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PubMed1999

Consultant surgeons' opinion of the skills required of basic surgical trainees.

BACKGROUND: Accurate and appropriate assessment of surgical trainees requires clear determination of the skills needed for surgical competence. This study was designed to identify those skills, rank them in order of importance and translate them into behavioural terms. METHODS: A Delphi technique, using anonymous postal questionnaires, was used. All consultant surgeons in South-East Scotland were asked to identify the skills they expected of surgical trainees. Skills identified were then returned to all consultants for weighting. Differences among specialties in the importance of each item were identified using analysis of variance. RESULTS: The qualities identified fell into five domains: technical skills, clinical skills, interaction with patients and relatives, teamwork, and application of knowledge. Consultants from all specialties gave high weightings to the generic domains of clinical skills, teamwork, and interaction with patients and relatives. CONCLUSION: This study has identified the skills considered necessary by consultant surgeons in Scotland for a successful surgical career. Contrary to expectation, consultant surgeons value many generic skills more highly than technical skills, indicating that they value well rounded doctors, not just those with technical ability. The characteristics identified are being used to develop an assessment tool for use on basic surgical trainees.

Attitude of Health Personnel↗
PubMed2000

Teaching the consultant teachers: identifying the core content.

OBJECTIVES: To determine the key themes for teaching hospital consultants how to teach. DESIGN: 1. In-depth interviews with a total of 19 experts, consultants and junior doctors to identify key topics. 2. Literature review from 1969 to obtain the main themes from the medical educational literature. 3. Analysis of the main themes in 11 'Teaching the teachers' courses. 4. Triangulation of interview data, literature themes and teaching courses content to generate 15 criteria for a questionnaire. 5. Questionnaire study to 593 senior and junior hospital doctors. SETTING: Hospitals in the West Midlands Region in England. SUBJECTS: Consultants and junior hospital doctors. RESULTS: Overall, 441 doctors replied (74% response rate). The top five themes were giving feedback constructively, keeping up to date as a teacher, building a good educational climate, assessing the trainee and assessing the trainee's learning needs. Results showed no statistically significant differences in the order of themes for all groups analysed, including seniority, gender, specialty, origin by medical school and consultants of different ages. CONCLUSIONS: Consultants need teaching in these topics. There are implications for funding and providing these courses for postgraduate deans, Royal Colleges and universities. Further research is needed to evaluate whether such an initiative does produce better teaching and learning, and a better educational climate in hospitals.

Consultants↗
PubMed2000

Pre-registration rotations into general practice: the concerns of pre-registration house officers and the views of hospital consultants.

AIMS: To explore the concerns of pre-registration house officers (PRHOs) and the views of hospital consultants in relation to pre-registration rotations with a general practice component. METHOD: As part of a larger qualitative study evaluating how a group of 24 PRHOs learn in hospital and primary care settings, face-to-face semistructured interviews were conducted with the PRHOs, and semistructured telephone interviews with the PRHOs' educational supervisors were carried out. RESULTS: The interviews with the PRHOs highlighted their concerns about how consultants might view PRHO rotations into general practice. However, the majority of consultants interviewed recognized and valued specific aspects of the experience to be gained by PRHOs in general practice, including the relationship between primary and secondary care; communications skills; specific clinical skills, and an understanding of the natural course of illnesses. The experience was seen as valuable for PRHOs considering either a general practice or a hospital career. Of the 17 consultants, 10 were also confident that 4-month placements in surgery and medicine would give PRHOs adequate experience in either specialty, providing the placements were sufficiently busy. CONCLUSIONS: Medical school deans and medical students considering PRHO rotations with a general practice component can be encouraged by the fact that, in this small study, the majority of hospital consultants interviewed valued the specific experience offered by these rotations, and felt that adequate medical and surgical experience could be gained in busy 4-month hospital placements.

Attitude of Health Personnel↗
PubMed2003

The future of consultation-liaison psychiatry.

