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PubMed2001

The purpose of the general practice consultation from the patient's perspective--theoretical aspects.

BACKGROUND: Medical practice and research are paying increasing attention to what patients want, as reflected by the growth of routine surveys of patients' satisfaction and more formal studies of patients' views of medical care. However, the field lacks conceptual clarity. OBJECTIVES: The aim of this study was to propose a theoretical clarification of the concept of the patients' purpose of a consultation by presenting a patient-centred definition, applicable for clinical work and research in general practice. METHODS: An extensive literature review was conducted to explore presumptions and definitions reported by previous studies. Most authors failed to define or distinguish the concept under investigation. We took these shortcomings as our starting point, added some significant dimensions drawn from a few selected authors who had discussed relevant perspectives in their work and arrived at a proposed working definition of the 'purpose' concept. RESULTS: The proposed definition allows for multiple purposes for the consultation. We incorporate what the patient hopes to gain from the consultation, as opposed to their 'expectations of the most likely outcome'. Our working definition aims to identify patients' a priori wishes and hopes for a specific process and outcome, while acknowledging that these may not be voiced and may be modified by the patient during the consultation. General characteristics of the doctor, such as being considerate or professionally skillful, are not included.

Communication↗
PubMed2002

Demand, appropriateness and prescribing of 'lifestyle drugs': a consultation survey in general practice.

BACKGROUND: The simultaneous launch of orlistat and sildenafil in 1998 provoked much media attention, particularly around the role of lifestyle drugs and their potential costs if controls were not established. Fears were also expressed that primary care would be overwhelmed by demand, and little information was available about the attitude of GPs to their new role as prescribers of lifestlye drugs. Partly in response to these concerns, tight prescribing guidelines and licensed indications, for sildenafil and orlistat, respectively, were issued. OBJECTIVE: Our aim was to describe levels of demand for orlistat and sildenafil in general practice, whether this demand was translated into a prescription, adherence to prescribing guidelines/licensed indications and the GP perception of appropriateness of an NHS prescription for either of these drugs. METHOD: We carried out an observational study in primary care conducted over a 6-week period during 1999. Twenty-seven GPs were recruited, each from a different practice. All GP consultations were recorded for the study period and the GP completed a structured questionnaire each time sildenafil or orlistat were discussed in a consultation. RESULTS: Sildenafil was discussed in 0.5% (68/13 394) of consultations and orlistat in 0.3% (42/13 394). GPs thought that a corresponding NHS prescription would be highly appropriate in 57 and 74% of cases, respectively, although for both lifestyle drugs, nearly 20% of GPs thought such prescriptions were inappropriate. An NHS prescription was issued in 43% of consultations in which sildenafil had been discussed and 33% in which orlistat had been discussed. Five out of 29 NHS sildenafil prescriptions were issued to patients failing to fulfil the requirements of prescribing guidelines; similarly, one out of 14 orlistat prescriptions fell outside licensed indications. There were four examples of NHS prescriptions for sildenafil which were given even when the GP thought the drug to be inappropriate, whereas orlistat was never given when the GP thought it inappropriate. CONCLUSIONS: Levels of demand for the two lifestyle drugs, sildenafil and orlistat, were modest when compared with earlier media predictions. Neither was there evidence that GP was pitted against patient in their negotiation concerning a lifestyle drug NHS prescription since most GPs agreed with their patients that such a prescription was appropriate. Prescribing guidelines and licensed indications were generally adhered to, but the modest level of demand raises questions about expanding the guidelines for sildenafil.

Anti-Obesity Agents↗
PubMed2002

"I" and "we": a concordancing analysis of how doctors and patients use first person pronouns in primary care consultations.

