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PubMed1987

Psychiatric consultation as conflict resolution.

Interpersonal conflict between patient and physician is a frequent concomitant of the complex issues arising from medical or surgical illness and hospitalization. It is an often unacknowledged stimulus for seeking psychiatric consultation. Consultation may be sought to assist in resolving conflicts over problem definition, the treatment contract, or the patient-physician relationship per se. An understanding of potential sources and manifestations of conflict guides effective intervention by the consultant. The integration of concepts of conflict and conflict resolution with existing models of consultation-liaison and practice is illustrated in several case discussion.

Adult↗
PubMed1988

Psychiatric consultation in the family physician's office. Advantages and hidden benefits.

Family physicians spend up to 40% of their time dealing with emotional and psychiatric problems and may be the only caretaker for 60% of all episodes of psychiatric illness. One way of strengthening the role of the family physician in managing psychiatric problems in their practices is by involving them in an initial psychiatric assessment, which may entail the patient being seen in the primary care setting. This intervention, offered by a community mental health center (CMHC) in Ontario, Canada, was evaluated by examining all cases referred by family physicians over a 3-year period and comparing those seen in consultation in family physicians offices with those seen in consultation in the CMHC. While the office consultation appears to be a cost-effective intervention, the main factor that determined whether it took place appeared to be the attitude of the referring physician rather than the nature of presenting problem. Other benefits arising from such a liaison-consultation relationship are also discussed.

Adult↗
PubMed1989

Effect of liaison psychiatry on attitudes toward psychiatry, rate of consultation, and psychosocial documentation.

Prior literature suggested that psychiatric liaison on medical wards would produce a more positive attitude towards psychiatry, more psychosocial chart documentation, and a higher consultation request rate. Over 3 years, liaison was conducted on two medical wards, and its effect was contrasted with two control (consultation only) medical wards. Liaison activities were more favorably received by consultees than consultation alone and increased the consultation request rate, but produced no change in psychosocial documentation. Additional effectiveness of liaison activities might be achieved through direct, focused interventions, and through active involvement of senior medical faculty.

Attitude of Health Personnel↗
PubMed1989

Psychiatric consultation on an otolaryngology liaison service.

Otolaryngology patients (especially those with tracheostomies) present a significant challenge to psychiatrists from both a diagnostic and therapeutic standpoint. To date, no study has been made of psychiatric disorders among this important group of patients. At the Mount Sinai Medical Center, a liaison psychiatrist has been involved with a specialized otolaryngology cluster unit since 1979. Using a 384-item computerized database protocol developed at Mount Sinai, data on 139 otolaryngology patients were recorded and compared with 1662 "Other" inpatient psychiatric consultations on the medical and surgical services during 1980-1987. The otolaryngology patients as a group were more likely to be male (p = 0.011), married (p = 0.001) and employed (p less than 0.001). Cancer was the most common medical disorder, and the average level of stress as reported on DSM-III's Axis IV (5.1, severe) was significantly greater (p less than 0.0001) than that for the "Other." The most common psychiatric response was adjustment disorder (36%). The length of stay of those ENT patients seen in psychiatric consultation was 26.4 days, in contrast to 11.1 days for all ENT patients. However, the length of stay of those patients on ENT receiving a psychiatric consultation was not different from the "Other" psychiatric consultation cohort (26.3 days). Despite the higher level of stress, the incidence of significant psychiatric morbidity was lower for the ENT cohort. The primary effect of the liaison psychiatrist was to lower the threshold for case identification that enhanced the referral rate on the ENT unit.

Adaptation, Psychological↗
PubMed1990

Psychogeriatric consultation. General Hospital versus home for the aged.

