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PubMed1999

Marriage and family consultation with ranch and farm families: an empirical family case study.

There is a paucity of marriage and family therapy literature addressing therapeutic consultation with farm and ranch families. This article describes a case study in which several Marital and Family Therapy approaches were used to consult with a ranch family. It also provides empirical data showing in which of five treatment phases changes occurred. Two generations, including four couples from an extended family, participated in family consultation over 42 months and completed assessments six times. Statistical results and clinical impressions confirm that the five-phase consultative process resulted in significant improvements in family satisfaction with adaptability and family strains levels and positive movement in seven other areas.

Adult↗
PubMed1975

Child custody consultation.

The limited influence of the needs of the child upon the decision-making process in child custody disputes is discussed, with particular attention to the consultant's role and unique aspects of this type of consultation. A case is described in which a multitude of consultants presented the court with a morass of parent-oriented conflicting testimony. It is concluded that clinicians can better serve children by seeking to consult not for one of the competing adult parties, but only for the court.

Child Advocacy↗
PubMed1977

Consultation on a pediatric surgical ward: creating an empathic climate.

Meaningful consultation to a pediatric surgical service must occur within an emotional climate that supports the consultative process. This paper examines the intangible qualities inherent in such a milieu and the consultant's role in structuring an atmosphere in which one's consultative skills can be utilized effectively.

Attitude of Health Personnel↗
PubMed1977

Problem-solving strategies in consultation.

Techniques for overcoming common stumbling blocks in consultation are outlined, and the advantages to consultants of viewing consultation as a mutual problem-solving process are discussed. It is suggested that the consultant-in-training can achieve confidence in this approach only through experiencing the relationship from the other side by gaining first-hand understanding of the situation of the consultee. Strategies towards this end are offered.

Attitude↗
PubMedDate not supplied

The quality professional's expanding role as internal consultant: practical tips and survival strategies--Part 2.

Part 1 of this two-part article addressed the approach and skills needed to gain a clearly defined and agreed-upon direction for the consulting mission. The importance of mental preparation and flexibility was emphasized and a number of ethical dilemmas were reviewed, including confidentiality issues. Part 2 addresses strategies for handling difficult psychological issues that often come up in the process of internal consulting. Transference, resistance, regressions, and counterproductive group dynamics are reviewed. These psychological issues may be the predominant source of stress in an internal consulting experience. Case examples are presented along with some empowering strategies. It is hoped that through this review, the quality professional will be better prepared to meet the exciting and rewarding challenges of internal consulting.

Consultants↗
PubMed2003

Joint consultation of general practitioner and rheumatologist: does it matter?

OBJECTIVE: To assess the effects of joint consultation on referral behaviour of general practitioners (GPs) in a prospective cohort study. METHODS: All patients with rheumatological complaints that 17 participating GPs, from the area of the University Hospital Maastricht, wanted to refer during a two year inclusion period (n=166) were eligible for inclusion. These patients were either referred to the outpatient clinic, or presented at a joint consultation held every six weeks at the practice of the GP, where groups of three GPs presented their patients to a visiting, consulting rheumatologist. The number of patients referred by each GP a year at the end of the trial, comparing participating and non-participating GPs, was the main outcome measure. RESULTS: During two years of inclusion, the 17 participating GPs presented 166 patients. The number of patients referred by each GP a year decreased for the participating GPs by 62% at the end of the whole study. By contrast, non-participating GPs maintained the same rate of referral. The range of diagnoses remained proportionally the same throughout the study, with the exception of fibromyalgia. The referral rate of this diagnosis decreased significantly (p=0.001). CONCLUSIONS: Joint consultation seems to be a good strategy in influencing the referral behaviour of GPs in the area of rheumatology. The decrease in referral is substantial and can subsequently lead to a reduction of waiting lists.

Adult↗
PubMed2006

Raising the benchmark for the 21st century--the 1000 cataract operations audit and survey: outcomes, consultant-supervised training and sourcing NHS choice.

