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PubMed2005

Doctors' consultations with children and their parents: a model of competencies, outcomes and confounding influences.

CONTEXT: The clinical consultation is an important aspect of the doctor's role. However, there is a particular shortage of methods for assessing its quality, and its complexity makes it a considerable assessment challenge. RESEARCH QUESTION: What are the key components of consultations involving children? METHODS: (1) A content analysis of relevant published and unpublished literature. (2) A nominal group consensus exercise with experienced paediatricians. RESULTS: The content analysis and consensus exercise suggested similar lists of doctor's characteristics, tasks and outcomes as being important components of the consultation. Doctor's characteristics include: clinical judgement, clinical knowledge, physical examination, information gathering, clinical questioning, information giving, patient-centredness, parent-centredness, interpersonal skills, and consultation management. Important tasks include: organisation and efficiency, rapport, information gathering, getting the family perspective, examination and procedures, evaluation, medically appropriate plans, family appropriate plans, enhancing understanding and recall, achieving consensus, sharing responsibility, family knows how to get further help and liaison with other relevant health-care professionals. Important outcomes include: family satisfaction, family perceptions, compliance, health, health-related problems and doctor's satisfaction. The studies reviewed in the literature also provided a catalogue of factors that have been shown to influence the doctor-patient interaction that could potentially confound the assessment of a doctor's performance. These include the doctor's: age, gender, training, speciality, income, social class and politics; the patient's: age, gender, health, prognosis, social class, education, health beliefs and preferences about control and risk. The length of the acquaintance between doctor and patient, and the workload and case-mix in the clinic also affect the interaction. In several studies it is clear that particular combinations of doctor-type and patient-type have especially good or bad interactions. CONCLUSIONS AND FURTHER WORK: These components are synthesised in a single model of the doctor-patient interaction to guide the development and evaluation of assessment instruments aimed at consultations involving children.

Child↗
PubMed2006

New nursing roles: the experience of Scotland's consultant nurse/midwives.

AIM: To describe career pathways of consultant nurses/midwives and identify postholders views on key factors in role initiation, development and progression to inform future development and appointment of nurse/midwife consultants in National Health Service Scotland. BACKGROUND: Nurse/midwife consultants represent the highest levels of clinical practice. Given the Scottish Executive Health Department's aim to treble numbers conditions and circumstances that enable them to flourish must be identified. METHOD: A postal survey was undertaken of all nurse/midwife consultants in post (n = 16). RESULTS: Key themes emerged around factors that consultant nurse/midwives considered important including mentorship, autonomy and clinical credibility. Barriers to role delivery included lack of understanding of roles and the wide scope of some posts. Considerable variation in support, conditions of service and line management arrangements was found. CONCLUSIONS: Development of a recognized career pathway and a consistent approach to employment and support of postholders is recommended.

Consultants↗
PubMed1981

Asthma in Danish general practice. Prevalence and consultation rates.

This study from Danish general practice with the participation of 131 practices covering a population of 450,000 persons assesses all consultations concerning asthma during a 1-year period from June 1977. Asthma was defined as paroxysmal bouts of dyspnoea of an expiratory type. Results are presented from three groups of practices differing in their self-estimated rate of reporting. A total of seven to nine per 1000 of the population contacted a general practice during the study year (men: 7-10, women: 6-8). The prevalence may be described by a two-peaked curve with maxima at ages 5-14 years and 50-70 years. In the former group the prevalence rate among boys is double that of girls. In the later group asthma is more common among women until the age of 55, after that age it is more common among men. More than half of the patients consulted with symptoms during the study year. The isle of Fyn had a lower prevalence rate with and without symptoms that all other regions. The consultation rate was 5.7 per asthma patient per year. In about 25-30% of these consultations patients presented with symptoms. The isle of Fyn had the lowest consultation rate.

Adolescent↗
PubMed2006

The mental health nurse: a valuable addition to the consultation-liaison team.

