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PubMed2006

Recurrent abdominal pain: what determines medical consulting behavior?

Recurrent abdominal pain (RAP) is associated with increased health care visits and school absences. In adults suffering from functional pain, psychosocial factors determine illness behavior and we aimed to investigate its role among children. A community sample of 40 RAP consulters, 41 RAP nonconsulters, and 36 pain-free controls and their mothers completed questionnaires on GI and non-GI symptoms, school absences, psychological symptoms, coping, self-esteem, and behavioral and cognitive responses to RAP. T-tests showed significant differences between RAP and controls in (1) GI and non-GI symptoms and school absences, (2) child distress and passive coping, and (3) mother's IBS severity, somatization, and fears about RAP. RAP consulters reported the same levels of GI symptoms and psychological distress as nonconsulters but missed significantly more school and their mothers reported more fears about RAP. Severity of symptoms and psychological distress did not predict consulting behavior. Only maternal fears about abdominal symptoms differentiated consulters from nonconsulters.

Abdominal Pain↗
PubMed1995

Operationalizing a bedside pen entry notebook clinical database system in consultation-liaison psychiatry.

No current system of computerized data entry of clinical information in consultation-liaison (C-L) psychiatry has been well received or has demonstrated that it saves the consultant's time. The inability to achieve accurate, complete, systematic collection of discrete variables and data entry in the harried C-L setting is a major impediment to the advancement of the subspecialty and health services research. The hand-held Notebook computer with Windows PEN ENTRY MICROCARES capabilities has permitted one-time direct entry of data at the time of collection at the patient's bedside. Variable choice and selection enhances the completeness and accuracy of data collection. For example, ICD-9, Axis III diagnoses may be selected from a "look-up" which at the same time automatically assigns the appropriate code and diagnostic-related groups, (DRG) number. A patient narrative can be typed at the nurse's station, a chart note printed for the medical record, and the MICRO-CARES literature database perused with the printing of selected citations, abstracts, and in some cases experts' commentaries for the consultee. The consultant's documentation time is halved using the NOTEBOOK WINDOWS PEN ENTRY MICRO-CARES software, with the advantage of more accurate and complete data description than with the traditional handwritten consultation records. Consultees preferred typewritten in contrast to handwritten notes. The cost of the hardware (about $2000) is less than that of an optical scanner, and it permits report generation and archival searches at the nurses' station without returning to the C-L office for scanning. Radio frequency or ethernet download from the Notebook permits direct data transfer to th C-L office archive computer.

Attitude of Health Personnel↗
PubMed1987

Why do people go to the doctor? Sex differences in the correlates of GP consultation.

This study explores the variables associated with consultation behaviour within the NHS of 256 men and women aged 16-45 and registered with one GP. The focus is on long term effects rather than on the immediate precipitants of a consultation and hence the dependent variable is the one year consultation rate. The predictor variables include predisposing, enabling and need factors. It is found that not only do women consult more often than men but also the correlates of primary care utilisation differ between the sexes. Health status (need) and social role factors (including parenthood and marital status) are found to be more important for men, while psychological predisposition is of greater significance among women in this setting. The implications of the findings are discussed.

Adolescent↗
PubMed2006

Implementing holistic practices in mental health nursing: a national consultation.

BACKGROUND: A national consultation exercise was held as part of a review of mental health nursing in England. OBJECTIVES: To gather views as to how best to develop mental health nursing to support a holistic approach to care, taking into account psychological, physical social and spiritual needs. DESIGN: National open consultation by email over a 3-month period. PARTICIPANTS: 326 written replies were received. The largest group of responses was from National Health Service (NHS) organisations (n=92, 28.2%); 69.9% of responses were from groups or organisations (n=225). METHODS: A consultation document was devised by a national reference group, including four questions relating to the development of practice in the four domains of: psychological, physical, social and spiritual care. RESULTS: The majority of responses supported mental health nurses (MHNs) providing psychological therapies (n=271, 95.1%). To support this happening, responders most frequently described a need for appropriate specialist training post-registration (n=114). To improve physical well-being of service users, the most frequent suggestion was that MHNs should promote healthy lifestyles, e.g. by encouraging physical activity and advising on ways to reduce illicit drug, alcohol and tobacco use (n=152). Responders most frequently cited the need for MHNs to understand resources to support social inclusion (n=110), e.g. knowing how to access local resources, benefits, housing and employment advice. MHNs were most frequently seen as requiring appropriate training to help them support spiritual/religious needs (n=96). CONCLUSIONS: The consultation was successful in obtaining views, in particular, of organisations and groups. These subsequently influenced national recommendations made by the Chief Nursing Officer's Review of Mental Health Nursing.

