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PubMed1988

Increasing patient participation using an extended consultation: an inner city study.

An inner city practice in Birmingham has developed a new style of extended consultation to increase patient participation in primary care, based on previous initiatives in the practice, in particular allowing patients access to medical records, adopting an open reception style, and including consultations with a nurse practitioner. In a three stage consultation lasting approximately 30 minutes patients were offered a session with a receptionist for assisted access to medical records, a session of 15-20 minutes with a doctor or nurse and a self help session with a receptionist. This extended consultation was welcomed by patients, who showed a marked degree of participation, and it also increased the satisfaction and cooperation of project staff. This type of consultation provides a model for increasing patient participation in general practice.

Appointments and Schedules↗
PubMed1985

Comparative rating of consultation performance: a preliminary study and proposal for collaborative research.

Factors governing the appropriateness, reliability and validity of rating scales in the measurement of professional performance are reviewed. The origin and preliminary testing among undergraduated and general practitioners of a brief consultation rating schedule is described.Statistical criteria are proposed for the analysis of ratings, by groups, in the comparison of consultation performance. Using these criteria the capacity of the 10 rating schedule items to discriminate between two contrasting consultations was examined. Each of the items was used at some time by students or doctors to express significant preference for the same consultation; and on this basis all the items are considered to merit inclusion. One item showed highly significant intra- and inter-observer reliability.The schedule is reproduced in full, together with a data-collection document and significance chart, with the aim of encouraging groups of doctors to test the validity of the items in the comparison of other pairs of consultations. It is proposed that future versions of the schedule should reflect the experience of such groups in testing existing items and in defining additional items which satisfy the proposed criteria.

Clinical Competence↗
PubMed1983

Consultation length and outcome in two group general practices.

Two group general practices were located which, while similar in a number of important respects, differed in the number of appointment consultations arranged per hour, and data was collected to see if corresponding differences in consultation outcome could be found. Information on all appointment consultations offered during a four-week period was analysed, and the number of patients returning for further attention in a subsequent four-week period was also determined. The practice offering longer consultations had a lower proportion of appointment consultations ending with a prescription, required a lower proportion of patients to return for a follow-up appointment, and had a lower proportion of patients themselves returning to seek a further appointment within four weeks of presenting with a new illness episode.

Appointments and Schedules↗
PubMed1981

Expectations and experience of people who consult in training practice.

All the patients (348) seen in one week in a training practice in Exeter were asked to complete a pair of questionnaires, one before and one after consulting, about the content of that consultation. Seventy-one per cent responded. Ninety-two per cent of respondents expected to be told what was wrong with them, although 72 per cent had a "pretty good idea" of what was wrong beforehand. In the event, 76 per cent felt they had actually been told what was wrong. Sixty-one per cent sought advice or suggestions for self-help. Fifty-four per cent expected to receive, and 57 per cent received a prescription, including 14 per cent who had not expected one. Ninety-three per cent were satisfied with what took place.The nine patients who were dissatisfied had expectations which differed little from those of the rest, but their experience in the consultation differed significantly, particularly in relation to discussion, comprehension and the exchange of information. It is concluded that the need for explanatory information greatly exceeded the need for medication in this sample of people.SOME SPECIAL PROBLEMS AND DIFFERENCES WERE IDENTIFIED AMONG PEOPLE WHO CONSULTED THE TRAINEE: in particular, their consultations were less likely to be relaxed and they expected to be, and were, followed up less often than those who saw a principal.

Adolescent↗
PubMed1980

Practitioners' use of non-verbal behaviour in real consultations.

Our analysis of real consultations in general practice suggests that eye contact and movements of the body are extremely important in effecting communication between patients and doctors. We have studied non-verbal behaviour in relation to verbal exchanges, and believe that non-verbal behaviour can aid or hinder communication and may sometimes prevent it.We give examples from general practice consultations and conclude that eye contact and posture are particularly significant when coupled with open questions or silences or when they occur at points in the consultation when the patient has reached a crucial part in disclosure.We also believe that the doctor's use of medical records during consultations is most important, and we give examples.We suggest that the non-verbal behaviour of doctors in the general practice consultation is a topic of immense importance and needs much further study.

Family Practice↗
PubMed1980

Factors contributing to the length of general practice consultations.

Ten general practitioners in a study of general practice consultations were shown to differ significantly in the time they spent in their consultations. Patient demographic characteristics contributed little to differences in consultation time. Consultations in which (a) there was a diagnosis of psychological disorder, (b) the practitioner and the patients focused attention on psychosocial matters, and (c) psychotropic drugs were prescribed, were found to be associated with increased length of consultation time.

Family Practice↗
PubMed1994

Comparative female to male consultation rates in NHS primary care: extrapolation to the Royal Navy.