Nurses, particularly those working in non-psychiatric settings, report that they do not feel adequately prepared to meet the mental health needs of patients. The psychiatric consultation-liaison nursing role has arisen in part, as a response to these difficulties and aims to facilitate access to mental health nursing expertise for general hospital patients and staff. The impact of the introduction of a nursing position into an established consultation-liaison psychiatry service was evaluated using an activity audit, a staff attitude survey, and staff focus groups. The findings demonstrated that the addition of the nursing role to the consultation-liaison psychiatry service improved access of general hospital patients to specialist mental health care. It also provided valued expert assistance to staff in the provision of care to this patient group, particularly those with complex problems and significant psychiatric comorbidity. The study found that the nursing consultation was particularly helpful because of its focus on practical and care-orientated interventions. The model of practice that evolved out of this project is described and the findings support the use of both direct and indirect patient interventions as important psychiatric consultation-liaison nurse activities.

Adolescent↗
PubMed1984

Medical staff in training to become consultant physicians with an interest in diabetes.

A census in 1982 of 44 registrars and 66 senior registrars each of whom intends to become a 'consultant with an interest in diabetes' revealed that the training posts are geared to produce the 11 consultants appointments per year which currently become available. However, on top of this 'ladder' are 26 senior registrars who are already due for a consultant post. This backlog would appear to be a permanent feature unless extra new consultant posts become available. A newly appointed senior registrar can anticipate an average of 6 years before a consultant appointment. The majority of junior staff approved the current regulations and training programmes, although 87% felt that they received insufficient guidance.

Consultants↗
PubMed2004

Achieving multiple topic shifts in primary care medical consultations: a conversation analysis study in UK general practice.

The 'by the way' phenomenon, while commonly described in medical texts on the consultation, has not been systematically explored from an interactional perspective. Starting from a 'noticing' of an example of this phenomenon we studied a collection of over 200 recorded consultations in British general practice. New topics were introduced by both parties, but more commonly by patients, who used two sorts of device to change topic: an announcement, usually at the start of a consultation, but sometimes later, that they had multiple topics, which we have called a 'pre-announcement', and an apparently unexpected sudden change of topic, which we have called an 'in-situ announcement'. These phenomena occurred in about one third of our unselected collection of recorded consultations, drawn from nine doctors, and 27 surgery (office) sessions. We argue that this management of multiple topics is an important and normal part of the consultation, in contrast to its problematic status implied in some medical literature.

Family Practice↗
PubMed1992

Management of severe pre-eclampsia and eclampsia by UK consultants.

OBJECTIVE: To determine the current management of severe pre-eclampsia and eclampsia in the United Kingdom. DESIGN: One-page postal survey to all (1007) UK consultant obstetricians with questions about use of antihypertensive and anticonvulsant drugs in severe pre-eclampsia and eclampsia, other management strategies, definition of factors determining severity, protocol development and regional review. RESULTS: 688 replies (69.6% response rate). The antihypertensive drugs used were mainly oral labetalol (35%), oral methyl dopa (23%) and parenteral hydralazine (29%); diuretics were not used. Diazepam was the preferred drug in eclampsia. Very few consultants used magnesium sulphate (2%). Anticonvulsants were also prescribed by 85% of consultants to prevent fits; the drugs then preferred were diazepam (41%), phenytoin (30%) and chlormethiazole (24%). Two-thirds of consultants felt there was a need for trials to study the effectiveness of antihypertensive and anticonvulsant drugs. In a woman with proteinuric hypertension, 15% of consultants did not regard the development of headache as indicating severe pre-eclampsia. Consistent management practices were not associated with agreement about protocols. Regional review does not appear to have occurred. CONCLUSION: Antihypertensive and anticonvulsant therapies are widely used but trials are considered necessary. Improvements in the management of women with severe pre-eclampsia or eclampsia might occur if UK obstetricians sought more collective opinion and undertook regional audit of protocols.

