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PubMed1999

Systems consultation and Head Start: an alternative to traditional family therapy.

As Marriage and Family Therapists (MFTs) enter Head Start programs, systems consultation emerges as a viable alternative to providing therapy to enrolled children and families. As systems consultants, family therapists can offer organizational consultation, training, and support to Head Start staff, classroom interventions, and direct work with families. This article describes a multidimensional model for providing comprehensive mental health consultation to Head Start programs. It explores the skills necessary for MFTs to work effectively as systems consultants. Finally, recommendations are made for applying the model in both university and private settings.

Adult↗
PubMedDate not supplied

An educational consultative model for general practice training programs.

A behavioral science consultant has been retained by two hospital-based general practice residency (GPR) programs and one advanced program in general dentistry at the University of Rochester, and Eastman Dental Center, NY. This consultant is available throughout the year and serves as an external consultant who knows the programs well, and can be used as a source of information on various existing and potential issues and problems. The model used by the consultant has been inductive and is based on the expressed needs of faculty members, trainees, and directors. A number of issues or problems were identified, including faculty member morale, evaluation of residents' growth, resident and supporting staff relations, curriculum development, cooperation with other departments and institutions, and dealing with patients' anxiety to dental treatment. For each, a specific plan was developed. Various types of experiential techniques were used, including brainstorming, role playing, and taping and feedback. Didactic activities included minicourses and workshops in which standard teaching methods were used, such as lectures, seminar discussions, literature study, and demonstration. The model has evolved, and as each activity has succeeded, more faculty members have sought help from the consultant.

Consultants↗
PubMed1973

Consultant surgeons and vasectomy.

In late 1971 410 consultant general surgeons and urologists-74% of a national random sample-responded to a postal survey about vasectomy. Probably about 50,000 vasectomies were performed by surgeons in England and Wales in 1970. The service was largely a private one: 60% of consultants' hospital vasectomies were not done under the National Health Service, and, in addition, 26% of the consultants who worked in relevant specialties performed vasectomies elsewhere than in hospital (usually in private nursing homes). Based again on consultants' estimates, probably 6,000 men in 1970 had their requests for vasectomy turned down by surgeons, or more than one turned down for every 10 done. The most common reason was that patients were "too young."About 90% of the consultants thought vasectomy could normally be performed safely and adequately as an outpatient procedure, yet only 64% said that 90% or more of their hospital vasectomies were done on this basis. While 69% regarded services in their areas as adequate, most were in favour of more special vasectomy clinics.

Age Factors↗
PubMed1988

Who undertakes the consultations in the outpatient department?

In a study of all 4275 outpatient consultations over one month in a district general hospital it was found that the clinics in surgical specialties had the largest numbers of patients. In general surgery less than half of new patients and only one third of all patients attending the clinic were seen by a consultant. (Nine months later about a third of all new patients had still not seen a consultant in the clinic.) In the medical clinics just over a quarter of patients were seen by doctors who had less than six months' experience in their present specialty after registration. Overall, doctors had been on continuous duty for at least 24 hours before a third of consultations. Doctors in training had actually worked during the previous night before attending a quarter of the clinics. Much of the large volume of work is performed by tired, incompletely trained doctors. It is suggested that a greater proportion of the work should be performed by fully trained staff. The workload might be reduced by modifying the pattern of the consultation.

England↗
PubMed1989

Ethnic differences in general practitioner consultations.

OBJECTIVE: To examine the levels of general practitioner consultations among the different ethnic groups resident in Britain. DESIGN: The study was based on the British general household surveys of 1983-5 and included 63,966 people aged 0-64. Odds ratios were derived for consultation by ethnic group by using logistic regression analysis adjusting for age and socioeconomic group. SETTING: The results relate to people living in private households in England, Scotland, and Wales. RESULTS: After adjustment for age and socioeconomic class, consultation among adults aged 16-64 was highest among people of Pakistani origin with odds ratios of 2.82 (95% confidence interval 1.86 to 4.28) for men and 1.85 (1.22 to 2.81) for women. Significantly higher consultations were also seen for men of West Indian and Indian origin (odds ratios 1.65 and 1.53 respectively). Ethnic differences were greatest at ages 45-64, when consultation rates in people of Pakistani, Indian, and West Indian origin were much higher in both sexes compared with white people. CONCLUSIONS: The ethnic composition of inner cities is likely to influence the workload and case mix of general practitioners working in these areas.