Prevailing wisdom accepts that women consult their GP more often than men. Those with a modicum of interest will know that across the NHS, all ages and all social classes for all grades of consultation, the approximate ratio is two female consultations for one male consultation. However, if the figures are carefully sifted to identify that group most clearly akin to Royal Naval personnel, the gap widens. The following figures and discussion describe how in Naval personnel's age, class and illness matched groups, extrapolating from NHS experience, the 'typical' Royal Naval 'Wren' might be expected to present as a fresh case (including family planning and pregnancy) three times more commonly and consult an RN GP four times more frequently than her male counterpart. In addition, a comparison of various pathology groups are compared and pronounced differences discussed.

Adolescent↗
PubMed1995

[Providing patients with an audio recording of the outpatient oncological consultation; experiences of patients and physicians].

OBJECTIVE: Gaining insight into the experiences of physicians and patients who were provided with an audiotape of an oncological consultation. DESIGN: Questionnaire study. SETTING: Academic Medical Hospital, Amsterdam. METHOD: Consultations with 30 consecutive patients referred to the gynaecology or urology outpatient clinic for an initial consultation regarding the diagnosis and (or) treatment policy were taped. Afterwards, patients took the tapes home. The following week they were phoned and asked what they had done with the tape and how they appreciated the intervention. By means of a questionnaire the physicians (n = 6) were asked about their experiences. RESULTS: Two patient could not be reached. Twenty-three out of 28 patients had listened to the tape, mostly together with others (spouse, relatives). Twenty-six out of 28 patients were positive about implementation of this intervention. According to most patients the tape contained information they had forgotten. Most patients found the tape contained reassuring information. Physicians regarded the optimal transmission of information achieved by this intervention as an advantage. Three out of six saw possible misinterpretation of the imparted information as a disadvantage. For some physicians, the taping of consultations led to more careful phrasing. Most physicians saw no logistical difficulties. In general, participation in the study did not take any extra time. CONCLUSION: This first study shows that both cancer patients and physicians find it useful to provide patients with an audiotape of the initial consultation.

Adult↗
PubMed1997

What does a GP consultation cost?

BACKGROUND: Demand for information regarding the cost-effectiveness of health care treatment options is growing. It is necessary to derive unit costs for services, such as general practice (GP) consultations, in order to inform the economic evaluation. AIM: To review the literature, provide a description of the three key steps that should be followed in the costing process and to provide a method for updating costs calculated in previous years. METHOD: A literature search was carried out to identify references that specifically describe the cost of a consultation in general practice. A total of 20 references were extracted, categorized and reviewed. A cost-price index for health care goods was obtained from the British Medical Association and used to construct a table to allow rapid reference and updating of cost results. The costs reported in the literature were updated and compared. RESULTS: Twenty published studies referring to the unit cost of a GP consultation were located in the searches. Half of these did not describe the methodology used to derive the costs; of those that did, less than half covered the necessary steps to derive unit costs. The cost of an average 10-minute consultation in 1995/96 figures was estimated to be 6.90 +/- 2.73 pounds. CONCLUSION: Great variation exists regarding the methodology for costing a GP consultation. If the methods used are stated explicitly and incorporate the three steps described, then results obtained in previous years may be updated using the cost-price index as shown (Table 1). Interpretation in this area must be made with caution.

Cost-Benefit Analysis↗
PubMedDate not supplied

The chiropractic consultation: a stressful experience?

INTRODUCTION: Psychosocial stress has been linked to compromised health status. Prolonged exposure to minor problems has been found to have an equal or greater impact on health status than exposure to isolated major events. Stress is, however, determined by the reaction of the individual to a stimulus; stress responses can be managed, and ill health outcomes can be minimized. This paper explores the stress level associated with the chiropractic consultation. METHOD: A case study using closed questions. Purposive sampling of chiropractors by the researcher and convenience sampling of patients by participating chiropractors was undertaken. Chiropractors and patients completed closed questions on the level of stress they believed patients associated with the chiropractic consultation. RESULTS: A case study of 25 chiropractors and 137 patients found that although the chiropractic consultation was not regarded as stressful by most patients, some patients found adjustment stressful. Chiropractors assessment of perceived stress varied according to the patient. The trend was for practitioners to overestimate the stress felt by the patient. CONCLUSION: Chiropractors demonstrated the personalized nature of their care by the specificity of their responses to each patient. The importance of explaining the adjustment and the sensations that patients are likely to experience, particularly in new patients, is confirmed. The desirability of scrutinizing the patient for evidence of stress and of using diverse strategies for minimizing the stress response are discussed. Although the chiropractic consultation is not generally regarded as a stress-provoking experience, chiropractors should actively screen their patients for evidence of stress and take steps to enhance their patients' perceptions of the chiropractic consultation as a stress-free experience.