PURPOSE: Clinical outcomes for phacoemulsification surgery are still compared with the almost 10-year-old benchmark of the 1997-98 National Cataract Surgery Survey (NCSS) published in this journal. Extraneous to the peer-reviewed research literature, more recent databases suggest much better results may be being obtained. This offered the rare opportunity to perform an audit as research investigating if this was indeed the case and a new benchmark is needed, with the additional standard of rigorous study peer review by independent senior ophthalmologists. At this pilot centre for Patient Choice provision, all cataract surgery was performed on Consultant-supervised training lists, a novel extension in-sourcing care using public resources rather than to an independent sector that may not be supervised by NHS Consultants. Patient satisfaction was also surveyed. We asked whether the NCSS is out-of-date, and whether good outcomes on Choice schemes are compatible with Consultant-led training within the National Health Service? METHODS: An audit of 1000 consecutive patients undergoing cataract surgery on Patient Choice at the Western Eye Hospital between October 2002 and September 2004. All subjects were scheduled for phacoemulsification. A novel policy was extending "choice" onto training list slots for this period. A validated questionnaire assessed patient satisfaction. RESULTS: A best corrected visual acuity of 6/12 or better was obtained in 93% of cases. Over 80% of cases were +/-1 D of target refraction (65.7% within 0.5 D). The total incidence of complications was 8.7%. Overall incidence of major complications was 2.4%. Incidence of vitreous loss was 1.1% and that of endophthalmitis 0.1%. Complications rates were lowest for consultants (less than 1%). User satisfaction with having cataract surgery on "patient choice" was high. CONCLUSIONS: Cataract surgery under patient choice on supervised training lists is associated with a visual outcome and an incidence of complications at least as good as the published national average. User satisfaction is high. Cataract surgery under patient choice is compatible with training activity in receiving hospitals. The improvement in outcomes since the 1997-98 NCSS suggest that the accepted standards for complication rates should be updated to reflect the fact that phacoemulsification has become an established procedure.

Adult↗
PubMed1984

Equity and consultation rates in general practice.

An attempt was made to distinguish different types of consultations and their variation by social class by a secondary analysis of the second national morbidity survey in general practice. The greatest difference in consultation rates, comparing patients in social classes IV and V with those in classes I and II, was for life threatening, urgent, chronic, or incapacitating conditions, thus matching the presumed difference in need. For more trivial conditions and for symptoms not specifically diagnosed the difference between social classes was less, and for married women in various ways consultation rates suggested less care seeking by patients in the lower social classes. The different uses made of primary care is more illuminating and more relevant to the question of equality in use of services than crude overall consulting rates by social class.

Adolescent↗
PubMed1985

Consultation length: general practitioners' attitudes and practices.

A survey by postal questionnaire of 190 Nottingham general practitioners on consultation length was conducted and a response rate of 82% achieved. Reported consultation length was associated with the doctor's gender, use of an appointment system, membership of the Royal College of General Practitioners, and the number of patients seen during an average surgery. Seventy two per cent of respondents would have liked to have offered longer consultations and most thought that longer consultations would result in a higher standard of care and a lower prescription rate.

Appointments and Schedules↗
PubMed1987

The consultant's role in continuing medical education of general practitioners: the case of rheumatology.

Consultant rheumatologists were surveyed by questionnaire about their contribution to the continuing education of general practitioners, and 84% (203/243) replied. Altogether 157 respondents had participated in some form of teaching, 147 in collective teaching sessions such as lectures and 99 in the teaching of small groups. Arthritis comprised 44% of the rheumatological topics taught; there was a noticeable lack of teaching on problems commonly encountered in general practice, such as soft tissue rheumatism and injury and back pain, and on clinical skills including examination and injection of joints. Eighty eight respondents made comments and suggestions. The favoured educational strategies were small group teaching, apprenticeship schemes, and interchange between general practitioners and consultants about shared cases. This contrasts with what was typically done--namely, formal lectures on rheumatoid arthritis in postgraduate medical centres. These findings raise questions about the continuing education of consultants themselves as well as about the consultants' role in teaching others.

Education, Medical, Continuing↗
PubMed1990

"Short report" staffing in practice: five years' experience of a consultant based service in obstetrics and neonatal paediatrics.

Recent government plans include the concept of a core of doctors of intermediate grade providing 24 hour emergency cover in hospital departments. Hinchingbrooke Hospital has, since its opening in 1983, been run on a two tier basis, with consultants and a part time senior registrar supported only by senior house officers in their first post, usually on general practice vocational training schemes. With a planned rate of around 2000 deliveries per year all high risk obstetric and neonatal paediatric procedures, including ventilation of very small babies, have been carried out within the hospital. A study of the first five complete years of operation of the obstetric and paediatric departments showed that the perinatal mortality rate was low (hospital rate 4.7/1000 in 9149 deliveries during 1984-8 v district rate 5.1/1000 during 1986-8), and patient satisfaction seemed to be high. In a separate prospective study of out of hours work performed by consultants in paediatrics (four weeks) and obstetrics (20 days) three consultants in paediatrics spent 71 hours working out of hours; for the obstetricians, of the 56 request for advice and 38 interventions, only five and six respectively occurred between midnight and 9 am. Although successful at this hospital, the two tier system would be expensive under the Royal College of Obstetricians' guidelines of one consultant to a maximum of 500 deliveries. An equal mixture of two tier and three tier systems might be the best solution for patient care and training of junior doctors.