Adolescent↗
PubMed1995

Attitudes of consultant physicians to the Calman proposals: a questionnaire survey. North West Thames Diabetes and Endocrinology Specialist Group.

OBJECTIVE: To determine the views of a large and representative group of consultant physicians on the Calman proposals, in which acute general medical services will change from being primarily consultant led to consultant provided. DESIGN: Postal questionnaires. SUBJECTS: All 236 consultant physicians in acute hospitals in North West and South West Thames regions. RESULTS: Replies were received from 179 (76%). One hundred and thirty seven (77%) indicated that they would not resume emergency residential duties, and 126 (71%) indicated that they would probably withdraw from general medical duties under these circumstances. One hundred and twenty six (70%) and 137 (77%) had not inserted a central venous line or temporary pacemaker, respectively, within the previous five years. Of 157 answering a question on the impact of the Calman proposals on the quality of patient services, 125 considered that it would be detrimental, and only 18 (11%) thought that it would be beneficial. CONCLUSION: Most consultant physicians are not prepared to resume emergency duties and could not do so without retraining in practical procedures. There is widespread antagonism to the Calman proposals, and most physicians consider that their impact on the quality of patient services will be detrimental.

Attitude of Health Personnel↗
PubMed1999

Descriptive study of cooperative language in primary care consultations by male and female doctors.

OBJECTIVE: To compare the use of some of the characteristics of male and female language by male and female primary care practitioners during consultations. DESIGN: Doctors' use of the language of dominance and support was explored by using concordancing software. Three areas were examined: mean number of words per consultation; relative frequency of question tags; and use of mitigated directives. The analysis of language associated with cooperative talk examines relevant words or phrases and their immediate context. SUBJECTS: 26 male and 14 female doctors in general practice, in a total of 373 consecutive consultations. SETTING: West Midlands. RESULTS: Doctors spoke significantly more words than patients, but the number of words spoken by male and female doctors did not differ significantly. Question tags were used far more frequently by doctors (P<0.001) than by patients or companions. Frequency of use was similar in male and female doctors, and the speech styles in consultation were similar. CONCLUSIONS: These data show that male and female doctors use a speech style which is not gender specific, contrary to findings elsewhere; doctors consulted in an overtly non-directive, negotiated style, which is realised through suggestions and affective comments. This mode of communication is the core teaching of communication skills courses. These results suggest that men have more to learn to achieve competence as professional communicators.

Communication↗
PubMed2004

Characteristics of consultants who hold distinction awards in England and Wales: database analysis with particular reference to sex and ethnicity.

OBJECTIVE: To determine whether women, ethnic minorities, and particular specialties are discriminated against in the receipt of NHS distinction awards. DESIGN: Analysis of database of consultants eligible for distinction awards. SETTING: England and Wales, 2002. MAIN OUTCOME MEASURES: Holding of B, A, and Aplus distinction awards, analysed for all awards, irrespective of when made, and for awards made in the last five years studied. RESULTS: Women and doctors from ethnic minorities were substantially under-represented among award holders when no account was taken of potential confounding factors. Differences diminished after multivariate analysis, but some remained significant. For example, the adjusted odds ratio of women holding awards compared with men was 0.69 (95% confidence interval 0.59 to 0.82) for any award and 1.37 (0.86 to 2.20) for Aplus awards; the odds ratio for any award for non-white doctors trained abroad compared with white doctors trained in the United Kingdom was 0.45 (0.37 to 0.56). In the last five years studied the adjusted ratio of women to men was 0.94 (0.79 to 1.10) for B awards and 1.54 (0.85 to 2.83) for Aplus awards. The adjusted ratio for non-white British trained consultants was 0.86 (0.62 to 1.17) for B awards and 1.20 (0.37 to 3.87) for Aplus awards; for non-white consultants trained abroad it was 0.68 (0.54 to 0.85) for B awards and 0.69 (0.15 to 3.10) for Aplus awards; and for white consultants trained abroad it was 0.70 (0.54 to 0.91) for B awards and 0.90 (0.38 to 2.15) for Aplus awards. CONCLUSION: Historical under-representation in award holding by women and doctors from ethnic minorities was partly explained by time spent as a consultant. Recent awards showed no under-representation of women and no appreciable under-representation of ethnic minorities overall. However, doctors who trained abroad-both white and non-white-remained under-represented for B awards.

