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The assessment of patients' waiting and nursing consultation times at urban clinics in the National Capital District, Papua New Guinea.

This study was conducted in the National Capital District during the months of August, September and October 2000. The study sites were the 3 urban clinics situated in the suburbs of Six Mile, Hohola and Konedobu. The aim of the study was to determine the patients' waiting times and nursing consultation times in the urban clinics. A total of 1075 patients were surveyed, including 264 children under 5 years of age. 58% of patients were males. 24% of patients were able to see a nurse within 30 minutes and 70% within 2 hours. 47% had to wait 1-3 hours to see a consulting nurse and a further 9.5% had to wait 3-5 hours. 67% of nursing consultations were 5 minutes or less, which is too short to interview, examine and prescribe treatment for the patients and to use the Paediatric 10 Steps. The short consultations of 5 minutes or less did not involve children under 5 years of age. There were only one to two nurses seeing the patients when 79% of patients were seen. This explains why the patients' waiting time was long. After consultations many patients (71%) were able to get their treatment within 30 minutes but 28% had to wait from 30 minutes to 2 hours for their treatment. The small number of nurses giving treatment leads to long waiting times. From the time of entry to exit out of the clinic, only 11% of patients spent 30 minutes or less in the clinic while 51% spent between 1 and 3 hours. The patients' waiting times and the short nursing consultation times are directly related to the insufficient number of nursing officers working in the clinics.

Adolescent↗
PubMed2006

CQI-2--a new measure of holistic interpersonal care in primary care consultations.

BACKGROUND: The Consultation Quality Index (CQI) is a holistic quality marker for GPs based on patient enablement, continuity of the care and consultation length. AIM: To evaluate the CQI-2, a new version of the CQI incorporating a process measure of GP empathy (the Consultation and Relational Empathy Measure). DESIGN OF STUDY: Cross-sectional questionnaire study. SETTING: General practice in the west of Scotland. METHOD: Empathy, enablement, continuity, and consultation length were measured in 3044 consultations involving 26 GPs in 26 different practices in the west of Scotland. CQI-2 scores were calculated and correlated with additional data on GPs' and patients' attitudes. Comparisons were also made with the UK-wide data from which the original CQI had been calculated. RESULTS: CQI-2 scores were independent of deprivation, access, demographics, and case-mix. GPs with lower CQI-2 scores valued empathy and longer consultations less than these GPs with higher CQI-2 scores. 'Below average CQI-2' GPs (those in the bottom 25%) also felt less valued by patients and colleagues. Patients' showed less confidence in and gained less satisfaction from these doctors. Data ranges from the study were comparable with the UK data ranges used to construct the original CQI. CONCLUSIONS: The CQI-2 is a new measure of holistic interpersonal care. In a small but representative sample of GPs it appears to differentiate between below and above average doctors. CQI-2 scores may reflect important aspects of morale, core values and patient-centred care. There may be potential for its use as part of professional development and as a component of the general medical services contract.

Attitude of Health Personnel↗
PubMed2006

The effect of interventions to alter the consultation length of family physicians: a systematic review.

BACKGROUND: Observational studies have shown differences in process and outcome between the consultations of primary care physicians whose average length of consultation differs, however, these differences may be due to self selection. AIM: To assess the effectiveness and cost effectiveness of interventions to alter primary care physicians' consultation length. DESIGN OF STUDY: Systematic review with narrative analysis. METHOD: Data sources included Medline, EMBASE, the Cochrane Controlled Trials Register and Effective Practice and Organisation of Care Group specialised register, the NHS National Research Register and author contacts. To be eligible, studies had to be controlled trials. They had to evaluate interventions to alter the consultation length of primary care physicians, and provide objectively measured process or outcome data. Data were extracted independently using agreed criteria and disagreements resolved by discussion. RESULTS: Six articles describing four trials were included. All took place in the UK and tested short term changes in the time allocated to each patient, and all had methodological weaknesses, particularly due to non random allocation of patients. Altering appointment length resulted in modest changes in average consultation length. There were no consistent differences in problem recognition, examination, prescribing, referral or investigation rates. There was some evidence that blood pressure was checked more frequently and smoking discussed more often when more time was available. None of the interventions were associated with differences in patient satisfaction. No trials examined cost effectiveness. CONCLUSIONS: Our findings do not provide sufficient evidence to support or resist a policy of altering consultation lengths of primary care physicians. Further trials are needed, focussing on health outcomes and cost effectiveness.

