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PubMed2006

The assessment of depressive patients' involvement in decision making in audio-taped primary care consultations.

OBJECTIVE: In primary care of depression treatment options such as antidepressants, counseling and psychotherapy are reasonable. Patient involvement could foster adherence and clinical outcome. However, there is a lack of empirical information about the extent to which general practitioners involve patients in decision making processes in this condition, and about the consultation time spent for distinct decision making tasks. METHODS: Twenty general practice consultations with depressive patients prior to a treatment decision were audio-taped and transcribed. Patient involvement in decision making was assessed with the OPTION-scale and durations of decision making stages were measured. RESULTS: Mean duration of consultations was 16 min, 6s. The mean of the OPTION-items were between 0.0 and 26.9, in a scale range from 0 to 100. Overall, 78.6% of the consultation time was spent for the step "problem definition" (12 min, 42 s). CONCLUSION: Very low levels of patient involvement in medical decisions were observed in consultations about depression. Physicians used the majority of their time for the definition of the patient's medical problem. PRACTICE IMPLICATIONS: To improve treatment decision making in this condition, general practitioners should enhance their decision making competences and be more aware of the time spent in each decision making stage.

Decision Making↗
PubMed2004

The expression of aversion to medicines in general practice consultations.

Although the relevance of patients' views about medicines for their medicine taking behaviour is now well established, little is known about the ways in which these views are discussed in primary care consultations. In particular, many studies have demonstrated patients' aversion to medicines. This paper examines the form that aversion talk takes in the consultation and how doctors respond to patients' expression of aversion to medicines. It is based on a dataset of 35 case studies of general practice consultations in England. In interviews with researchers, aversion to medicines was expressed in 34 of the 35 cases. In consultations with doctors, aversion was expressed in 10 cases. The interactional dimension of aversion talk in consultations was analysed using Conversation Analysis, and two general patterns were identified. Aversion could be used as an interactional resource, or it could be a topic in its own right. If used as an interactional resource, no real discussion of patients' views of medicines took place. When aversion was a conversational topic in its own right, two situations were observed. Firstly, the doctor elicited patients' views directly. Secondly, patients initiated aversive talk using a range of indirect strategies to do so. Even when patients managed to express their aversion to medicines, doctors did not engage them in any real discussion of their views. A scheme of interpretation is suggested to explain these findings. In this scheme patients perceive medicines to be an extension of the doctor and to be beneficial. In this view it is right for doctors to prescribe medicines and for patients to take medicines. The results of this paper suggest that using aversion as an interactional resource might be the only safe way for patients to express their aversion without seeming to breach the social contract.

Adult↗
PubMed2006

Communicative and strategic action in interpreted consultations in primary health care: a Habermasian perspective.

We report a qualitative study of accounts of interpreted consultations in UK primary care. The study sought to explore how three Habermasian tensions between (a) system and lifeworld, (b) communicative and strategic action, and (c) interpersonal and macropolitical spheres played out in the triadic consultation between clinician, interpreter and patient. In a total of 69 individual interviews and two focus groups, we collected narratives from service users (through interpreters or bilingual researchers), interpreters and doctors and other staff in general practice. We recorded, transcribed and analysed these, taking the story as the main unit of analysis. Our data suggest that the preconditions for communicative action are rarely met in the interpreted consultation. The interpreter's presence makes a dyadic interaction into a triad, adding considerable complexity to the social situation and generating operational and technical challenges. Lack of trust, intense pressure of time, mismatch of agendas (biomedical versus lifeworld), firm expectations of a specific outcome (e.g. referral, prescription) and profound power imbalances all promote strategic action (i.e. speech that seeks consciously or unconsciously to manipulate an outcome) rather than communicative action (i.e. sincere efforts to achieve understanding, and reach consensus) by all parties. In consultations interpreted by family members (an option traditionally seen as 'second best' by policy makers), the social situation is very different. Family members are generally trusted, share the lifeworld agenda, and shift the power balance in the patient's favour. The interpreter occupies multiple social roles, including translator, interpersonal mediator, system mediator, educator, advocate, and link worker. The essence of professionalism in interpreting is shifting judiciously between these potentially conflicting roles. We discuss the implications of our findings for communication with limited English speakers in healthcare consultations and for realizing contemporary policy goals such as concordance, shared decision-making, empowerment, and choice.

Communication Barriers↗
PubMed2004

[Characteristics and evolution of consultants, their risk factors and their behavior at the free anonymous HIV screening center of Colmar (France)].