OBJECTIVE: To review the status of consultation-liaison psychiatry and the factors shaping it, and suggest strategies for its future development. METHOD: In addition to searches of the main computerized psychiatric databases and review of relevant Commonwealth of Australia publications, the author drew on discussions with national and international colleagues in his role as convenor of the International Organization for Consultation-Liaison Psychiatry. RESULTS: Physical/psychiatric comorbidity and somatization, the conditions in which consultation-liaison psychiatry specializes, are the commonest forms of psychiatric presentation in the community. They are as disabling as psychotic disorders, and comorbid depression in particular is a predictor of increased morbidity and mortality. Acknowledging this, the Second Australian National Mental Health Plan called for consultation-liaison psychiatry to be allowed to participate fully in the mental health care system. It stated that failure to define the term 'severe mental health problems and mental disorders' in the First Plan had led to some public mental health systems erroneously equating severity with diagnosis rather than level of need and disability. The call has been largely unheeded. The implication for patient care is both direct and indirect; the context created for psychiatry training by such a restricted focus is helping to perpetuate the neglect of such patients. This is a worldwide problem. CONCLUSIONS: Proactive involvement with consumers is required if the problem is to be redressed. At a service level, development of a seamless web of pre-admission/admission/post-discharge functions is required if patients with physical/psychiatric comorbidity and somatoform disorders are to receive effective care, and consultation-liaison psychiatry services are to be able to demonstrate efficacy. Focus on comorbidity in the Australian Third National Mental Health Plan may force resolution of the current problems.

Australia↗
PubMed2001

Characteristics of a telecytology consultation service.

Although numerous reports describe the application of remote video microscopy to pathologic diagnosis (telepathology), only a few address some of the special issues surrounding remote cytologic diagnosis (telecytology). These studies have generally suggested a high correlation between telecytologic diagnoses and those arising from direct examination of the glass slides, but factors affecting the clinical utility of routine cytologic diagnosis have not been examined. In this report, we describe our experience in telecytologic consultation on 99 cases seen at the Armed Forces Institute of Pathology between October 1995 and November 1999. The mean time between receipt of the telecytologic images and the contributor receipt of the faxed report was 9.9 hours (median, 5.13 hours). Using stringent criteria for agreement, we find fair to good (48%) concordance between the contributor's impression and the consultant's opinion. The concordance between the consultant's telecytologic diagnosis and the subsequent glass slide diagnosis is imperfect; in 8 (31%) of 26 cases in which the glass slide was sent after the telecytology consultation, a minor discrepancy between these diagnoses was found. No major discrepancies were found between the consultant's telecytologic and glass slide diagnoses.

Cytodiagnosis↗
PubMed2001

Impact of gastroenterology consultation on the outcomes of patients admitted to the hospital with decompensated cirrhosis.

Managed care has strongly discouraged generalists from referring patients to specialists in an effort to reduce the costs of health care. The aim of this study was to compare patient outcomes when generalists work together with gastroenterologists or alone in the management of patients admitted to the hospital with decompensated cirrhosis. Consecutive patients admitted to the hospital with decompensated cirrhosis over a 1-year period were identified. We compared the length of stay, cost of hospitalization, incidence of hospital readmission, and mortality for patients who did and those who did not have a gastroenterology (GI) consultation. A GI consultation was requested for 107 of the 197 patients (54.3%). Patients who had a GI consultation had a significantly shorter length of stay (5.6 +/- 3.5 vs. 10.1 +/- 5.8 days, P <.001) and a lower cost of hospitalization ($6,004 +/- $4,994 vs. $10,006 +/- $6,183, P <.001) than those patients who were managed by generalists alone. The 30-day incidence of readmission (13.3% vs. 27.8%, P =.01) and mortality (7.5% vs. 16.7%, P =.045) were significantly lower in the GI consultation group. During a median follow-up of 618 days (range, 2-970), patients who had a GI consultation during hospitalization had a significantly longer time to hospital readmission (P <.001) and improved survival (P =.02) compared with those who were managed by generalists alone. In conclusion, for patients admitted to the hospital with decompensated cirrhosis, individuals who were managed by generalists in conjunction with gastroenterologists had better outcomes than those who were managed by generalists alone.

Aged↗
PubMed1981

The role of the consultant in the case conference: some neglected aspects.