Appointments and Schedules↗
PubMed1991

A model for faculty development and continuing education in medical ethics: medicine and humanities consultations.

Despite the significant increase in teaching medical ethics to medical students and residents, little has been done to train teaching faculty and community practicing physicians in medical-ethical decision making. The Medicine and Humanities Consultation Series described here has been a successful model for faculty development in helping practicing physicians with such decision making. The consultations among clinical physicians and humanities scholars were held about every 3 months at an off-campus site to remove the participants from professional intrusions. The 8-hour consultations, conducted informally, addressed social and ethical topics concerning medical practice. Several preselected short articles were distributed to the participants 2 weeks prior to the consultations. Each consultation was led by a visiting guest leader who was sometimes a physician but usually a humanities scholar. This model has been implemented successfully in both Virginia and Texas under very different circumstances. Physicians reported being more comfortable with their ethical decision making--not in terms of what to decide but in terms of how to decide. The consultations enriched the participants' funds of knowledge and their methods of thinking.

Curriculum↗
PubMed1991

The effect of the 1989 health benefits package on prescribing and consultation patterns in general practice.

OBJECTS: this study aims to assess the effect of the 1989 health benefits package on the prescribing and consultation rates of the contributing general practitioners. METHODS: following the introduction of the health benefits package in February 1989 information on the consultation rates and prescribing records of twenty-eight computerised general practitioners was obtained for the two three month periods of February, March and April 1988 and 1989. Analysis was undertaken both on the pooled data and by comparing consultations for adults, beneficiaries aged 60 or older, beneficiaries less than 60 years and children. RESULTS: the number of consultations increased from 57,209 in 1988 to 63,736 in 1989. The number of items prescribed decreased from 66,984 in 1988 to 62,284 in 1989 indicating a mean decrease in the number of prescription items per consultation from 1.02 in 1988 to 0.83 in 1989. Based on the 1988 figures provided by the study the actual percentage decrease in pharmaceutical use by the contributing doctors during the study time frame was 9.3% whereas the expected increase was 11.4%. CONCLUSIONS: there was an increase in consultation rates and a decrease in prescribing among the contributing general practitioners during the 1989 study period compared with the 1988 study period. These changes may be attributed to the introduction of the 1989 health benefits package.

Adult↗
PubMed1990

Human companion-animal relationships in the veterinary consulting room.

A questionnaire, based on 14 years' private practice experience and psychological principles, was compiled to establish the reasons why veterinary clients are involved with their pets. Questionnaires were sent to South African veterinarians country-wide and only clients visiting veterinarians were requested to complete the questionnaires anonymously. Questionnaires (n = 612) were returned and the data was processed by computer. The results indicated that clients are involved with their companion animals for emotional, social and relaxational reasons, which all have psychological implications. They are, however, also involved with their animals by caring for them, and they keep them for utility or economical reasons and also due to their general interest in nature. The latter reasons could be seen as natural reasons for keeping pets. The same relationship between clients and their pets continue during veterinary consultations. Because of this continuing involvement, some clients may consult veterinarians mainly for psychological reasons and others mainly for clinical reasons. There is a constant interaction between these motivations for veterinary consultations. Client consultations of veterinarians could thus be categorised into psychological consultations which are predominantly human/client orientated and clinical consultations which are predominantly animal/patient orientated.

Animals↗
PubMed1990

The GP's dilemmas: a study of knowledge need and use during health care consultations.

For use in system development, a method based on both qualitative and quantitative data was employed to study the difficulties--the dilemmas--a general practitioner (GP) faces during daily consultations. Video recordings were used for stimulated recall of the consultation. From 46 consultations, 262 dilemmas were identified by the 12 GPs involved. Medical dilemmas were encountered during three out of four consultations. Dilemmas in the communication with the patient occurred during two consultations out of three, while dilemmas in the organizational environment and dilemmas challenging the GP's personal competence occurred during one consultation out of three, respectively. A phenomenological analysis of the comments showed that few dilemmas were described as problems during "hypothetico-deductive reasoning". In many cases the GP found it difficult to understand the situation as a whole. Based on these qualitative data, a model of the GP's management of ill-structured complex dilemmas is discussed and proposed, to be taken into account in the development of decision support systems for outpatient practice.

Adult↗
PubMed1995

[Family physician consultation by patients with rheumatoid arthritis or gonarthrosis/coxarthrosis].