INTRODUCTION: Data collected in free anonymous HIV screening centers (Centre d'Information et de Dépistage Anonyme et Gratuit du VIH, CIdAG) are numerous but poorly exploited. The characteristics of the consultants, their risk factors and their behavior were rarely analyzed previously. MATERIAL AND METHODS: Data of 3995 patients attending the CIdAG of Colmar between January 93 and February 99 were prospectively analyzed. Two 18-month periods at the beginning and end of the study were compared. RESULTS: The activity of the center was stable. Nine HIV infections were detected (2 p. 1000 consulting). The male/female ratio was 1.2 and the mean age was 26 years. The proportion of very young patients (<20 years) was 30 p. 100 and increased significantly between the two periods. Six per cent of the consultants were male homo/bisexuals and 2 p. 100 used intravenous drugs. A regular use of condoms when having occasional sexual relations was reported by 40 p. 100 of consultants before 20 years of age, but this proportion decreased regularly as the age increased. It was minimal among intravenous drug users (19 p. 100), and greater among male homo/bisexuals (46 p. 100) than among male heterosexuals (37 p. 100) and women (33 p. 100). This proportion increased significantly during the study period in heterosexual men and women but not in male homo/bisexuals. The number of sexual partners did not vary but the knowledge of the partners'status for HIV infection and drug addiction progressed significantly. Some subjects who attended the centre several times were identified anonymously. They differed from the other consultants by an older age (mean: 31), a higher proportion of male homo/bisexuals (14 p. 100) and a less regular use of condom (26 p. 100). COMMENTS: In some French anonymous HIV screening centers, information and prevention currently appears to prevail over detecting new HIV infections. Modifying at-risk behaviour is difficult. Current messages for prevention must be improved.

Adult↗
PubMed2005

[Welcome and I'll see you again, or hello and goodbye?: Communication behaviour of medical residents at the beginning and the end of consultations].

OBJECTIVES: To describe the communicative behaviour by residents at the beginning (reception and first seconds after obtaining information) and closing of the consultation and to evaluate in what way very early interruptions in the patient monologue affect within-consultation results, such as the duration of their closing and the appearance of new concerns in this phase. DESIGN: Descriptive observational study. SETTING: Primary care clinics. PARTICIPANTS: Thirty seven third year residents of family medicine and 307 patients with incidental problems. Material and method. All the consultations were videotaped and analysed by 2 trained observers who used previously validated established ad hoc procedures. RESULTS: The reception and closing of the consultations by the residents were very short and very poorly communicated since they used very few relational abilities. Half of the doctors redirected the initial discourse of the patient very early on (in 16 sec) and this was significantly associated (P=.03) with new concerns by the patient at the time of closing and with longer goodbyes (P=.001). CONCLUSIONS: The conduct of the residents in the moments studied surely limits their ability to establish and maintain a clinical relationship, to obtain information and explain what they are giving to the patients. The dysfunctional closures are most probable when the doctor assumes a dominant role very early: this behaviour does not shorten the consultations.

Adult↗
PubMed1997

Persisting improvement in complaint-related cognitions initiated during medical consultations in functional abdominal complaints.

BACKGROUND: Previously it was shown that during a series of out-patient consultations dysfunctional complaint-related cognitions and anxiety diminished significantly in patients with functional abdominal complaints (IBS). The aim of the present study was to assess the maintenance of positive changes initiated during medical consultations in the patients' complaint-related cognitions and anxiety, as well as the influence of these cognitions on the severity of the complaints, 6 months after the first visit to the out-patient clinic. METHODS: One hundred and five consecutive patients with IBS referred by their general practitioners to the out-patient clinic for internal medicine completed questionnaires about their complaints and their complaint-related cognitions and anxiety before the first and after the last out-patient visit and again at follow-up, 6 months after the first out-patient consultation. RESULTS: Positive changes in the patients' complaint-related cognitions during the consulting period were found to persist during the follow-up period. Improvement in abdominal complaints at follow-up was found to be related to the level of the patients' state anxiety, fear of cancer, and catastrophizing cognitions at the last out-patient visit. CONCLUSIONS: Medical consultations can bring about long-lasting positive changes in prognostically unfavourable cognitions and anxiety. These changes appear to be related to a better outcome of IBS.

Ambulatory Care↗
PubMed1998

Taping outpatient consultations: a survey of attitudes and responses of adult patients with ocular malignancy.