THE case conference is a staple of academic life in psychiatry. Ostensibly, it provides the teaching hospital with a forum for considering issues of diagnosis, treatment, and interview technique. On an inpatient service, the case conference also holds the potential for uncovering the covert dynamics at work in the treatment setting; it is the task of the consultant who leads the conference to see that this potential is met. A major part of the consultant's work is bringing to life the hidden agendas of the conference. These hidden agendas are usually unconscious needs or wishes of the staff which are played out in relation to the consultant. Staff members attempt to influence the consultant to fulfill one of three basic wishes: the wish that the consultant ally himself with a certain faction; the wish that he sanction a position that has already been adopted; the wish that he expose or punish those whom the staff members are afraid to confront directly. These agendas provide the key to identifying central conflicts which obstruct therapeutic work. Although most often these conflicts appear between staff and patient, they also arise among staff members as well as between the unit staff and the hospital administration. This paper will examine examples of the dynamics of these hidden agendas and show how they reflect the influence which the patient has on the staff.

Adult↗
PubMed2003

Improved availability of specialist consultations in primary health care: impact on physician visits.

OBJECTIVE: How do physician visits vary when GPs are given the opportunity to send their patients to private specialists for consultation rather than simply to hospital outpatient clinics. DESIGN: An experimental study. SETTING AND SUBJECTS: In the City of Turku, 3 populations were served over 34 months by different service models. The first model was implemented in municipal health centres by 10 GPs with a list system and an option to consult private specialists. In the second model, there were four GPs in municipal health centres without a list system or the consultation option. In the third model, there were four private GPs with a list system and the consultation option. OUTCOME MEASURES: Visits to doctors as reported by the population. RESULTS: The populations on a GP's list had more physician visits than those not covered by a list system. Persons not on a health centre GP's list had fewer visits to the private sector and more visits to hospital than those covered by a list system. CONCLUSION: The possibility for a GP to send a patient for consultation to a private specialist improves the prerequisites for high-quality care without affecting the total number of physician visits.

Family Practice↗
PubMed2002

Development of an assessment tool to measure the influence of clinical software on the delivery of high quality consultations. A study comparing two computerized medical record systems in a nurse run heart clinic in a general practice setting.

A rating scale was developed to assess the contribution made by computer software towards the delivery of a quality consultation, with the purpose of informing the development of the next generation of systems. Two software programmes were compared, using this scale to test their ability to enable or inhibit the delivery of an ideal consultation with a patient with heart disease. The context was a general practice based, nurse run clinic for the secondary prevention of heart disease. One of the programmes was customized for this purpose; the other was a standard general practice programme. Consultations were video-recorded, and then assessed by an expert panel using the new assessment tool. Both software programmes were oriented towards the implementation of the evidence, rather than facilitating patient-centred practice. The rating scale showed, not surprisingly, significantly greater support from the customized software in the consultation in five out of eight areas. However, the scale's reliability measured by Cronbach's Alpha, was sub-optimal. With further refinement, this rating scale may become a useful tool that will inform software developers of the effectiveness of their programmes in the consultation, and suggest where they need development.

Ambulatory Care↗
PubMed1998

Factors influencing outcome in consultations for chronic pelvic pain.

We aimed to document the demographic and clinical characteristics of women referred by primary care physicians for investigation of chronic pelvic pain to a university hospital gynecology outpatient clinic and to test the hypothesis that specific patient features and the quality of doctor/patient communication at the initial consultation would influence pain outcomes. A clinical questionnaire, visual analog scales for pain, and instruments for hostility and the experience of the consultation were administered at the initial clinic attendance to 105 consecutive women. Follow-up pain scores were obtained 6 months later from 98 women. The mean hostility score was highly significantly elevated compared with normative data (p < 0.001). In a logistic regression model, a favorable patient rating of the initial consultation was associated with complete recovery at follow-up and interacted significantly with whether or not exercise was impaired (p < 0.005). For those in whom symptoms persisted, significant factors found by multiple regression models to predict continuing pain levels were the initial level of pain, the number of functions of daily life impaired, endometriosis, and the doctor who carried out the initial consultation. Patient hostility scores and the doctor's level of experience or gender were not significantly associated with continuing pain. This study highlights the importance of good communication as a basis for successful treatment of a group of hostile patients and indicates the influence in individual doctors of subtle attitudinal and personality factors that modify patients' experience of the medical consultation.

Adolescent↗
PubMed2005

Changes in diagnosis, treatment, and clinical improvement among patients receiving telemedicine consultations.