Anticonvulsants↗
PubMed1996

A description of an occupational reproductive health nurse consultant practice and women's occupational exposures during pregnancy.

It is estimated that each year 20 million workers in the United States are potentially exposed to a variety of reproductive hazards. In 1986, Wisconsin implemented an advanced practice public health nurse role to serve as the occupational reproductive health consultant to employees, employers, health care professionals, unions, and others. This article describes this advanced practice role in public health nursing and the women who sought reproductive health consultation. Data on the types of workplace exposures that these consultees had during pregnancy are used to illustrate the occupational history and its importance for pre-conceptional and early-pregnancy counseling. The sample for analysis was limited to the 118 women, aged 19-43 years, who received consultation services between 1990 and 1993 and whose pregnancies resulted in live births. Data were abstracted from the consultant's records of telephone and written consultations and linked to birth certificate records to provide information on smoking and alcohol use during pregnancy. The findings are summarized using descriptive statistics. Implications of the findings for public health nursing are discussed.

Adult↗
PubMed1991

Effectiveness of geriatric psychiatry consultation in an acute care hospital: a randomized clinical trial.

OBJECTIVE: To evaluate the effectiveness of geriatric psychiatry consultation in reducing the severity of confusion, anxiety, depression, abnormal behavior, and functional disability among a selected group of aged medical and surgical inpatients. DESIGN: Randomized clinical trial. Cases assessed on enrollment at 2, 4, and 8 weeks later. SETTING: Primary acute care hospital. PATIENTS: Eighty hospitalized patients aged 65 or older who were referred to a multi-disciplinary team and had not received a psychiatric consultation in the month prior to referral. Sixty-three patients completed the trial. INTERVENTIONS: Patients in the treatment group received a geriatric psychiatry consultation and, when appropriate, follow-up at least once per week for 8 weeks. Control patients received usual medical care. MAIN OUTCOME MEASURES: Short Portable Mental Status Questionnaire, Anxiety Status Inventory, Geriatric Depression Rating Scale, and Crichton Geriatric Behavioral Rating Scale. RESULTS: The effect of the consultation on psychiatric symptoms and functional status was positive but small. The differences in scores of all measures between treatment and control groups were not statistically significant, but there were consistent trends for more treatment than control cases to have improved on all measures, significantly so on the Anxiety Status Inventory (P less than 0.05). Cases with delirium or depression improved most often. More control than treatment cases were discharged after 4 and 8 weeks, but twice as many treatment cases were discharged home. CONCLUSIONS: Geriatric psychiatry consultation, while not highly effective overall, may be beneficial if targeted to those most likely to benefit and compliance by referring physicians can be improved.

Aged↗
PubMedDate not supplied

A comparison of the concordance of digital images, live examinations, and skin biopsies for the diagnosis of hospitalized dermatology consultation patients.

OBJECTIVE: The goal of this study was to compare live and digital image examination of hospitalized dermatology consultation patients. DESIGN: A medical student digitally imaged patients with a Nikon Coolpix 950 digital camera (Nikon Corp., Tokyo, Japan). A resident reviewed these images and the student recorded the differential diagnosis. Digital examination was followed by live dermatologic examination by the dermatology resident and then by a supervising board certified dermatologist. The diagnoses in 29 of these cases were compared with definitive diagnostic tests (e.g., skin biopsy). SETTING: Montefiore Hospital, Bronx, NY Patients. In March, 2000, 48 of 58 consecutive hospitalized patients for whom dermatology consultations were requested and from whom consent for photographs could be obtained. MAIN OUTCOME MEASURES: The accuracy and consistency of the examiners top (up to three) digital diagnoses, (up to three) live diagnoses, and histopathologic diagnoses were compared. RESULTS: Eighty-one percent (38/47) of resident digital consult diagnoses agreed with live resident diagnoses. Live resident diagnosis agreement with live supervising board certified dermatologists diagnosis was 90% (18/20). Resident digital image diagnosis correlation with definitive diagnostic test results was 76% (22/29). Live supervising board certified dermatologist diagnosis correlation with definitive diagnostic test results was 73% (14/19). CONCLUSIONS: Digital image review results in reliable and accurate diagnosis compared to live consultations. For inpatient consultations, three-dimensional lesions are more amenable to digital diagnosis than flat, generalized rashes.