Attitude of Health Personnel↗
PubMed2006

Sub-optimal patient and physician communication in primary care consultations: its relation to severe and difficult asthma.

INTRODUCTION: Asthma control can be influenced by a range of non-medical issues, including psychosocial factors. Little is known about the views of patients, particularly those with severe and/or difficult asthma, towards their asthma control and their asthma-related primary care consultations. AIMS AND OBJECTIVES: To explore patients' experiences of their asthma and primary care asthma consultations in order to identify target areas for intervention. METHODS: This was a qualitative study of 14 asthma patients based in grounded theory. Questions were asked about: asthma understanding; control issues; and interactions with primary care health professionals. Data were analysed using the constant comparative method and framework approach. RESULTS: Participants with severe and/or difficult asthma normalised control issues, were reluctant to discuss non-medical factors with healthcare professionals (HCPs), reported poorer communication with HCPs, and were reluctant to raise relevant but non-medical factors in the consultation. CONCLUSIONS: Our data identifies that patients, particularly those with severe and/or difficult asthma and poor control, underplay symptoms and do not discuss non-medical factors which may impact on asthma control in primary care consultations. This poor communication is associated with patients underestimating disease severity and/or what could be achieved in terms of disease control. Training HCPs in the use of patient-centred communication skills may optimise asthma management in primary care.

Adult↗
PubMed2005

Report on a WHO consultation on immunological endpoints for evaluation of new Japanese encephalitis vaccines, WHO, Geneva, 2-3 September, 2004.

The World Health Organization (WHO) is undertaking consultations on immunological responses as parameters for evaluation and licensure of new Japanese encephalitis (JE) vaccines. Immunological markers could be used by vaccine developers and regulatory authorities to assess vaccine efficacy in absence of clinical efficacy data. The consultation which is reported here reviewed current data on mechanisms of protective immunity gathered from animal experimentation, clinical data from licensed vaccines and from vaccine candidates still in clinical development. Immunological assays and readouts for use in evaluation of candidate vaccines were also discussed. The consultation made a series of recommendations for specifications on immunological criteria to assess JE vaccine efficacy. More detailed recommendations will be drafted following further consultations to serve as WHO guidelines for evaluation and licensure for new JE vaccines.

Antibodies, Viral↗
PubMed2003

Displaced supracondylar humeral fractures in children: results of a national survey of paediatric orthopaedic consultants.

Several aspects of the management of displaced supracondylar fractures in children remain controversial. Displaced supracondylar humeral fractures (Type III) in children have traditionally been considered orthopaedic emergencies. Recent studies have suggested that closed Type III supracondylar fractures without vascular compromise may be treated in a delayed manner without compromise to functional and cosmetic outcome. Debate continues over the fixation method of choice in these difficult fractures. A postal questionnaire of 121 practising paediatric orthopaedic consultants in the UK was performed to explore these issues. Seventy-seven replies were obtained (63.6%). The 54.5% of the respondents managed displaced supracondylar fractures without vascular compromise in a delayed manner (more than 8h from presentation). The incidence, initial assessment and factors which influence the timing of surgery of these fractures are discussed. The fixation method of choice reported was closed reduction and the use of smooth Kirshner wires (93.4%). Of these, crossed pin fixation is used by 83.9% of respondents and 9.7% employed laterally placed wires. The majority of consultants (69.7%) considered the operative treatment of these fractures a consultant-led procedure. This survey has established an overview of the current practices of paediatric orthopaedic consultants in the UK in the management of these difficult fractures.

Bone Nails↗
PubMed1996

Local voices: evolving a realistic strategy on public consultation.