OBJECTIVE: To determine how often patients with rheumatic joint disease consult their general practitioner (GP), and if there are disease and patient characteristics that influence GP consultation of gonarthrosis/coxarthrosis patients. DESIGN: Prospective record investigation. SETTING: Seven GP centres in the southeast of the Netherlands. METHOD: All patient contacts were registered prospectively in the seven GP centres: 46 concerned patients with rheumatoid arthritis (RA), 122 patients with gonarthrosis/ coxarthrosis. Patient and disease characteristics were collected on intake sheets. RESULTS: Three-quarters of the RA patients were periodically seen (mostly by a specialist), and 47% of the gonarthrosis/coxarthrosis patients (as often by their GP as by a specialist). Of the RA patients and of the gonarthrosis/coxarthrosis patients 74% and 89% respectively consulted their GPs in one year (the average numbers of contacts were 4.7 and 5.0); 50% and 57% did so because of the chronic joint disease (with 2.2 and 1.6 contacts respectively). No disease characteristics and only a few patient characteristics (arthroplasty, chronic use of medication) of patients with gonarthrosis/coxarthrosis influenced GP consultation. CONCLUSION: Patients with rheumatic joint disease often consult their GP, but not always because of this illness. If they consult their GP, they usually do so more than once a year.

Activities of Daily Living↗
PubMed1993

[Prostatism syndrome in external consultation in urology. Incidence at a regional hospital].

Dysuria coexisting with frequency and urgency in a 60-year-old male is readily ascribed to the prostate, and the morbid state which results from urethral obstruction is diagnosed as prostatism. This common syndrome, however, is not always due to prostatic disease. The present study analyzed the underlying cause of the cases of prostatic syndrome that had been seen in the Urology services of a hospital during 1991. A total of 3854 patients had consulted. Of these, 1214 had consulted for the first time and the remaining 2640 had consulted for the second time. Prostatic syndrome was the reason for consultation in 260 (21%) of those who had consulted for the first time, accounting for 10% of the second consultations and 7% overall. We looked at patient age, the area of health they pertained to, whether they had been referred by the GP or the doctor attending the emergency services, and if rectal examination had been performed. Previous work-up, previous treatment, treatment requested by the referring doctor micturition pattern, diagnostic methods, differential diagnosis and the recommended treatment were also analyzed. We can conclude that the incidence of this pathology is high and has a tendency to increase; the approach in primary care needs to be improved; little importance is given to rectal examination and drug therapy affords excellent control of the syndrome.

Adult↗
PubMed1994

Case mix and content of trainee consultations: findings from the north of England study of standards and performance in general practice.

BACKGROUND: Previous studies have examined the differences in the work of trainees and trainers. However, they have not investigated how many of these differences are due to differences in the case mix seen by trainees. AIM: A study was undertaken to investigate the effect of case mix on the content of consultations with trainee general practitioners. METHOD: Details of surgery consultations with 207 trainee general practitioners and 255 principals in 62 training practices in the north of England were prospectively recorded during one week in each of four consecutive years. RESULTS: Trainee general practitioners saw a higher proportion of younger patients and those categorized as suffering from an acute minor condition compared with principals. They saw a lower proportion of patients categorized as suffering from chronic intermediate, chronic major and female conditions. The reported content of trainee and principal consultations differed over all four years in that trainees examined more patients, issued more new prescriptions, issued fewer repeat prescriptions, arranged fewer return appointments and referred fewer patients. However, adjusting for case mix reduced the number of significant differences between trainees and principals to two: trainees issued fewer repeat prescriptions and had more consultations lasting longer than nine minutes. CONCLUSION: The case mix and content of consultations differ between trainees and principals and some of the differences in content are due to the differences in case mix; trainees generally behave more like principals than has been previously suggested. Thus, case mix is an important factor in understanding the content of trainee consultations.

Diagnosis-Related Groups↗
PubMed1994

Consultation rates and incidence of intercurrent morbidity among patients with chronic disease in general practice.