Awards and Prizes↗
PubMed1974

Communications between general practitioners and consultants.

During 1972-3 a survey was made of the pattern of communication between 80 consultants in four hospitals in south-east England and 100 general practitioners in the catchment areas of these hospitals. This aimed to identify the factors which affect the efficiency of communication between these two groups and to look for ways of improving this.Face to face contact between consultants and general practitioners was extremely limited. The main communication links were the letters of referral and discharge, but even this form of communication had serious defects. Though most doctors were satisfied with communications in general the evidence suggested ways of improving communication between consultants and general practitioners, such as encouraging domiciliary visits where both doctors are present and consultant sessions in health centres, but that any innovation in this field could only be successful if the attitude of the consultants and general practitioners were in harmony with the new venture.

Communication↗
PubMed2006

The new consultant survey 2005.

BACKGROUND: Consultants in emergency medicine have to deal with a wide range of problems, many of which they will not have encountered during their training. One way to assess the adequacy of specialist training is to ask recently appointed consultants whether or not they feel adequately prepared for their role. METHODS: A questionnaire was sent out to 60 newly appointed consultants in emergency medicine in January and February 2005 and the results analysed. RESULTS: Many respondents feel that there should be greater emphasis on acquiring clinical skills, partly by greater consultant supervision and partly by providing more experience of anaesthetics and intensive care. New consultants also feel inadequately prepared for their management responsibilities, and this is a source of great stress. CONCLUSIONS: Specialist training in emergency medicine needs to pay more attention to the acquisition of clinical skills and to preparation for management responsibility.

Attitude of Health Personnel↗
PubMed2004

Implementation of community consultation for waiver of informed consent in emergency research: one Institutional Review Board's experience.

BACKGROUND: This article describes how one Institutional Review Board (IRB) chose to implement the issue of waiver of consent for a research study involving brain trauma victims brought to an emergency department. METHODS: Presentations were conducted in the state of Mississippi among cultural and ethnic groups representative of Mississippi's demographic composition. Individuals from the neurotrauma research team, including neurosurgeons and nurse study coordinators, conducted all of the presentations. One IRB member served as an objective "community liaison" and attended all presentations. This individual administered evaluation forms to attendees that measured their levels of comprehension and acceptance for the use of waiver of consent in the brain trauma study. RESULTS: All of the 137 attendees in 7 community consultation meetings gave their approval for the use of "waiver of consent." Continued community consultations are planned for the duration of the brain trauma study. CONCLUSION: Based on our experience, we conclude that in collaborating with local IRBs, research teams can successfully develop strategies for obtaining "acceptable community consultations" as required by regulatory mandates. We suggest that standardized community consultation guidelines be developed for obtaining waivers of informed consent in emergency research. Such criteria should form the basis for local IRBs to obtain their respective community consultations.

Adolescent↗
PubMed1998

The scope for the involvement of patients in their consultations with health professionals: rights, responsibilities and preferences of patients.