PURPOSE: To study the attitudes and responses of cancer patients to audiotaped consultations as a communication aid in an ophthalmic clinic. METHODS: Ninety-four patients attending an ocular oncology clinic were given an audiotape of their initial consultation. They were then administered a structured interview with questionnaire regarding their views on the tape when they attended an outpatient clinic for follow-up after surgery or radiotherapy. RESULTS: 91% of patients had listened to the tape at least once, often prior to their treatment or follow-up visit. Most patients had shared the tape with immediate relatives, including their spouse (58%) or other family members (45%). Of those who had listened to the tape, 94% described it as very useful or quite useful in helping them understand their condition. The majority had found it valuable in helping them understand their treatment and its side-effects, in reducing their fears and anxieties and in their emotional and psychological adjustment to their illness. Most commented on the tape as a valuable communication aid to the consultation process. CONCLUSIONS: Taping of the consultation as a method of improving communication is popular among cancer patients. The vast majority benefit greatly from being able to hear their consultation again in their own time.

Adult↗
PubMed1994

An analysis of audio-recordings of general dental practitioners' consultations with adolescent patients.

Dental consultations of 30 general practitioners with 132 patients aged 10-17 years were recorded. The dental consultation was found to have a consistent structure composed of a sequence of stages, although not all were present in each consultation. Criteria by which verbal communication in a dental consultation can be assessed are identified and the frequency with which they occurred is presented. Although the majority of dentists studied used important communication skills on some of their patients, there were many consultations in which basic techniques such as greeting the patient and using the patient's name were not used. The findings indicate that many dentists could improve their communication with young patients and the investigation suggests mechanisms by which undergraduate and postgraduate education could be improved in this important area.

Adolescent↗
PubMed1999

Students conducting consultations in general practice and the acceptability to patients.

OBJECTIVES: The General Medical Council has recommended that medical students should gain more experience in general practice. The study set out to determine patients' reactions to consultations conducted by a medical student alone prior to seeing their GP. DESIGN: A random sample of patients attending general practice surgeries in the Oxford area completed a questionnaire following consultation with a medical student. SETTING: Six general practice teaching surgeries. SUBJECTS: Fifth-year medical students. RESULTS: Of 130 responders 98% experienced no disadvantage in seeing the student; 35% considered that there were advantages in seeing the student; 98% said that they would be prepared to consult with a student again; 85% expressed no concerns about the gender of the student. CONCLUSIONS: The results of this study are very reassuring concerning the acceptability to patients of consulting with medical students and are more favourable than those reported for studies of students being present in consultations by GPs.

Education, Medical, Undergraduate↗
PubMed2001

A survey of deep venous thrombosis management by consultant vascular surgeons in the United Kingdom and Ireland.

OBJECTIVES: The aim of this study was to detail the current consensus amongst vascular surgeons in Great Britain and Ireland regarding their investigation and management of patients with suspected or proven deep vein thrombosis (DVT). METHODS: The database of the Vascular Surgical Society of Great Britain and Ireland (VSS) was utilised to send coded postal questionnaires to all consultant surgeon members. RESULTS: Replies were received from 281 (65%) consultants. Duplex ultrasound is used alone to confirm DVT by 69% of respondents. A thrombophilia screen is always performed by 14% of consultants, for patients with proven DVT, and is more commonly requested by consultants based in a teaching hospital. The majority (57%) of consultants treat DVT with unfractionated heparin (UFH) and warfarin, whereas only 38% utilise low molecular weight heparins (LMWH) and warfarin. A management policy for DVT is reported to be in place by 59%, and a set policy for the specific management of calf vein DVT by just 20%. CONCLUSION: New diagnostic modalities and treatments have been developed for DVT that are more convenient and cost-effective. Although clinical guidelines for the management of patients with DVT are beginning to emerge, there is still a wide discrepancy in many areas of DVT management, and practice at variance with the current evidence base, amongst vascular surgeons in the United Kingdom and Ireland.

Anticoagulants↗
PubMed1995

[An consultation concept for integrating psychosomatic medicine in gynecology].