As more elderly persons are institutionalized in long-term care settings, there will be an increasing need for psychiatric consultation-liaison (C/L) services. An understanding of how patterns of C/L service provision differ in these settings from those in the general hospital is important for efficient use of resources. In this study, certain characteristics of psychiatric consultations for the elderly patients in a general hospital were compared to consultations in a home for the aged. Three groups of 30 patients were examined: patients age 60 and over in a general hospital (GH), patients under age 60 in a general hospital (GHY), and patients in a home for the aged (HA). GH and GHY shared many characteristics, but there were significant differences between HA and GH: Consultations for HA were less likely to be urgent and more likely to be for management. Dementia was diagnosed in 70% of HA versus 27% in GH. Types of interventions were similar in GH and HA except that more psychotherapy was done in HA. In HA more contact was made with allied health professionals, while in GH there was more contact with medical personnel. GH patients were seen more intensively during the first 2 weeks following referral. We conclude that the major part-time attendance of a psychiatrist skilled in both the behavioral management of demented patients and liaison with allied health professionals is likely to be sufficient in long-term care institutions for elderly patients. However, the psychiatrist must also be proficient in the education of the staff of the institution so as to encourage the referral of all those patients who require psychiatric attention.

Aged↗
PubMed1992

A randomized trial of psychiatric consultation with distressed high utilizers.

This study reports the results of a randomized trial of a psychiatric consultation intervention with distressed, high utilizing patients of 18 physicians in two primary care clinics. Psychiatric consultation was associated with a significant increase in the use of antidepressants in intervention patients compared with controls in the first 6 months after intervention. Intervention patients were also significantly more likely to continue antidepressant treatment than control patients. The primary care physicians receiving psychiatric consultations increased the rate of prescribing antidepressant medications in their practice from 32 prescriptions filled per 1,000 visits before their participation in four consultations to 44 new prescriptions per 1,000 visits in the 12-month period after. There were no significant differences between intervention patients and controls at 6 and 12 months after randomization in psychiatric distress, functional disability, or utilization of health care (ambulatory visits, radiographic and laboratory testing services, admissions to inpatient medical care).

Ambulatory Care↗
PubMed1996

The European Consultation-Liaison Workgroup (ECLW) Collaborative Study. I. General outline.

Previous C-L psychiatric service research is seriously limited by its parochial nature; very few results can be generalized outside of the hospital in which the original study was performed because of differences in the nature of the hospital and the type of C-L service. This article presents the general outline and methodology of a European multicentered C-L service delivery study effected by the European Consultation-Liaison Workgroup for General Hospital Psychiatry and Psychosomatics (ECLW). The study is unique in its kind as it allows the comparison of very different C-L services; for example, some services are run by C-L psychiatrists, others are run by C-L psychosomaticists and the study encompasses a large variety of different settings. As a result, both common factors in C-L service delivery and specific local patterns can be explored. The overall hypothesis tested in this study was that the most developed services would see (as well as more patients) a wider variety of clinical problems than small services. The implication is that the absence of well-developed C-L services in a general hospital may mean that there are patients with unmet mental health needs. In separate articles the training and reliability testing of the new Patient Registration Form (PRF) and the Institutional and Provider characteristics will be described. The former includes the use of ICD-10 in the general hospital setting. This study is a collaborative effort made by 226 consultants from 56 psychiatric C-L services in 11 countries. Each consultant recorded details of 1 year's caseload leading to a thorough description of 14,717 patients collected between 1991 and 1993. The advanced methodology included a multicentered international approach, rigid training for all participating consultants, and the development and testing of new instruments. This will allow us to assess the impact of important structural and process variables on the outcome of C-L service delivery in several European countries. These results will be reported in papers both in the international and national literature of the participating countries.

Adolescent↗
PubMed1988

Contributions of patients to general practitioner consultations in relation to their understanding of doctor's instructions and advice.

126 patients of 6 general practitioners were tape recorded in consultation with their doctor and interviewed immediately afterwards, and 81 of the patients were interviewed again 2 days later. We related the accuracy of patients' accounts of the instructions and advice they were offered to two characteristics of patient's participation during their consultation: (i) the frequency of spontaneous comments or queries about diagnosis, cause, consequences or treatment of the problem presented, and (ii) the frequency of comments and queries which sought to clarify something said by the doctor. The incidence of the latter was unrelated to accuracy of patients' subsequent accounts. However, people who made errors or omissions in both immediate and home interviews in their accounts of instructions and advice offered, were more likely than those who gave accurate accounts to have produced spontaneous comments or queries during their consultation. Whether the doctor accepted, rejected or ignored these ideas was irrelevant to the incidence of post-consultation errors and omissions.