Biopsy↗
PubMed1989

Outcomes of systemic/strategic team consultation: I. Overview and one-month results.

This is the first in a series of reports on an experimental, small-sample study of systemic/strategic team consultations. This report describes a "Milan-informed" method of team consultation for resolving therapy impasses. It then focuses on the initial one-month outcomes from the larger 3-year project. Eleven therapists were asked to select two ongoing cases matched for difficulty. While all cases continued in regular therapy, one of each therapist's cases was also selected at random to participate in a systemic/strategic, five-part team consultation. Analyses of one-month follow-up data showed that clients who participated in the team consultation were more likely to achieve their main and overall treatment goals than clients who received only regular therapy (p's less than .05, eta2 as a measure of effect size ranging from 32% to 41%). The strong findings of this initial study encourage more widespread use of team consultations as a context for treatment, training, and research.

Adult↗
PubMed1991

Potential perils of the demonstration-consultation interview in family therapy: a case study of contextual confusion.

This article focuses on a specific aspect of consultation in contemporary family therapy, namely, problems that arise in the context of a consultation that simultaneously serves as a demonstration of a particular model of therapy. The demonstration-consultation interview is used widely in family therapy, but has received little attention in the literature. We use a case example of the apparent persistent deterioration in the clinical state of a patient following such a family interview with a visiting expert, and examine the possible contribution to the patient's deterioration that the demonstration-consultation context creates for the various participants. We offer provisional guidelines to minimize the risk of negative effects of the demonstration-consultation interview, pending empirical research into this phenomenon.

Adult↗
PubMed1991

Selection of patients who attempted suicide for psychiatric consultation.

A total of 1018 self-poisoned patients were treated during one year (1983) at the emergency room of Helsinki University Central Hospital for 1207 suicide attempts; 46% were left without psychiatric consultation. Women were consulted more frequently than men. Patients with previous psychiatric treatment were referred more often for psychiatric consultation. The use of alcohol was more frequently present in suicide attempts that did not lead to psychiatric consultation. Somatic seriousness was also less severe in this group. It was assumed that those left without consultation were not in mortal danger. There were no differences in the suicide mortality of these 2 groups during a 5-year follow-up.

Adult↗
PubMed2005

The effect of consultant-led interactive pre-clinic case note review on follow-up rates of an otology outpatient clinic.

The effect of pre-clinic consultant-led interactive case note discussion on the follow-up rate of an otology outpatient clinic was assessed. The clinic was divided into two groups. In one group, all cases were delegated by the consultant at the beginning of clinic without discussion. In the other group, before the start of clinic, the team reviewed all case notes and formed a management plan for each patient. Overall, lower follow-up rates were observed in cases which were discussed prior to the start of clinic (53.2-45.7%; p = 0.02). This was found in all doctor grades, although statistically significant only for middle grade (consultant: 48.3-41.6%, p = 0.10; middle grade: 58.5-45.5%, p = 0.05 and senior house officer: 60.2-57.8%, p = 0.73). Junior doctor's follow-up rates were much higher than the consultant's rates (p < 0.01). In conclusion, pre-clinic consultant-led case note review reduced otology outpatient follow-up rate.

Ambulatory Care↗
PubMedDate not supplied

Child care health consultation: an ecological model.

ISSUES AND PURPOSE: To present an ecological model of child care health consultation that defines the role of the health consultant as a resource and advocate within child care programs, as well as a supportive link among families, child care providers, and the healthcare system. CONCLUSIONS: Nurses have provided health consultation to child care programs for more than 30 years and represent the majority of health consultants nationally. Pediatric nurses and advanced practice nurses are well prepared to shape and lead the development of this emerging role. PRACTICE IMPLICATIONS: With expertise in caring for children, understanding families, and care across systems, pediatric nurses and advanced practice nurses should engage in current state and national efforts to develop child care health consultants.