Consultants↗
PubMed1994

Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers.

OBJECTIVE: To study stress, anxiety, and depression in a group of senior health service staff. DESIGN: Postal survey. SUBJECTS: 81 hospital consultants, 322 general practitioners, and 121 senior hospital managers (total 524). MAIN OUTCOME MEASURES: Scores on the general health questionnaire and the hospital anxiety and depression scale. RESULTS: Sixty five (80%) consultants, 257 (80%) general practitioners, and 67 (56%) managers replied. Of all 389 subjects, 183 (47%) scored positively on the general health questionnaire, indicating high levels of stress. From scores on the hospital anxiety and depression scale only 178 (46%) would be regarded as free from anxiety, with 100 (25%) scoring as borderline cases and 111 (29%) likely to be experiencing clinically measurable symptoms. The findings for depression were also of some concern, especially for general practitioners, with 69 (27%) scoring as borderline or likely to be depressed. General practitioners were more likely to be depressed than managers (69 (27%) v 4 (6%) scored > or = 8 on hospital anxiety and depression scale-D; P = 0.004) with no significant difference between general practitioners and consultants. General practitioners were significantly more likely to show suicidal thinking than were consultants (36 (14%) v 3 (5%); P = 0.04) but not managers (9 (13%)). No significant difference could be found between the three groups on any other measure. CONCLUSIONS: The levels of stress, anxiety, and depression in senior doctors and managers in the NHS seem to be high and perhaps higher than expected.

Anxiety↗
PubMed2005

Promotion to hospital consultant: regression analysis using NHS administrative data.

OBJECTIVES: To examine factors influencing promotion to hospital consultant. DESIGN: Multivariate logistic regression analysis of NHS administrative data between 1991 and 2000. SETTING: Hospitals in NHS Scotland. Population All registrars, senior registrars, and specialist registrars in Scotland. MAIN OUTCOME MEASURE: The proportion of doctors promoted to NHS consultant. RESULTS: Compared with doctors who graduated in Scotland, graduates from the rest of the United Kingdom and from overseas were less likely to be promoted to consultant (odds ratio 0.65, 95% confidence interval 0.52 to 0.82; and 0.37, 0.28 to 0.50, respectively). Promotion and holding an honorary contract before promotion were positively associated (1.37, 1.03 to 1.83); and the number of years since graduation (5.98 per year, 4.94 to 7.23). Women were less likely to be promoted (0.73, 0.60 to 0.90), as were doctors who worked part time (0.27, 0.17 to 0.42). Probabilities of promotion did not have a clear time trend between 1993 and 2000, and NHS boards in non-metropolitan areas of Scotland were more likely to offer promotions than NHS boards in metropolitan areas, presumably reflecting a higher gap between demand and supply in these boards. CONCLUSION: As the proportion of women in hospital medicine increases, government targets for the recruitment of consultants are unlikely to be met unless the promotion process is examined. It is unclear whether more recent reforms of the medical career structure will deal with these issues.

Career Mobility↗
PubMed1993

Use of primary health services in sparsely populated country districts by patients with musculoskeletal symptoms: consultations with a physician.

STUDY OBJECTIVE: To examine the extent to which people consult health centre doctors about various musculoskeletal symptoms and to identify those groups of patients who are responsible for the main workload in primary health care caused by musculoskeletal complaints. DESIGN: A cross sectional investigation based on case records of people who visited health centre physicians. SETTING: The population of six Finnish health centre districts (93,000 inhabitants, 64 physicians' posts in primary care centres). SUBJECTS: 6526 patients (7634 visits) who consulted a physician at any of six health centres during a two week period, of which 1380 consulted for musculoskeletal symptoms. MEASUREMENTS AND MAIN RESULTS: The reasons for the visits were abstracted from the case records and were analysed by cross tabulation. The rate of people visiting for musculoskeletal symptoms during a two week period was on average 15 per 1000 inhabitants. It was highest in men aged 45-54 years (25/1000) and in women aged 55-64 years (26/1000); the rate fell to the average in men over 54 and women over 64 years. Patients with musculoskeletal symptoms accounted for 21% of all patients and 27% of those over 15 years of age. Low back pain was the most common reason for consultation in men aged 25-54 years, while for women aged 35-74 years, the most common reason was neck and shoulder pain. CONCLUSIONS: Over one quarter of adults visiting a health centre doctor do so because of musculoskeletal disorders. This fact must be considered when developing health care services and organising basic education and further in-service training for doctors.