Family Practice↗
PubMed1996

Patient-physician interactions in diabetes management: consistencies and variation in the structure and content of two consultations.

The structure and content of medical consultations concerning diabetes were examined in two, successive quarterly medical consultations between two physicians and their diabetes patients (N = 44). The consultations were audio-taped and coded for structure (e.g. question asking, information giving) using a modified version of the Roter Interactional Analysis System (inter-coder correlations typically exceeded 0.90 for the composite variables derived from the coding system). The tapes were also coded for content by monitoring the topics discussed (e.g. diet, medication, exercise). The majority of the interactions consisted primarily of information giving and positive talk on the part of both patients and providers. Nutrition-related issued, blood glucose monitoring, medication and exercise were addressed in the majority of interactions, but other regimen areas such as foot care, smoking habits, and alcohol were seldom discussed. There was little stability across the two consultations in terms of either structure (median test-retest correlation = 0.24) or content (majority of test-retest correlations were below 0.30). The importance of studying more than one patient-physician encounter when studying interaction style and content is discussed, as is the need for investigation of interactions between non-physician health care providers and patients with chronic disease.

Diabetes Mellitus↗
PubMed1996

Developing a training programme in patient-centred consulting for evaluation in a randomised controlled trial; diabetes care from diagnosis in British primary care.

AIM: To develop a feasible/theoretically based training programme in patient-centred consulting, for evaluation in a randomised controlled trial of diabetes care from diagnosis. METHODS: The programme was developed with four primary care teams and their patients in an action research framework, with observation of diabetes review consultations before and after training, and evaluated by questionnaire after each training session, among 23 general practitioners and 32 practice nurses from 21 practices in the trial. RESULTS: The observation study identified opportunities and obstacles to introducing a patient-centred approach into daily practice, especially in relation to time management and skill needs. The modified training programme was rated highly by participating general practitioners and nurses. CONCLUSIONS: Developing training programmes with the help of participating primary care teams ensures relevance and feasibility. Patient-centred consulting demands a shift from habitual consulting patterns. Practitioners are implementing the approach in practice, and the impact on patients is now under evaluation in the randomised controlled trial.

Diabetes Mellitus, Type 2↗
PubMed1994

The Palliative Care Consultation Service of the Medical College of Wisconsin.

Palliative care has not become a routine aspect of US academic medicine due to lack of reimbursement for clinical services, little research funding, and the perception that care for the terminally ill is not important in academic medical centers. This article describes the clinical activities of a new Palliative Care Consultation Service (PCS) for inpatients and outpatients, which was started at the Medical College of Wisconsin in April 1993. The goals of the PCS are to provide symptom control, assist with end-of-life decision making, and serve as a resource for appropriate discharge planning for all dying patients, not only those with cancer. Since its inception, an average of five consultations per week have been seen. Pain and end-of-life decisions were the most frequent reasons for consultation. Thirteen different clinical services consulted the PCS, most commonly internal medicine and oncology. Cancer and acquired immunodeficiency syndrome (AIDS) were the most frequent diagnoses. The PCS has also been used as a resource for assessment of inpatients with chronic nonmalignant pain who were believed to be drug addicts. The PCS has received widespread acceptance by the medical, nursing, and support staffs. The clinical and educational role of a dedicated palliative care service in academic medicine is discussed.

Humans↗
PubMed2005

Consultations concerning contraception and induced abortions among university students--trends in Finland 1986-2003.