Child↗
PubMed2006

Peer consultation: a unique experiential model for P/MHNP students.

TOPIC: Peer consultation: A unique experiential model for P/MHNP students. PURPOSE: The purpose of this paper is to describe the consultation component of the Adult Psychiatric Mental Health Graduate Program at UMASS Lowell. The consultation requirement is described in the Professional Role competency as "provides consultation to healthcare providers and others to enhance quality and cost-effective services for patients and to effect change in organizational systems" (NONPF, 2003, p. 10). The activity described in this paper also includes demonstration of components of the competencies for assessment, diagnosis, plan of care, and teaching/coaching (NONPF, 2003). SOURCES: This paper is based on review of the literature and the author's clinical and teaching experience. CONCLUSIONS: Form of classroom instruction is a unique way of assisting students in the development of the professional role as a consultant.

Adult↗
PubMed1993

The benefits of telephone-access medical consultation.

A major disadvantage of rural medical practice is the limited reserve of consultative options. To determine the perceived clinical utility and educational impact of the West Virginia University Medical Access and Referral System (MARS), a 24-hour prompt telephone-consultation service, a mailed questionnaire was administered to 303 West Virginia clinicians who had used MARS for infectious disease problems. The overall questionnaire response rate was 62 percent. Callers included family practitioners (35%), medical specialists (32%), surgical specialists (13%), pediatricians (11%), obstetricians (5%), and nonphysicians (4%). Major referral questions posed were therapeutic (60%), diagnostic (48%), and epidemiologic (10%) in nature. On a scale of 1 (not useful) to 5 (very useful), survey responders rated the overall clinical usefulness of MARS as either a 4 (22%) or 5 (76%). Callers felt that MARS consultation assisted in accurate case diagnosis in 80 percent of cases, and aided in successful therapeutic management of 96 percent of cases. An educational benefit was reported by 96 percent of responders. Physicians located in more rural, underserved areas tended to use MARS to a greater degree than colleagues in more populated, medically accessible areas (P < 0.005). These findings suggest that an academic telephone-access consultation program can be a clinically relevant and educational consultative tool for practicing clinicians, especially those located in rural areas.

Academic Medical Centers↗
PubMed1992

Medical Information Service via Telephone. The pioneer of physician consultation services.

The organization and development of MIST were a response to the needs of health professionals in Alabama, principally rural physicians, who expressed a desire to access the knowledge of the faculty at the UAB Medical Center. MIST provides free service on a 24-hour, 7-day-a-week basis for physicians around the world. At any time, practitioners can obtain specific medical information and discuss possible diagnoses or patient-related problems with UAB specialists. MIST, the first and largest medical professional telephone consultation program of its kind, receives numerous requests from other institutions seeking information and advice on developing similar programs. Such programs now exist in many states. One reason for the success of MIST is that it has always enjoyed high visibility with UAB physicians, credibility with the physician callers, and priority within UAB's Office of the Vice President for Health Affairs. As a consultative system, MIST continues to contribute to improved health care for citizens of Alabama and beyond and to save patients and taxpayers the expense of unnecessary or inappropriate treatment. MIST provides consultation and continuing education at the moment of need for the professional in private practice. In return, UAB specialists are given access to vital research and demographic information, as well as patient referrals. MIST plays an important role in removing barriers to education and consultation for busy medical personnel and in facilitating patient referrals to an acclaimed center of research and excellent patient care. Rather than searching for the proper contact, one call to an easy-to-remember number puts the health professional in touch with the appropriate source. Rural doctors, as well as medical personnel working in urban areas, can feel that they are practicing "right next door" to an outstanding university medical center where colleagues who are ready and able to offer expert consultation and support at the critical moment of need are only a telephone call away.

Academic Medical Centers↗