The aim of this study was to determine whether outpatient telemedicine specialty consultations to primary care clinicians result in changes in a patient's diagnosis, treatment management, and clinical outcomes. Medical records of patients who received two or more clinical telemedicine consultations in dermatology, psychiatry, and endocrinology were evaluated in a nonconcurrent retrospective analysis. Three indicators were used to measure changes in the processes of care and clinical outcomes: change in diagnosis, change in treatment, and patient clinical improvement. A retrospective review of 223 individual telemedicine patient medical records was conducted. Specialty telemedicine consultations were found to result in changes in diagnoses in 48% of the cases, changes in treatment therapy in 81.6% of the cases, and clinical improvement in 60.1%. These results are consistent with previous literature that has assessed changes in processes of care and outcomes from face-to-face specialty consultations in outpatient clinics. Changes in diagnosis and treatment therapy were found to be associated with clinical improvement with odds ratios (ORs) of 2.66 (95% confidence interval [CI]: 1.47-4.83) and 11.22 (95% CI: 4.49-31.48), respectively. This study found that telemedicine consultations resulted in changes in diagnosis and treatment regimens and also are associated with clinical improvements.

Adolescent↗
PubMed1997

Infectious diseases consultation: impact on outcomes for hospitalized patients and results of a preliminary study.

In the absence of detailed and specific data on outcomes, specialists are thought to contribute excessively to the cost of care. Infectious diseases physicians are at further risk of heavy utilization of medical resources because their patients often are those with serious complications or expensive underlying diseases (e.g., AIDS). By using readily available information in a sophisticated computer database, we examined the crude economic impact of an inpatient infectious diseases consultation and identified important matching variables for more refined analysis. The study was performed at LDS Hospital (Salt Lake City), a tertiary care facility with four full-time infectious diseases physicians. A total of 496 cases (patients who were seen by an infectious diseases consultant) were matched with 3,117 controls (patients who were not seen by an infectious diseases consultant). Matching was performed on the basis of age, sex, exact discharge diagnosis-related group, minimum length of hospital stay equal to the interval from admission to consultation for cases, and measures of the severity of illness (nursing acuity score and the number of secondary diagnoses). Cases had longer lengths of hospital stays, longer intensive care unit lengths of stays, and higher antibiotic costs than did matched controls, and if the consultation occurred in the last one-third of hospitalization, cases had shorter lengths of hospital stay and lower antibiotic costs than did controls.

Case-Control Studies↗
PubMed2000

The effect of the full moon on general practice consultation rates.

BACKGROUND: The effect of the full moon on human behaviour, the so-called 'Transylvania hypothesis', has fascinated the public and occupied the mind of researchers for centuries. OBJECTIVE: The aim of the present study was to determine whether or not there was any change in general practice consultation patterns around the time of the full moon. METHOD: We analysed data from the fourth national morbidity study of general practice. The data set was split into two groups and analysed separately: consultations on ordinary weekdays and consultations on weekends and bank holidays. The data were split randomly into two equal sets, one for model building and one for model validation. The lunar cycle effect was assumed to be sinusoidal, on the grounds that any effect would be maximal at the time of the full moon and decline to the new moon, following a cosine curve (with a period of 29.54 days, the mean length of a lunar cycle). RESULTS: There was a statistically significant, but small, effect associated with the lunar cycle of 1.8% of the mean value [95% confidence interval (CI) 0.9-2.7%]. This equates to an average difference between the two extremes during the cycle of 3.6%. For this data set, this accounts for 190 (95% CI 95-285) more consultations on days at the peak of the cycle compared with those at the bottom of the cycle, or, put another way, about three consultations per practice. CONCLUSION: We can speculate neither as to what the nature of these moon-related problems may be, nor as to the mechanisms underpinning such behaviour. However, we have confirmed that it does not seem to be related to anxiety and depression.

Family Practice↗
PubMed1995

An interdisciplinary mental health consultation team in a nursing home.

The Mental Health Consultation Team (MHCT) at the Portland Veterans Affairs Medical Center nursing home is an interdisciplinary group of mental health professionals and primary care providers established to triage mental health consultations, improve communication between consultants and primary care providers, help staff translate consultants' recommendations into patient care, and furnish education in the management of mental health problems. The MHCT has decreased the demands for formal psychiatry and psychology consultations while increasing mental health services through innovative use of existing staff.

Activities of Daily Living↗
PubMed2005

Training community consultants to help family members improve dementia care: a randomized controlled trial.