The Finnish Student Health Service (FSHS) provides primary health care services to university students in Finland. The material for this study was drawn from the statistics of the FSHS. From 1986 to 2003, the number of students increased by 50%, while physician consultations did not, indeed to the contrary. The numbers of family planning consultations fell from 358 to 217 per 1000 female students. The induced abortion rates among university students are very low compared with the population in general and decreased from 4 to 3 per 1000 female students. Students are responsible, and because they want to postpone pregnancy after studies, they use contraceptives effectively. The FSHS has succeeded in guaranteeing contraception services and in preventing unwanted pregnancies and minimizing the need for induced abortions among university students while at the same time decreasing physician consultations. This was possible by changing the distribution of tasks among physicians and nurses, and by adding telephone contacts instead of face-to-face consultations with physicians.

Abortion, Induced↗
PubMed2006

Consultation in palliative care: the relevance of clarification of problems.

This study aims to determine the extent and nature of problems in palliative care that are newly identified in the consultation process and the factors influencing their identification. The consultation process includes clarification of problems mentioned by professionals requesting advice. Data are derived from the standard registration forms of Palliative Care Consultation teams. Multilevel logistic regression analysis was carried out with newly identified problem as dependent variable. Fifty seven percent of problems (n=7854) were newly identified. Most newly identified problems were related to physical and pharmacological problems. If psychosocial/spiritual problems were identified, this occurred in most cases through clarification (70%). Newly identified problems were more likely to be identified in the domain of spiritual and psychosocial problems, in bedside consultations, in requests from clinical physicians, and for patients accommodated in a hospice or hospital. Explicit clarification of problems facilitates the identification and addressing of a more comprehensive and specific scope of problems.

Adult↗
PubMed2004

Impact of hand-carried cardiac ultrasound on diagnosis and management during cardiac consultation rounds.

AIM: To evaluate the impact of hand-carried cardiac ultrasound (HCU) on the diagnosis and management of patients during cardiac consultation rounds. METHODS AND RESULTS: One hundred and fifty patients hospitalized in non-cardiac units were included after the consulting cardiologist felt that an echocardiographic examination was indicated as part of his work-up. They were randomly allocated to echocardiography with an HCU device (SonoHeart, SonoSite, Inc.) (75 patients) or with a full-featured standard echo (FE) system (75 patients). The consulting cardiologist noted whether a definitive diagnosis was made or further study was necessary. Diagnosis and change in management were noted. In the HCU patient group there were 103 clinical questions. Seventy-two percent of the referral questions required no comprehensive echocardiographic evaluation. For questions of left ventricular function, valve abnormalities and pericardial effusion this was 98%. In 48% there was an immediate change in clinical management. In the FE patient group there were 94 clinical questions. In 32% the FE examination led to change in clinical management. CONCLUSION: HCU echocardiography provides clinically worthwhile assessment of left ventricular function, valve abnormalities and pericardial effusion in 98% of the cases. A direct assessment of cardiac function and anatomy at the bedside by an experienced cardiologist results in a significant immediate change in clinical management during consultation.

Echocardiography↗
PubMed2004

Barriers to the adoption of computerised decision support systems in general practice consultations: a qualitative study of GPs' perspectives.

INTRODUCTION: Computerised decision support systems are increasingly important in primary care for the practice of evidence-based medicine and the development of shared GP-patient decision making. However, despite their emergence, such systems have not been entirely embraced by GPs. There is little qualitative research exploring practical barriers to the adoption of decision support systems in this setting. METHOD: Qualitative interviews with 15 GPs in the West Midlands. RESULTS: Several practical barriers were identified to the use of computerised support systems in primary care consultations. These included limitations of practitioners' IT skills, problems for GPs in understanding the risk output of systems and GP concerns about communicating risk sufficiently well to patients. Concerns over the time implications of using a system in a consultation was also identified as a barrier. CONCLUSION: Designers of decision support systems for use in primary care consultations must account for the practical needs of users when developing computerised support systems. Systems must be acceptable to the format of a consultation, include definitions of what output means, and help facilitate dialogue between the GP and the patient.