BACKGROUND: Information on frequency of consultation and presented morbidity among patients with chronic disease is relevant to the management of these patients in view of the increasing prevalence of chronic diseases. AIM: This study set out to examine consultation rates and incidence of intercurrent morbidity in general practice in cohorts of patients with five common chronic diseases: hypertension, chronic ischaemic heart disease, diabetes mellitus, chronic respiratory disease and osteoarthritis. METHOD: In seven practices with 15 general practitioners the records of all patients were screened for inclusion in the study. The data used for analysis were from 962 patients, whose diagnoses were made in agreement with diagnostic criteria, who were not under specialist care, and who were followed up for 21 months. A distinction was made between patients with one, or two or more of the five chronic diseases studied. For the single disease subgroups of patients with hypertension or diabetes two reference groups of people without a chronic disease, standardized for age and sex, were identified from the population in the same practices. RESULTS: Consultation rates were higher for patients with comorbidity than for patients with a single disease. Intercurrent diseases were presented more frequently to the general practitioner by patients with comorbidity than by patients with a single disease. Most intercurrent morbidity consisted of acute common diseases such as myalgia, upper respiratory tract infection and urinary tract infection. Patients with only hypertension or only diabetes had higher consultation rates than the corresponding reference group but did not have higher total incidence rates of intercurrent morbidity. CONCLUSION: Patients with chronic disease consult their general practitioner frequently, and patients with more than one chronic disease consult even more frequently. The general practitioner has to deal with chronic disease and intercurrent acute disease in a single patient.

Adult↗
PubMed1996

What do patients think about during their consultations? A qualitative study.

BACKGROUND: The consultation has been widely examined, but chiefly from the doctor's standpoint. Comparatively little is known about how patients view the event even though shared understanding is an accepted goal of each consultation. AIM: The aim of the study was to describe the range and types of thoughts which patients have during their consultations. METHOD: In semistructured interviews, prompted by video playback and transcript, 18 patients gave detailed accounts of their thoughts and feelings during a recent consultation. RESULTS: The study confirmed patients' central desire for understanding but also revealed a complex mix of other thoughts. Multiple problems and aims were usual. Patients routinely considered their relationship with the doctor, the doctor's willingness, ability and available time, and altered their behaviour accordingly. CONCLUSION: Patients and doctors have different models of the consultation-better understanding of how patients consult should lead to better training for doctors and improve shared understanding.

Adolescent↗
PubMed1998

Observations of sexually transmitted disease consultations in India.

OBJECTIVES: To assess the quality of sexually transmitted disease (STD) case management provided in public and private health facilities in selected areas of Madras, Tamil Nadu, India, in order to make recommendations for improving the quality of care and promote the syndromic approach to STD treatment. METHODS: Structured observations of consultations for STDs in health care facilities. Scoring of the observations according to standards for history taking, examination, treatment and provision of basic health promotion advice allows evaluation of STD case management. RESULTS: With STD treatment adequacy scored against Indian national guidelines (which recommend aetiologic treatment), history taking, examination and treatment were satisfactory in 76 out of 108 (70%) of observed consultations. However, if STD treatment adequacy is scored with respect to the syndrome approach towards selected STD (male urethritis and non herpetic genital ulcer for both sexes), only 8 out of 81 (10%) of the patients were satisfactory managed. During 32 out of 108 (30%) of the consultations, advice on the use of condoms in order to prevent STD or HIV/AIDS was given. Instructions regarding how to use condoms were offered to seven (6%) patients and condoms were only provided to one patient (1%). Patients were urged to refer their partner(s) for treatment during 29 (27%) of consultations. A criterion of adequate use of the STD consultation for health promotion, requiring both promotion of condoms and encouragement to refer partner(s) for treatment, was met during 13 (12%) of consultations. CONCLUSIONS: Monitoring and improving the standards of care at facilities at which STDs are treated have become key roles of STD/HIV/AIDS programmes. The present report suggests that in Madras the activities of medical practitioners who treat STD patients are far from ideal at present. Improvements would involve simplifying existing treatment guidelines by promoting the syndromic approach to STD management, continuing education programmes for health care providers in the public and private sectors and repeat assessments and feedback of the quality of STD care.

Case Management↗
PubMed1998

Comparison of video-recorded consultations with those in which patients' consent is withheld.

BACKGROUND: Video-recorded consultations are widely used for research in general practice. Recently, video recordings have begun to be used for the purposes of general practitioner (GP) registrar assessment. It is unknown, however, whether consultations in which patients withhold consent for recording differ from those that are recorded. AIM: To compare clinical problems and demographic characteristics of adult patients who consent to the video recording of consultations with those who withhold consent. METHOD: This was prospective study of 538 adult patients consulting 42 GPs, based in practices throughout Leicestershire. Each patient attended a surgery session with one of the 42 GPs between April 1995 and March 1996. Clinical presentations and demographic characteristics of patients consenting and withholding consent to the video recording of their consultations were compared. GPs' perceptions of whether patients in these two groups were distressed/upset or embarrassed were also compared. RESULTS: A total of 85.9% (462/538) of adults consented to video recording, and 14.1% (76/538) withheld consent. Multiple logistic regression revealed that patients who presented with a mental health problem were more likely to withhold consent to recording (odds ratio 2.5, 95% confidence interval 1.4-4.6). Younger patients were also more likely to withhold consent to video recording. Additionally, where patients' consent was withheld, GPs perceived patients to be more distressed or embarrassed. CONCLUSION: Younger patients and those suffering from mental health problems are more likely than others to withhold consent to being video recorded for research purposes in general practice. The implications of this study for the assessment of registrar GPs using video-recorded consultations are discussed.