Australia↗
PubMed1997

[A study of the demand for neuropediatric services in a general hospital. II. Reasons for consultation].

INTRODUCTION AND OBJECTIVE: The ambit of the work of each medical specialty is determined initially by the consultations it receives. Study of this will contribute to discovering the needs of the population, to establishing diagnostic strategies in the commonest clinical conditions and to the design of the healthcare organization necessary to fulfil these needs. Material and methods. We reviewed the reasons for consultations for neurological problems in 2,046 children evaluated during a 5 year period, between May 1990 and May 1995 in the Hospital Miguel Servet in Zaragoza, which did not previously have such a specialist. RESULTS AND CONCLUSIONS: The commonest reason for consultation was paroxystic disorders, which led to 33% of the consultations and affected 40% of the children seen. Other common causes of consultation, in decreasing order of frequency were: psychomotor retardation, head injury, perinatal distress, headache, disorders of movement, morphological changes, disorders of oculomotricity, visual disorders and acute encephalopathy.

Child↗
PubMed1998

Why do patients call out-of-hours following a recent consultation with their GP? A qualitative study in one general practice.

BACKGROUND: The reasons for the increase in demand for out-of-hours primary care are not clear. OBJECTIVES: We aimed to elicit the proportion of patients who call out-of-hours within 2 days of a GP consultation, and to explore the reasons for the out-of-hours call. METHOD: In one inner-city general practice, details were collected of all out-of-hours calls, over a 6-week period. Patients who called out-of-hours within 2 days of a GP consultation were identified and interviewed. Twenty semi-structured interviews were analysed using standard qualitative techniques. RESULTS: Fifteen per cent of the out-of-hours calls occurred within 2 days of a GP consultation. The reasons for the calls recorded by the doctor out-of-hours and described by the patient at interview were similar. In two-thirds of cases the calls were related to the initial problem, but there was no evidence suggesting dissatisfaction with the first contact as a reason for the call. Less than a quarter of calls were for ongoing acute medical problems, and a quarter were about medication prescribed at the first consultation. A third of the patients had mental health problems with other physical, social and emotional problems. Many of this group were high users of this and other health services, including accident and emergency and private medicine. Some people called with specific queries or were seeking general information to enhance their understanding of illness. CONCLUSION: This small study in one inner-city practice indicates that patients do not appear to call out-of-hours due to dissatisfaction with a previous consultation. There seems to be a wide variety of reasons why this pattern of service use occurs. The diversity of patients and problems and the prevalence of people with multiple problems highlights current challenges in inner-city primary health care.

Adolescent↗
PubMedDate not supplied

Coping with pressures in acute medicine. The Royal College of Physicians Consultant Questionnaire Survey.

OBJECTIVES: To assess the impact of reduced junior doctors' hours and increasing emergency admissions on patterns of acute medical care, and to evaluate recent innovations. METHODS: Questionnaire survey of all 2,980 consultant physicians in England, Wales and Northern Ireland potentially involved in acute medicine. The response rate was 63% with 1,3632 respondents undertaking unselected takes. RESULTS: WORKLOAD: The median average number of admissions per 24 h was 20-24, but 25% of consultants admitted > or = 30. The median frequency of take duties was 1 day in 5. COMPOSITION OF RESIDENT MEDICAL TEAMS: The most common permutation was one specialist registrar (SpR), senior house officer (SHO) and house physician (HP), coping with 20 admissions on average. However, the teams of 25% of respondents did not include a SpR, and 9% consisted solely of one SHO and one HP, with an average 17 admissions. PARTIAL SHIFT ROTAS: Forty-two per cent of consultants had introduced these. Most were critical of them because of their adverse impact on continuity of care and junior staff training, and their unpopularity with trainees. PATTERNS OF CARE: Only 10% of consultants indicated that myocardial infarction patients were managed exclusively by a cardiological team. Forty per cent operated an age-limit (varying between 65 and 85) for admission under care of the elderly physicians. Seventy per cent had introduced an admissions ward. NEW INITIATIVES TO COPE WITH ADMISSIONS: These included twice-daily consultant take rounds, use of nurse practitioners and staff-grade doctors, 12-hour takes and ward-based admission schemes. Measures to expedite discharges included 'discharge lounges', nurse facilitators, low-dependency wards and 'hospital at home' schemes.

Aged↗
PubMed1995

Communication between primary care physicians and consultants.

