of this use of psychiatric expertise.

Child↗
PubMed1992

Critical analysis of the content and enforcement of mandatory consultation and patient profile laws.

OBJECTIVE: This study evaluates the experience of 12 states that mandate that pharmacists provide consult services to patients and maintain drug profiles. DATA SOURCES: An analysis of each state's statutes and regulations was complemented by telephone interviews of state licensing board staff. RESULTS: Nine states specify the information to be provided during consultations, but only one (Florida) requires a comprehensive list of drug information, including adverse drug reactions, drug-drug interactions, directions for use, and necessary warnings. Eleven of the 12 states also require pharmacists to maintain patient drug profiles, but only 6 states specify the type of information to be included in profiles. State efforts to inform consumers about the pharmacist consultation requirement are limited, with only 7 states undertaking minimal promotional programs. The fact that no states reported any consumer consultation complaints or disciplinary actions against pharmacists for failure to consult illustrates the limited nature of mandatory consultation statues and regulations. CONCLUSIONS: The wide variety of requirements demonstrates that these laws do not represent a uniform standard of practice. The lack of documented evidence regarding implementation invites questions regarding their usefulness and reinforces the need for enhanced monitoring activities.

Counseling↗