Adolescent↗
PubMed2003

Randomized clinical trial comparing consultant-led or open access investigation for large bowel symptoms.

BACKGROUND: Referral of patients with large bowel symptoms is common and increasing. Currently most of these referrals are assessed at an outpatient clinic to determine the need and priority for investigation. METHODS: Over 21 months, 1131 patients referred by the general practitioner with large bowel symptoms were randomized. Patients in the consultant-led group were assessed by surgeons with a colorectal interest while those in the open access group underwent colonoscopy if they were 55 years or older and flexible sigmoidoscopy if younger. RESULTS: The most common symptom among referred patients was rectal bleeding (69.1 per cent) followed by change in bowel habit (48.8 per cent) and abdominal pain (32.3 per cent). There was a significant trend (P < 0.001) for patients in the consultant-led to have more investigations, and more patients in this group had no investigations (P < 0.001). Despite this, the percentage of patients with colonic or other pathology diagnosed was the same in both groups, 63.6 per cent in the consultant-led group compared with 61.8 per cent in the open access group (P = 0.558). Likewise the percentage of patients with cancer or other significant pathology was similar in both groups (13.9 versus 15.4 per cent; P = 0.532). The mean(s.d.) time to diagnose cancer or other significant pathology was 55.1(39.2) days in the consultant-led group compared with 57.4(33.6) days in the open access group (P = 0.514). The cost per patient was almost pound 105 more for patients in the consultant-led group. CONCLUSION: Patients referred by the general practitioner with large bowel symptoms should go directly to a properly managed and staffed open access large bowel investigation unit. This would enable most patients to have their investigations completed at one hospital attendance.

Ambulatory Care↗
PubMed1992

Why physicians should not do ethics consults.

Increasing complexities facing physicians negotiating the bedside decision continue to fuel the debate over who is the appropriate party to offer ethics consults, should one be needed, during the decision-making process. Some very good arguments have been put forth on behalf of clinical ethicists as being the proper and best party to engage in ethics consultations. However, serious questions remain about the role of the clinical ethicist and his ability to provide the necessary level of objectivity called for in an ethics consult. I argue that the clinician's professional psyche, or mode of thinking as a professional, leaves him little room to maneuver as an objective and detached third party ethics consultant. Several factors are cited and discussed that greatly influence the analyses applied to a case problem by physicians. The most formidable of these factors are habits and the practice of defensive medicine. I conclude that clinical ethicists are less suited for the overall tasks required of an objective consultant in medical cases that appear to involve insurmountable ethical issues.

Decision Making↗
PubMed1991

Why philosophers should offer ethics consultations.

Considerable debate has occurred about the proper role of philosophers when offering ethics consultations. Some argue that only physicians or clinical experienced personnel should offer ethics consultations in the clinical setting. Others argue still further that philosophers are ill-equipped to offer such advice, since to do so rests on no social warrant, and violates the abstract and neutral nature of the discipline itself. I argue that philosophers not only can offer such consultations but ought to. To be a bystander when one's discipline does offer insights and methods of value discernment is pusillanimous. But this position requires a view of clinical medical ethics as one that arises out of the clinical practice of medicine, and not just from an application of general ethical principles to the practice of medicine. I conclude with some skills that trained philosophers can bring to the consultation service, and note that all consultations are in the form of recommendations that the patient, family, and physician are still free to accept or reject. Philosophers in the clinical setting do not make decisions.

Casuistry↗
PubMed1988

How to make consultations work.

The consultation process exists to improve patient care in an era of medical complexities, but breakdowns in the process are common because of poor communication and inadequate physician education on the subject. The referring physician and the consultant both need to assume important responsibilities if quality patient care is to be ensured. The referring physician has to establish the reasons for and urgency of the consultation, communicate them to the consultant, and supply appropriate clinical information. The consultant has to determine the questions being asked, evaluate the patient, and communicate the findings and recommendations back to the referring physician. Whenever possible, the patient should be included in the decision-making process.

Communication↗