Attitude of Health Personnel↗
PubMed2005

Electronic patient-provider communication: will it offset office visits and telephone consultations in primary care?

BACKGROUND AND AIM: Electronic patient-provider communication promises to improve efficiency and effectiveness of clinical care. This study aims to explore whether a secure web-based messaging system is an effective way of providing patient care in general practices. METHOD: We conducted a randomised controlled trail and recruited 200 patients from the waiting area in one primary clinic in Norway. Participants were randomised to either the intervention group, which received access to a secure messaging system, or the control group receiving standard care without such access. Primary outcome measures were number of online consultations, telephone consultations and office visits in the two groups. Data were derived from patient records and collected 1 year prior to (baseline), and 1 year after the intervention. RESULTS: Forty-six percent of the patients who were given access to the messaging system (n=99) used the online communication system on at least one occasion (ranging from 1 to 17 messages per patient per year). A total of 147 electronic messages were sent to six general practitioners during a 1-year trial period. Eleven percent of the messages were to schedule an appointment. In 10% of the messages, the GP was unable to respond adequately and recommended an office visit. The reduction in office visits over time was greater for the intervention group than for the control group (P=0.034). There was however no significant difference in the number of telephone consultations between the groups during the study (P=0.258). CONCLUSION: The use of a secure electronic messaging system reduced the number of office visits at the general practice, but not phone consultations.

Adult↗
PubMedDate not supplied

Chiropractic consultation requests in the Veterans Affairs Health Care System: demographic characteristics of the initial 100 patients at the Western New York medical center.

OBJECTIVES: The objectives of this study were to review the demographic characteristics of Veterans Affairs (VA) chiropractic patients and to determine the level of appropriateness of chiropractic consultation requests within a VA chiropractic clinic. Information regarding the volume of requests and wait times for appointments were obtained to provide insight on the demand for and access to VA chiropractic services. METHODS: A purposive sample of the first 100 chiropractic consultation requests received through the Computerized Patient Record System at the VA of Western New York Health Care System was selected for data collection and analysis. RESULTS: The VA chiropractic patients in this study were primarily older men with chronic low-back pain that had not responded to medical management and other treatment modalities. More than half of the patients had service-connected disabilities. Consultation requests came largely from primary care, and most requests were for patients for whom chiropractic was clinically indicated and requested preconsultation diagnostic studies had been performed. CONCLUSIONS: The VA chiropractic patients in this study differed from traditional non-VA chiropractic patients with regard to age and sex. A review of the chiropractic consultation requests that were considered inappropriate resulted in a revision of the instructions for requesting providers within the Computerized Patient Record System. Additional health systems research is indicated to evaluate chiropractic implementation on a larger scale within the VA Health Care System.

Adult↗
PubMed2004

Women's views of optimal risk communication and decision making in general practice consultations about the menopause and hormone replacement therapy.

Primary care consultations about the menopause and hormone replacement therapy (HRT) involve decision making in the face of clinical uncertainty. This qualitative study used focus groups and semi-structured interviews with primary care patients to explore patients' perspectives of optimal risk communication and decision making, and their views on how to improve its effectiveness. The study was set in two general practices in Cambridge, and the participants were 40 women aged between 50 and 55 years, known to be Current-Users (CU), Ex-Users (EU), or Never-Users (NU) of HRT. The majority of participants favoured communication of risks and benefits to facilitate an informed and personalised choice resulting in informed shared decision making, while some wanted a more directive approach. Women felt that risk communication would be optimised by the provision of unbiased, truthful and summarised information, and also by the personalisation of both this risk information and subsequent management of the menopause and treatment with HRT. Barriers to optimal risk communication and decision making included lack of time, GP attitudes and poor communication in the primary care consultation. In summary, consultations concerning the menopause and HRT involve complex decision making in the face of uncertainty, and most patients favour evidence-based, individualised risk information and shared decision making leading to informed choices. Some patients wish for a more directive approach, and practitioners need to develop skills to evaluate each patient's needs at each consultation.

Attitude of Health Personnel↗