The degree and nature of patient involvement in consultations with health professionals influences problem and needs recognition and management, and public accountability. This paper suggests a framework for understanding the scope for patient involvement in such consultations. Patients are defined as co-producers of formal health services, whose potential for involvement in consultations depends on their personal rights, responsibilities and preferences. Patients' rights in consultations are poorly defined and, in the National Health Service (NHS), not legally enforceable. The responsibilities of patients are also undefined. I suggest that these are not to deny, of their own volition, the rights of others, which in consultations necessitate mutuality of involvement through information-exchange and shared decision-making. Preferences should be met insofar as they do not militate against responsibilities and rights.

Choice Behavior↗
PubMed2006

Headache and migraine in primary care: consultation, prescription, and referral rates in a large population.

BACKGROUND/AIMS: Headache is the most common new neurological symptom seen by general practitioners and neurologists. This study describes headache consultation, prescription, and referral rates in a large sample of UK general practices. METHODS: Analysis of data from patients > or = 15 years registered at 253 UK general practices diagnosed with headache/migraine from 1992 to 2000. Rates were age standardised using the European standard population for reference. RESULTS: There were 13.2 million patient years of observation. Headache consultation rates were 6.4/100 patients/year in women and 2.5 in men. They were highest at 15-24 years (15.8/100 in women; 5.8/100 in men), decreasing with age. Antimigraine drugs were prescribed at 36.7% of consultations for women and 26.6% for men. Among referrals to specialists, 55% were to neurology and 30% to general medicine. The neurology referral rate in patients with headache was 2.1/100, and was higher in men (2.7/100) than women (1.9/100). CONCLUSIONS: These results provide precise age specific and age standardised estimates for headache consulting in general practice, in addition to prescribing and referral to specialist care. Consultation rates are highest in young women; hospital referrals peak in middle aged men. Research is needed into reasons for referral, and on better ways of delivering headache services.

Adolescent↗
PubMed1996

Survey of perceived stress and work demands of consultant doctors.

OBJECTIVES: The objectives of this study were to assess the work demands as potential stressors of health service consultants, and to describe the development of tools for measuring stress experiences of consultants. METHODS: A stratified random sample of 500 NHS consultants in Scotland was targeted by a postal questionnaire and 375 (75%) returned a valid response. They completed questionnaires, including information on demographic factors, work demands, occupational stressors, and burnout. RESULTS: Principal components analysis showed that professional work demands of consultants fell into three categories: clinical, academic, and administrative. Their perceived stressors separated into four main factors: clinical responsibility, demands on time, organisational constraints, and personal confidence. These were assessed by 25 questions in the specialist doctors' stress inventory. Specific questions about perceived stressors which resulted in a high positive response included questions about demands on time, and organisational change in the NHS. CONCLUSION: These self reported data characterise and measure the consultants' work demands and their role as potential stressors. These measurements could form the basis for strategies to reduce occupational stress in these workers.

Adult↗
PubMed2006

Understanding reasons for asthma outpatient (non)-attendance and exploring the role of telephone and e-consulting in facilitating access to care: exploratory qualitative study.

OBJECTIVE: To understand factors influencing patients' decisions to attend for outpatient follow up consultations for asthma and to explore patients' attitudes to telephone and email consultations in facilitating access to asthma care. DESIGN: Exploratory qualitative study using in depth interviews. SETTING: Hospital outpatient clinic in West London. PARTICIPANTS: Nineteen patients with moderate to severe asthma (12 "attenders" and 7 "non-attenders"). RESULTS: Patients' main reasons for attending were the wish to improve control over asthma symptoms and a concern not to jeopardise the valued relationship with their doctor. Memory lapses, poor health, and disillusionment with the structure of outpatient care were important factors implicated in non-attendance. The patients were generally sceptical about the suggestion that greater opportunity for telephone consulting might improve access to care. They expressed concerns about the difficulties in effectively communicating through non-face to face media and were worried that clinicians would not be in a position to perform an adequate physical examination over the telephone. Email and text messaging were viewed as potentially useful for sending appointment reminders and sharing clinical information but were not considered to be acceptable alternatives to the face to face clinic encounter. CONCLUSIONS: Memory lapses, impaired mobility due to poor health, and frustration with outpatient clinic organisation resulting in long waiting times and discontinuity of care are factors that deter patients from attending for hospital asthma assessments. The idea of telephone review assessments was viewed with scepticism by most study subjects. Particular attention should be given to explaining to patients the benefits of telephone consultations, and to seeking their views as to whether they would like to try them out before replacing face to face consultations with them. Email and text messaging may have a role in issuing reminders about imminent appointments.