PURPOSE: We investigated whether community consultants could be trained to teach family caregivers a systematic behavioral approach for reducing mood and behavior problems in persons with Alzheimer's disease. DESIGN AND METHODS: This study consisted of a randomized controlled trial; we randomly assigned 95 family caregivers and care recipients with Alzheimer's disease to STAR-caregivers (STAR-C) or control groups. Masked interviewers conducted assessments at baseline, after treatment, and after 6 months. Consultants were master's-level health care professionals who were currently practicing in community settings serving older adults. We assessed the extent to which consultants were able to learn and adhere to the treatment protocol, and the relationship between adherence and measures of caregiver mood, burden, and care recipient mood and behavior. RESULTS: Community consultants were able to learn and adhere to the behavioral treatment protocol. Caregivers receiving STAR-C training showed significant improvements in depression, burden, and reactivity to behavior problems in the care recipient. There were also significant reductions in the frequency and severity of care recipient behavior problems, and improved quality of life. Results were maintained at 6-month follow-up. IMPLICATIONS: Community-based consultants successfully implemented a behavioral intervention with family caregivers of persons with Alzheimer's disease. Consequently, STAR-C seems to be a practicable and reasonable evidenced-based approach to caregiver training in actual clinical settings.

Aged↗
PubMed1978

Social work consultation to nursing homes: a study.

This is a study of 39 social work consultants to nursing homes in the Southeast who continued their consultation activities after the federal government removed the requirement for nursing homes to employ social work consultants to qualify for reimbursement of cost through federal programs. It examines their knowledge and attitudes about aging and their consultative skills in relation to case, process, and program consultation and three types of group work.

Aged↗
PubMed1996

The influence of the opinion of an infectious disease consultant on the appropriateness of antibiotic treatment in a general hospital.

The antibiotics chosen in hospitals are not always the most appropriate. A comparative prospective study with sequential analysis was designed to assess how the opinion of an infectious disease consultant affected the clinical efficacy of antimicrobial treatment in a general hospital. We studied 250 patients who had microbiologically documented infections according to Center for Disease Control criteria. The patients were divided in two groups with similar initial characteristics. Group G1 comprised 100 patients without infectious disease consultation, and group G2 contained 150 patients with infectious disease consultation. The influence of the consultant's opinion was assessed as the percentage of initially appropriate treatments, and by the number of inappropriate ones that were changed after the microbiological results were known. The appropriateness of initial treatment was significantly higher in group G2 (66% vs 55%), as were the number of treatments changed on the basis of the microbiological results (57.6% vs 33.3%). This lead to higher rates of cure, fewer deaths, and fewer cases of persistent infection in group G2. In 42.4% of G2 patients, antibiotic treatment was not changed in spite of the microbiological results and the opinion of an infectious disease consultant. We conclude that antibiotic treatment for the most clinically significant infections can be optimized if it is dispensed according to carefully developed guidelines.

Anti-Bacterial Agents↗
PubMed2003

Inpatient pediatric consultation-liaison: a case-controlled study.

OBJECTIVE: To conduct a prospective case-controlled study of pediatric inpatients referred for consultation in a tertiary care children's medical center. METHOD: Referrals (n = 104) were matched with nonreferrals (n = 104) for age (4 to 18 years), gender, and illness type/severity and completed parent- and self-report (dependent on age) behavioral rating scales to assess for adjustment/functioning. Nurses completed in-hospital ratings of behavioral/adjustment difficulties. Goal attainment and satisfaction ratings were obtained from the referring physicians, parents/guardians, and the consultant. RESULTS: Referrals exhibited more behavior/adjustment/coping difficulties than nonreferrals by parent, nurse, and self report. Frequently employed interventions included coping-strategies intervention, cognitive and behavioral therapies, and case management. Referring physician and consultant ratings of goal attainment were high, as were physician ratings of satisfaction and parent/guardian ratings of overall helpfulness. CONCLUSIONS: Pediatric inpatients referred by their physicians had significantly more internalizing and externalizing disturbances than their nonreferred hospitalized peers. Many of the behavioral and adjustment problems that lead to in-hospital consultation referral were evident in global behavior difficulties prior to hospitalization. Referring pediatricians, parents/guardians, and consultants rate the outcome as benefiting the patients via assisting in the overall management of their health concerns, coping, and adjustment.

Adaptation, Psychological↗