The publication of Local Voices in 1992 challenged Health Authorities to develop an effective system for their public consultation activities compatible with the requirements of the internal market.1 The general rhetoric was persuasive, but it was less clear how, and to what extent, Local Voices work would influence Health Authority decisions. Serious questions about the nature, purpose and impact of Local Voices were raised within a year of publication.2 This paper re-examines the issues and discusses some of the benefits and limitations of public consultation exercises, using as illustrations two projects carried out in East Lancashire, one on adult mental illness3 and the other on maternity services.4 Particular consideration is given to the precise impact on commissioning of public consultation exercises, and the dilemmas and tensions which emerge as the commissioners consider different findings from different methodologies and different population subgroups. The final section of the article summarises the lessons learnt and sketches out a more systematic and critical approach to public consultation.

Adult↗
PubMed2002

The impact of general practitioners' patient-centredness on patients' post-consultation satisfaction and enablement.

The concept of patient-centredness is complex, but is generally seen as an approach that emphasises, on the part of the health professional, attention to patients' psychosocial (as well as physical) needs, the use of psychotherapeutic behaviours to convey a sense of partnership and positive regard, and active facilitation of patients' involvement in decision-making about their care. To date, there is little consistent evidence that doctors' use of a 'patient-centred' consulting style leads to better patient outcomes. However, previous studies have been limited by a lack of conceptual clarity and methodological consensus, and by the absence of a clear theoretical framework linking patient-centredness to outcomes. In this study, three specific, conceptually distinct dimensions of a patient-centred consulting style were operationalised: the 'biopsychosocial perspective', 'sharing power and responsibility' and the 'therapeutic alliance'. These dimensions were measured in terms of three 'socio-emotional' and two 'task-relevant' general practitioner (GP) behaviours using in-depth observational techniques applied to 173 videotaped GP consultations. Theoretically-derived hypotheses were tested concerning relationships between these patient-centred behaviours and two different consultation outcomes: patient satisfaction and enablement. Multivariate regression showed that GPs' patient-centred behaviours did not predict either outcome. The robustness of these findings is considered within the context of study strengths and weaknesses, and implications for future research are discussed.

Adolescent↗
PubMed2000

Interactive collaborative consultation model in end-of-life care.

With interactive communication becoming an engaging and accessible venue, the specialized field of end-of-life care could greatly benefit by utilizing the Internet to ensure comprehensive palliative care for many underserved areas worldwide. Interactive communication can enhance the care of patients with advanced disease and their families by providing practitioners with current research-based information to empower their clinical decision-making. A collaborative consultative Internet relationship can support practitioners in providing comprehensive palliative interventions for their patients in a timely manner. This paper describes the development of the interactive collaborative consultation model and its demonstration between a rural palliative care nurse practitioner and an urban medical research physician. Expert consultation for individual patients through the Internet can help improve access to palliative consultation and, ultimately, enhance the care of many dying persons living within underserved or remote areas worldwide.

Critical Care↗
PubMed1994

Audit of procedures related to outcome of chest clinic consultation.

We audited the case records of 493 new patients referred to a chest clinic to determine for eight consultants and five middle-grade staff the average number of investigations performed, the follow-up rate and prolixity (the length of the letter written to the general practitioner). The outcome of the consultation was assessed by a questionnaire administered to the patients' general practitioners. Practitioner mean investigation rates varied from 0.1 to 8.7 investigations per patient, follow-up rate from 45 to 100% and average prolixity from 53 to 200mm. The prolixity of the eight consultants was significantly related to their investigation and follow-up rates. Consultation outcome was at least satisfactory for 97.4% of patients. We conclude that considerable potential exists for savings of laboratory, clinic and secretarial time and costs by reducing investigation and follow-up rates and writing shorter letters to general practitioners.

Family Practice↗
PubMed2002

How consultants, hospitals, trusts and deaneries affect pre-registration house officer posts: a multilevel model.