Adolescent↗
PubMed1995

Added value of radiologist consultation to family practitioners in the outpatient setting.

PURPOSE: To measure the added value of a radiologist's consultation to the interpretation of radiographs previously read by a family practitioner. MATERIALS AND METHODS: The authors reviewed 1,674 chest and extremity radiographs previously read by a family practitioner and consulting radiologist. The 196 radiographs in which there was a discrepancy between the family practitioner's and radiologist's report were evaluated by a radiologist and family physician not involved in and blinded to the original interpretations. The overall accuracy of the participants was determined and differences statistically quantified. RESULTS: The overall sensitivity of the radiologists was greater than that of the family practitioners (92% vs 86%); specificity was not significantly different. For extremity examinations, there were no significant differences in accuracy of the radiologists and family practitioners; the sensitivity of radiologists for chest studies was considerably greater (89% vs 80%). Radiologic consultation was of particular value in the detection of pneumonia and masses. CONCLUSION: At a family practice center, the radiologist's role for extremity radiographs might be limited to individual consultation, with review of all chest radiographs.

Ambulatory Care↗
PubMed2005

[What are users views of medical residents attending primary care consultations?].

OBJECTIVE: To find what users think of the presence of medical residents (MIR) at primary care consultations. DESIGN: Observational and cross-sectional descriptive study. SETTING: Urban health centre. PATIENTS: 421 patients, selected by systematic sampling, attending consultations of MIR tutors. METHOD: A structured questionnaire was drawn up, with some closed questions with multiple-option replies on the Likert scale; and others with a yes/no or "indifferent" reply. The questionnaires were filled out in the waiting-rooms. RESULTS: 100% (63% women, 37% men) answered the questionnaire. 71% preferred to be seen by the same doctor; and 68% thought they were better treated if they were always seen by the same doctor. 89% thought that the presence of the resident was a necessary part of his/her training; 90% were not bothered by his/her presence during the consultation; 82% thought the resident did not obstruct in any way their relationship with the doctor; 94% thought that the presence of the resident had never stopped them mentioning something important; 55% thought that patients had the right to an opinion on the presence of the resident. CONCLUSIONS: Most patients valued the presence of residents at consultations positively and thought it a necessary part of their training.

Cross-Sectional Studies↗
PubMed2005

[Degree of satisfaction of primary health workers regarding a consultancy-based specialty care model].

OBJECTIVE: To evaluate the degree of satisfaction of primary health care workers with a model of specialty care based on consultancy. METHODS: A questionnaire was delivered to the nurses and physicians of a Primary Care centre, in order to assess their satisfaction with the different activities in the specialty of endocrinology (1-5 points). RESULTS: The consultancy activity itself was given 4.41 +/- 0.89 points by the nurses (n = 39) and 3.60 +/- 0.97 by physicians (n = 32) (p < 0.05), clinical sessions, 4.21 +/- 0.74 and 3.82 +/- 1.02, and diagnostic and therapeutic protocols, 4.12 +/- 0.71 points (physicians) (p < 0.05 vs consultancy). Global scores was 4.33 +/- 0.70 and 3.76 +/- 0.89 points, respectively. 74% and 80% of the nurses and 58% and 69% of the physicians considered the present model appropriate for other specialties and primary care center, respectively. CONCLUSIONS: The health care workers at the primary care center assesse show a high degree of satisfaction with this model of specialised care based on consultancy.

Adult↗
PubMed1998

Determinants of doctor consultation for micturition problems in an elderly male population.

OBJECTIVE: To study which factors influence doctor consultation when a subject has micturition problems. METHODS: Postal questionnaire in an open population of older men (n = 1,695), followed by investigations in 10 general practices, including uroflowmetry. RESULTS: 25% of the men had micturition problems, of which 10-30% presented their symptoms to a doctor. Almost 60% experienced an influence of their micturition habits on activities of daily living. More than 85% of the men were not able to compare their micturition pattern with others. In multiple logistic regression, presentation to a doctor was independently associated with obstructive symptoms, dysuria, men defining their situation as a complaint, depressive mood, more frequent sexual desire and smoking. Many other factors which might play a role in diagnosis and timing of treatment were not found to influence consultation. CONCLUSION: Most men deal with micturition problems without consulting, although symptoms have a substantial impact on daily life. Consultation was associated with symptoms, psychological factors and smoking.

Aged↗