This paper is meant to survey the results of an interdisciplinary concept of psychosomatic patient treatment carried out for two years at the Department of Gynaecology and Obstetrics of the University of Cologne. This integral programme offers a psychosomatic consultation hour taking place once a week at the Department of Gynaecology and Obstetrics. Each first consultation is attended both by a psychosomatic specialist and a gynaecologist. The hypothesis underlying this new programme, which supposes that the integration of the psychosomatic treatment into the everyday routine of the clinic would make it easier for the patients to find access to psychological help, has proved right in view of the experience made so far. In comparison to the former counselling concept, the newly established gynaecologic-psychosomatical programme has increased the attendance by 300%. Thanks to the integrated consultation hour the way of seeing gynaecological problems in a psychosomatic context has increased considerably within the clinic itself so that these problems can now often be solved directly between gynaecologist and patient without making use of the offered consultation hour. Experiences made so far prove that the psychosomatic consultation hours are a valuable contribution to the diagnostic and therapeutic spectrum of the Department of Gynaecology and Obstetrics.

Abortion, Induced↗
PubMed2005

Utilizing theatrical tools in consultation training. A way to facilitate students' reflection on action?

The aim was to give the individual student a group-based opportunity to reflect on possible consultation strategies as the consultation was evolving. An actress acted as patient in the consultation training for a group of 30 students. The consultation was stopped at each critical incidence, and time-out given to allow the students to reflect on possible continuation strategies, and then to carry out one of them. The project was evaluated adopting a pragmatic version of the reflective practitioner research strategy as developed by Taylor. The evaluation was based on tutor and actress's field notes, students' written free text evaluation and students' evaluation through two focus groups. The qualitative analysis resulted in the three categories: the fiction created, temporality manipulated, and students' learning through reflection. Implications for students' learning process are discussed. We conclude that our way of creating fiction and manipulating temporality in the consultation training was paralleled by most students' report on substantial learning feed-forward abilities from reflection on action.

Education, Medical↗
PubMed2002

Promoting physical activity in a socially and economically deprived community: a 12 month randomized control trial of fitness assessment and exercise consultation.

The main aim of this study was to assess the effects of a fitness assessment and exercise consultation on physical activity over 1 year in non-regularly active participants drawn from a socially and economically deprived community. Of 3000 people invited to volunteer for either intervention, 225 fitness assessment volunteers were randomly assigned to an experimental or control group; 145 exercise consultation volunteers were similarly assigned. Physical activity was measured at baseline, 4 weeks, 3 months (plus an intervention re-test), 6 months and 1 year. Analysis of variance and follow-up Bonferroni analysis showed that, for those not regularly active at baseline, physical activity increased significantly to 4 weeks, was maintained to 6 months but had fallen by 1 year. Only those receiving an exercise consultation significantly increased their physical activity after 1 year. Compared with fitness assessments, chi-square analysis showed that significantly more non-regularly active participants volunteered for an exercise consultation and those receiving an exercise consultation had significantly better long-term study adherence than those receiving a fitness assessment. The study also showed that, contrary to popular opinion, those in a socially and economically deprived community are not 'hard to reach' and respond well to physical activity interventions.

Adult↗
PubMed1998

The Kaiser Permanente/USC Patient Consultation Study: change in quality of life. University of Southern California.

The impacts of two models of pharmacist consultation on patient function and health-related quality of life (HRQOL) relative to a control model were studied. Patients in the random-assignment study and the areawide study of the Kaiser Permanente/USC Patient Consultation Study were surveyed three times over a two-year period. The patients were receiving pharmaceutical services under the Kaiser Permanente model of consultation (KP model), a state model of consultation, or a control model and were stratified according to prescription drug use. A global visual-analogue scale and Short Form-36 were used to assess HRQOL. In the areawide study, only 2 of 42 comparisons of the effects of the KP or state model on HRQOL were significant; both were associated with the state model and involved only small increases. In the random-assignment study, 3 of 21 estimated effects of the KP model on HRQOL were positive and significant; 2 of these were significantly different between the KP model and the state model. Although the KP and state models of consultation were associated with some changes in HRQOL, the overall influence was not consistent and not clinically important.

Ambulatory Care↗
PubMed2004

Meeting patient's expectations in primary care consultations in Lithuania.