OBJECTIVE: To examine variation in reported quality and working conditions of pre-registration house officer (PRHO) posts. To use multilevel modelling to determine how much of the variation was due to the effects of consultant firms, hospitals, trusts and deaneries, as well as variation at the level of the individual doctor. DESIGN: Questionnaire survey of national sample of PRHOs at the end of the pre-registration year. Multilevel modelling was carried out using MLwiN. SETTING: PRHOs working in UK approved medical and surgical posts in NHS hospitals from August 1996 to January 1999. PARTICIPANTS: One thousand, four-hundred and thirty-five PRHOs who had previously been part of an extended cohort study of medical student selection and training. They reported on a total of 4926 posts, on 2721 identifiable consultant firms, in 336 hospitals, in 264 trusts and in 17 deaneries. MAIN OUTCOME MEASURES: PRHOs' perceptions of the overall quality of all PRHO posts they had worked in, and working conditions in the current post. RESULTS: Twenty percent of PRHO posts were described as excellent and 34% as very good, through to 6% reported as not very good, poor or bad. The overall rating of the post showed highly significant variation at the level of hospital/trust, and consultant firm. Other aspects of posts, such as working conditions showed variation at the level of deanery, trust, hospital and firms, with different patterns for the different measures. Assessments of stress in PRHOs (GHQ, burnout, response to uncertainty), and a desire to leave medicine, showed no variation at the level of deanery, trust, hospital or firm. CONCLUSION: Some aspects of a PRHO post, in particular overall rated quality, but also many aspects of working conditions, show substantial variation at the level of hospital, trust and consultant firm, suggesting that differences reflect local variation in working practices and treatment of PRHOs, with the possibility of change and improvement. The lack of any variation at the level of deanery, trust, hospital or firm in stress of PRHOs suggests that these responses are idiosyncratic, individual responses by doctors themselves, rather than a general characteristic of posts, hospitals, trusts or deaneries.

Attitude of Health Personnel↗
PubMed2004

[Free anonymous screening consultation and clinical management of HIV infection].

In France, since 1988, anonymous and free consultations (called CDAG) have been settled in the country to facilitate an individual and volunteer approach for HIV screening. At the time, there are more than 380 CDAG with newly defined objectives. CDAG are supposed to encourage early screening, facilitate access to precarious persons and persons at risk for sexually transmitted diseases, and reinforce prevention, helping consultants to define a personal preventive strategy. CDAG are also supposed to play a role in prevention of both hepatitis B and C, and syphilis. They may help to link screening and healthcare. Their activity is increasing and the rate of positive test is twice that of private laboratories. Patients consulting those facilities are younger and more at risk than general population. Between 1000 and 2000 HIV positive tests are detected in CDAG each year (11 % of positive tests in the country). The real impact on prevention and screening at the national level is unknown, in part because of anonymity. To improve the characterization of consultants, data collection will be modified in 2004, and a network of selected and volunteer centres will collect continuously more accurate data.

Anonymous Testing↗
PubMed2002

Peer consultation as a method for promoting problem-based learning during a paediatrics course.

In problem-based learning (PBL) there are problems during tutorial group sessions, for example lack of participation, interaction and cohesion, and withdrawing. The authors evaluated whether these problems could be avoided with a peer consultation model. Peer consultation takes advantage of cooperation between students by encouraging them to accept more responsibility for learning from their peers. Forty-nine fifth-year students participated in three group sessions where they solved a paediatric case problem. The students were working in small groups, assuming the following roles in turn: presenters, facilitators and observers. The students reported that this consultative method forced one to actually define the problem, helped to develop communication skills and to identify problematic issues from different viewpoints and offered the possibility to evaluate personal problem-solving strategies. The method also gave an opportunity for students to learn in practice how to utilize new technology in data searching. These experiences suggest that the model of peer consultation adds new flavour, increasing enthusiasm in problem-based learning.

Cooperative Behavior↗
PubMed2003

Challenging heteronormativity in the consultation: a focus group study among general practitioners.

OBJECTIVE: To reflect on and further understand mechanisms of heteronormativity in the consultation, with special focus on the relative invisibility of lesbian women. DESIGN: Tape-recorded focus group interviews transcribed verbatim and analysed using qualitative methods. SETTING: General practitioners (GPs) from the city of Göteborg, Sweden, who had formerly answered a postal questionnaire about lesbian women in the consultation, were invited to take part in subsequent focus groups. SUBJECTS: Ten GPs from the questionnaire who accepted the invitation and volunteered to participate in focus groups. MAIN OUTCOME MEASURES: A discourse analytical approach using interaction regarding consensus and disagreement between informants in creating major and minor themes. RESULTS: Consultation skills were forwarded as a major tool in receiving optimal information from patients. However, traditional concepts of family and sexuality restricted information and hampered an accepting attitude. Bringing up issues of sexual identity/orientation was left to the lesbian patient and strongly related to her reason for attending. CONCLUSION: Consultation skills are a useful but not sufficient means of making lesbian women visible in the doctor-patient relationship. Doctors also need to transcend traditional concepts of family and sexuality and reflect on what is a relevant issue from the patient's perspective.