Optimal communication between primary care physicians and consultants includes transfer of relevant clinical information, including the patient's perspectives and values, and provides a means of collaboration to provide meaningful and health-promoting interventions. Communication difficulties arise because of lack of time, lack of clarity about the reason for referral, patient self-referral, and unclear follow-up plans. Also, primary care physicians and consultants may have different core values and may have little day-to-day contact with each other. Poor communication leads to disruptions in continuity of care, delayed diagnoses, unnecessary testing, and iatrogenic complications. Changes in the health care system offer the opportunity for improved collaboration between physicians by creating smaller administrative units within large health care systems that facilitate contact between primary care physicians and consultants; incorporation of discussions of uncertainty, patient preferences, and values into referral letters; adoption of a friendlier consultant letter format; and the improvement of the transfer of clinical data.

Adult↗
PubMed1993

Consultant opinion on orthodontic treatment plans used by dental practitioners: a pilot study.

Prior to 1987, dental practitioners in England and Wales intending to carry out all but the simplest orthodontic treatment within the National Health Service, were required to submit pretreatment study models, details of the orthodontic assessment and the proposed treatment plan to the Dental Estimates Board prior to starting treatment. Models taken at the end of treatment were required by the Board to enable payment to be made. In this pilot study, the acceptability of orthodontic treatment plans used by practitioners working in the General Dental Services was assessed by eight hospital consultants, using information about 40 cases submitted to the Dental Estimates Board in 1987/88. All consultants considered a high proportion of plans to be unacceptable, but agreement between the consultants was variable and some agreed with one another on very few plans. A single scorer used the weighted PAR (Peer Assessment Rating) index to assess the degree of departure from normal occlusion of both pre- and post-treatment models. Using accepted standards, only nine cases were greatly improved (PAR reduction > 70%) and the mean percentage reduction in PAR score was low. Consultant opinion on the appropriateness of treatment planning was not related to the outcome of orthodontic treatment.

Clinical Competence↗
PubMed1992

Development of a hospital ethics committee: lessons from five years of case consultations.

The development and consultation experience of an ethics committee in an urban community hospital has been presented, and various approaches to case consultation have been considered. Our committee has concentrated on the clinical evaluation model. As expected, most consultations have centered on issues of withdrawing or limiting medical care. Most patients evaluated have been unable to clearly express their wishes concerning further treatments, highlighting the need for promoting advance directives. When resorting to substituted judgment, our committee has supported continued care in a majority of cases. Limitation of the consultation process to the attending physician has, in our experience, actually served to increase the credibility of the committee and has promoted acceptance of its recommendations. The committee's most useful function seems to be in assisting physicians and their patients in defining realistic goals and limitations of treatment. Within this context, the coming decade may find ethics committees concerned less with promoting the autonomous wishes of individual patients than with defining the limits of that autonomy against the competing demands of the larger society. Such a shift should be approached with caution.

Advance Directives↗
PubMed2004

Interactive video specialty consultations in long-term care.

OBJECTIVES: To assess provider and resident satisfaction with and outcomes of specialist physician consultations provided via interactive video to residents of a long-term care (LTC) center. DESIGN: Cross-sectional survey. SETTING: Two Veterans Affairs Medical Centers (VAMC) and a state LTC center. PARTICIPANTS: Physicians (n=12) at the VAMC and nurses (n=30) and residents (n=62) at the LTC center. INTERVENTION: Interactive video conferencing to provide physician specialty visits to residents at the LTC center. MEASUREMENTS: Satisfaction ratings and record review to determine changes in treatment plan and follow-up care. RESULTS: Data were collected on 76 individual consultations in six clinics. The most frequent outcome was a change in treatment plan with the resident remaining at the LTC setting (n=29, 38%) or no change in treatment (n=26, 34%). Physicians' ratings were 78% good to excellent for usefulness in developing a diagnosis, 87% good to excellent for usefulness in developing a treatment plan, 79% good to excellent for quality of transmission, and 86% good to excellent satisfaction with the consult format. Overall, 72% of residents were satisfied with the consult format, and 92% felt that it was easier to obtain medical care via telemedicine. Nurses felt that the telemedicine clinics were a good use of their time and skills (100%). CONCLUSION: There was a high rate of physician, patient, and nurse satisfaction with interactive video conferencing. Care delivered to residents of LTC settings via video conferencing offers a number of potential advantages, including avoidance of travel for patient and provider and potentially greater continuity of care.

Cross-Sectional Studies↗
PubMed1999

[Comments on separate consultations for second opinions].

Second opinion consultations are an accepted phenomenon in daily clinical practice. In well defined situations such a consultation may be welcomed as a mean to obtain proper medical counselling and advice. However, to preserve a good doctor-patient relationship it is of utmost importance for what reason and by whom such a consultation is initiated. Setting up a specific second opinion outpatient clinic, where oncological patients are welcomed without prior knowledge of the primary consultant, is medically unnecessary and may well be the wrong solution for counselling problems that may originate in busy surgeries of general hospitals.

Humans↗