OBJECTIVE: Patient satisfaction with health care services is considered an important factor of health care. Although research on patient satisfaction has become standard in Western Europe, in countries such as Lithuania the concept of patient satisfaction is still a relatively new one. This study aimed to investigate how the meeting of patients' expectations is related to increased satisfaction with medical consultation. STUDY DESIGN: The methodology used by Williams et al. in the UK was applied to the Lithuanian health care setting. Forty physicians from 22 primary health care centres attending courses on general practice at Vilnius University were recruited for the study. Every third adult patient coming to a practice during a 5-day period was invited to participate in the study. In all, 609 patients coming to meet their physician regarding health problems were included in the study sample. The patients were asked to complete three standardized questionnaires: the Patient Intentions Questionnaire prior to the consultation, and the Expectations Met Questionnaire and Medical Interview Satisfaction Scale after the consultation. Cronbach's alpha statistic was used for the validation of the questionnaires and principal components analysis was used to determine the factors of patient expectations. RESULTS: The response rate was 78%. ANALYSIS: of 460 sets of questionnaires revealed that satisfaction with medical consultation is higher among patients who have a greater number of expectations met. Physicians' success in meeting different types of patient expectations also had different influences on patient satisfaction. The most important expectations to be met were "understanding and explanation", followed by expectations of "emotional support", while "getting information" was less important. CONCLUSIONS: The most frequently reported expectations on the Patient Intentions Questionnaire were for "getting information" and "understanding and explanation" of the patients' health problem items, and the least mentioned were for emotional support items. Patients with more expectations met were found to have significantly higher scores on the satisfaction index. Satisfaction with the consultation is best predicted by meeting the patient's expectations for understanding and explanation, and for emotional support. Providing desired information to the patient as well as meeting the patient's expectations for diagnostic procedures and treatment is less associated with patient satisfaction.

Analysis of Variance↗
PubMed2002

Collaboration and consultation: a survey of board certified music therapists.

The purpose of this study was to examine the consultation and collaboration practices of board certified music therapists (MT-BC) in order to establish a baseline of service provision for this profession. Board certified music therapists who are members of the American Music Therapy Association (n = 2039) were asked to complete a survey regarding collaboration and consultation in their professional practice. Specific areas of investigation included (a) population(s) with whom the MT-BC works and site of service delivery, (b) selfidentification as a collaborator and/or a consultant (c) populations with whom the MT-BC collaborates, and (d) frequency, methods, purpose, locations, and personnel for whom they provide consultative services. Responses (n = 873, 42.8%) from each of the 8 regions designated by the American Music Therapy Association (AMTA) indicated a significantly higher report of collaboration versus consultation among music therapists. Implications for music therapy education and need for further research are discussed.

Adult↗
PubMed2004

What do consultant occupational physicians do in the National Health Service? An audit.

AIM: To assess the range of activities undertaken by National Health Service (NHS) consultant occupational physicians, and quantify the proportion of time spent on these so that appropriate guidance and a model job description may be developed by the Association of NHS Occupational Physicians (ANHOPS). METHODS: A questionnaire was developed and sent to all full time consultant occupational health physicians (as recorded on the ANHOPS database). RESULTS: Sixty-five questionnaires were sent out, of which 38 were returned (59%). Only 31(48%) of replies matched the entry criteria of being full-time NHS consultants returning fully completed questionnaires. An average of 18 h face-to-face clinical work (range = 0-36 h) over five sessions (range = 0-9 sessions) was found. Remaining time was predominantly spent on clinical administrative work although some consultants took on a variety of other managerial activities. CONCLUSIONS: Responding full-time NHS consultant OHPs found it difficult to quantify and categorize their workloads, particularly for non-clinical work. Their responsibilities vary widely. Of use for job planning purposes is the average commitment of clinical sessions (five).

Humans↗
PubMed2002

Use of robotic telepathology for frozen-section diagnosis: a retrospective trial of a telepathology system for intraoperative consultation.

Telepathology is the practice of digitizing histological or macroscopic images for transmission along telecommunication pathways for diagnosis, consultation, or continuing medical education. Previous studies have addressed static versus dynamic imaging in several specimen types with a wide variety of systems and communication pathways. The goal of this paper was to assess the validity of a Web-based telepathology system for frozen section consultation within the Army Medical Department. The system provides real-time, dynamic remote control of a robotic microscope over standard Internet connections. Oftentimes, a solo pathologist is called on to provide diagnostic services without the support of immediate second or expert consultation during an intraoperative consultation. The use of telepathology is attractive because it provides an opportunity for pathologists to obtain immediate consultation. For purposes of the study, 120 consecutive frozen section cases were diagnosed at a distance using the system. Intraobserver agreement between the telepathology diagnosis and glass slide diagnosis was observed. Diagnostic agreement was 100% for a wide variety of specimens. This study suggests that such a system will help support pathologists located at distant sites.

Cytodiagnosis↗