Adult↗
PubMed2004

The quality of GP consultation in two different salary systems.

OBJECTIVE: To compare the quality of consultations between two Finnish employment contract systems: the capitation-based contract (CB) and the time-based contract (TB). DESIGN: Cross-sectional study based on paired questionnaires answered by patients and general practitioners (GPs). SETTING AND SUBJECTS: 81 GPs with their patients from four health care centres in Finland, 2191 encounters. MAIN OUTCOME MEASURES: Both patients' and GPs' opinions on the role of personal doctor, medico-professional quality, quality of communication, consultation conditions, economic quality (= number of examinations and treatments), and duration of consultation. RESULTS: Patients were more satisfied than the doctors with the quality of consultations. We found no differences between the groups in the patients' opinions on the quality. The GPs in the CB group rated their work quality higher than the GPs in the TB group. The patients' and the GPs' understanding of the GP as a personal doctor varied so that the patients considered their GP as their personal doctor more often than the GPs in question. CONCLUSIONS: The GPs with a capitation-based contract evaluated the quality of their work higher than other GPs. Patient satisfaction was not dependent on the GP's contract.

Adolescent↗
PubMed1998

Prospective evaluation of referrals to a hospice/palliative medicine consultation service.

A hospice/palliative medicine consultation team was formed in July 1993 in a U.S. teaching hospital to provide patient care and education. The team consists of an attending physician, nurse, fellow, and any residents or medical students rotating on the service. More than 500 consultations are received each year. Beginning in January 1995,108 consecutive referrals to the service were assessed using a standard form completed by the nurse. The average age was 62 years. The gender of patients was 58% male and 42% female. At the time of consultation 87% were hospitalized on general medical services (including hematology/oncology), 4% were on surgical services, 3% on the neurology service, and 6% were in an intensive care unit. Cancer was the primary diagnosis in 52%, AIDS in 24%, with the rest being distributed among cardiac, renal, pulmonary, neurologic, and other diseases. The most prominent physical symptoms were 48% weakness/malaise, 44% pain, 28% dyspnea, and 23% agitation/confusion. The average length of time patients were followed was 2 days (range 1-10). We conclude that a hospice/palliative medicine consultation service sees a broad range of patients and problems and is a rich resource for teaching hospice and palliative medicine.

Journal Article↗
PubMed1998

Complex health problems in general practice: do we need an instrument for consultation improvement and patient involvement? Theoretical foundation, development and user evaluation of the Patient Perspective Survey (PPS).

BACKGROUND AND OBJECTIVES: Many patients in general practice present with complex health problems. It is argued that the GP who is in a prime position to counsel patients with such problems, will, however, often perceive a lack of tools to manage them. The aim of the present study was to develop a novel instrument in terms of a patient-administered questionnaire, the Patient Perspective Survey (PPS), designed to enhance the quality of clinical communication in the consultation. It is based on a biopsychosocial patient perspective, patient centredness, patient resources, involvement and coping, and quality of life orientation. METHODS: Development of the PPS has included comprehensive literature research, discussions and advice, during several phases, from groups of GPs, patients, broad panels of experts and testing in pilot studies. After many revisions, a 102-item version, consisting of a main somatic, mental and social domain axis, was evaluated by GPs and patients in 213 consultations. RESULTS: The basic idea, theoretical elements and purpose of the PPS appeared in general to be well accepted. Seventy-five to eighty-five per cent of the patients found the questions relevant and easy to understand and there were high positive scorings regarding influence on the doctor-patient relationship, communication, resource and coping aspects, occurrence of new information and general satisfaction with the consultation. Similar scorings were obtained from the GPs' evaluation. Both parties agreed that there is a need for a shorter and more specific PPS version, and that the resource and coping dimension should be even more extended. CONCLUSIONS: We consider it well documented that there is a need for this new instrument to deal with complex health problems in general practice, and that it has promising potentials for consultation improvement.

Attitude of Health Personnel↗