Adult↗
PubMed1987

Future directions in consultation-liaison psychiatry.

Consultation-liaison psychiatry in the United States has had to reassess its priorities with the change in health care economics in the 80 s. Liaison programs and educational programs for primary care staff are jeopardized. The emphasis has shifted from liaison to reimbursable consultation activities. Hospital stays are shorter with emphasis on outpatient and prepaid settings. Less expensive health care professionals are often asked to see patients previously evaluated by psychiatrists. This paper will discuss the need for focused cost-effective liaison services in this climate. Funding strategies for consultation-liaison programs, models of staffing consultation-liaison services, continuity of care from inpatient to outpatient services, integration of consultation-liaison psychiatrists in prepaid health care settings, primary-care educational programs, and psychosocial intervention programs for high-risk primary-care patients will be discussed.

Forecasting↗
PubMed1991

Relationships between requests for psychiatric consultations and psychiatric diagnoses in long-term-care facilities.

OBJECTIVE: The authors' objective was to investigate reasons for referral of elderly nursing home residents for psychiatric consultation and the relationship of these reasons for referral to psychiatric diagnoses. METHOD: They examined 197 nursing home residents consecutively referred to a consulting team in a university-affiliated mental health center. These patients represented all patients evaluated by the consulting team at six nursing homes over a 2-year period (Sept. 1, 1984, through Aug. 30, 1986). RESULTS: Reasons for referral were diverse but fell into seven broad clusters: behavioral problems; mood-related problems; consultations requested by involuntary treatment services, patients, physicians, or other referring agencies; psychotic features; physical signs; impaired activities of daily living; and other. Behavioral problems were most commonly cited and tended to be associated with dementia diagnoses. Mood-related reasons for referral were most strongly associated with diagnoses of affective disorders, and diagnoses of schizophrenia and adjustment disorder were each associated with two or more reasons for referral. However, reasons for referral were distributed widely across diagnostic groups and were relatively weak predictors of diagnoses. CONCLUSIONS: The results illustrate the variety of problems for which nursing home staff are willing to seek psychiatric consultation but emphasize the need for professional psychiatric evaluation to establish a diagnostic base on which treatment interventions can be built.

Adjustment Disorders↗
PubMed1992

A randomized controlled study of psychiatric consultation guided by screening in general medical inpatients.

OBJECTIVE: The purpose of the study was to test the hypothesis that psychiatric consultation would reduce health care utilization during and after medical hospitalization. METHOD: A randomized, double-controlled clinical trial of psychiatric consultation was conducted on the general medical inpatient services of a university hospital. After meeting inclusion criteria, 1,541 patients were screened for depression, anxiety, confusion, and pain over a period of 21 months. The 741 patients with high levels of psychopathology or pain were subdivided into baseline control subjects (N = 232), contemporaneous control subjects (N = 253), and an experimental consultation group (N = 256). The major outcome measures were length of hospital stay and hospital costs. Secondary outcome measures were posthospital health status, rehospitalization rates, and use of outpatient medical care. RESULTS: This study did not demonstrate an effect of experimental psychiatric consultation on hospital resource use or posthospital medical care utilization after adjustment was made for disease severity. Hospital resource use decreased in the entire sample over the 21-month duration of the study. CONCLUSIONS: The brief, efficient screen for anxiety, depression, confusion, and pain identified a group of patients who also used more hospital resources, but a single experimental psychiatric consultation did not reduce costs. The double-controlled nature of the design proved essential to avoid being misled by background changes in hospital resource use.

Adult↗