BACKGROUND: It is widely accepted that "partnership" with patients is desirable, and that patients should be enabled to participate in decisions, but it is not clear to what extent doctor-patient interactions represent partnership in action. OBJECTIVE: Our aim was to measure aspects of doctor-patient interaction through the deployment of the first person pronouns "I", "me", "we" and "us" in general practice consultations. METHODS: The study design was a concordance-based language analysis of spoken data. Concordancing software was used to interrogate a database of 373 consultations with 40 doctors in UK general practice. The frequency and function of first person pronouns used in these consultations were scrutinized. Concordancing enables identification of strings of text with similar lexical properties and uses specialized statistics to assess relationships between words and phrases ("collocates" being words commonly found together) as well as their patterns of use (MI, mutual information, describes the likelihood of two words or phrases being associated). Analysis is therefore quantitative and qualitative. RESULTS: Doctors use the word "we" far more often than patients or companions do (doctors 23.5% and patients 2.9% of all personal pronoun occurrences). Doctors are far less likely to use "I", after which a verb of thinking is usually selected (38 collocates with MI >3). However, after 'we', doctors select verbs of physical activity or auxiliary verbs. Three types of doctor use of "we" were distinguished: to include patients ("you and I"), exclude them ("we doctors" or "we as a practice") or to mean "all of us as human beings". CONCLUSIONS: The findings suggest a prototypical pattern of interaction in primary care: PATIENT: I suffer. Doctor: I think. We will act. This, within the current paradigm which values partnership between doctor and patient, might seem encouraging; but there is evidence to suggest that power relationships in the consultation may still be unequal.

Communication↗
PubMed1987

Participation of patients during general practice consultations: comparison between trainees and experienced doctors.

Consultations with 494 patients were tape-recorded, transcribed and coded. The sample consisted of 168 patients of six experienced general practitioners from training practices, and 326 patients of six trainee general practitioners. Talk in the consultations of trainees and experienced doctors was similar in many respects, including total quantity of talk per consultation. However, twice as many patients of the trainees than those of the experienced doctors produced questions and comments which followed from something already said by the doctor. In addition, the trainees were more likely than the experienced doctors to ask the patients questions about the suggested treatment, rather than simply to offer instructions and advice. These features of doctors' and patients' behaviour were significantly correlated with each other for both the trainees and the experienced doctors. It is suggested that the strategy of engaging patients in discussion about treatment, used more by the trainees, encouraged patients to think of queries which otherwise might not have occurred to them during the consultation.

Family Practice↗
PubMed2003

"Fire away": the opening sequence in general practice consultations.

BACKGROUND: Proponents of recent models of the doctor-patient relationship, such as concordance and shared decision making, have emphasized mutuality rather than paternalism or consumerism. However, little attention has been paid so far to the ways in which this might actually be achieved. OBJECTIVES: The aims of this study were to establish whether there are any rules governing the opening sequence in general practice consultations, and to analyse the ways in which the observing or breaking of such rules contributes to the development of mutuality between patients and GPs. METHODS: The paper is based on a qualitative study of 62 patients consulting 20 GPs in 20 practices in the Midlands and Southeast of England. Consultations were audio recorded and transcribed; patients were interviewed before and after each consultation, and doctors were interviewed afterwards. Data were analysed using the sociological method of Conversation Analysis. The outcomes were participants' own understandings as demonstrated in their speech. RESULTS: A selection rule was identified whereby doctors choose between the questions "How are you?" and "What can I do for you?" to elicit patients' concerns. Deviations from this selection rule may be either repairable or strategic. Repairable deviance is based on misunderstanding between participants, and is resolved interactionally, usually by patients. Strategic deviance is the attempt by doctors to emphasize or de-emphasize certain aspects of their relationships with particular patients. Deviations from the rule which are not repaired lead to misalignment between participants. CONCLUSION: In relation to concordance, or shared decision making more generally, this analysis demonstrates that alignment or misalignment between participants will occur before any discussion about treatment options occurs. In cases of misalignment, concordance will be much harder to achieve. Mutuality is an achievement of both patients and doctors, and requires the active participation of patients.

Communication↗
PubMed2005

Consumers leading public consultation: the general public's knowledge of stroke.

BACKGROUND: The need to make health services and research relevant to the general public through user involvement and consultation has been recognized and formalized in guidelines and research publications. OBJECTIVES: We had the following objectives (i) to involve and enable lay people to identify and direct a research study as co-researchers consulting members of the general public about their awareness and knowledge of stroke and stroke risk; and (ii) to consult members of the general public aged between 40 and 65 years old to identify what they know about the signs of stroke and potential risk factors in order to inform local public health programmes. METHODS: A 20-point multiple choice questionnaire was designed by two consumers trained in research skills at a year long training programme. The questionnaire was sent to 250 randomly selected patients from one general practice in North Staffordshire. RESULTS: A 57% response rate was achieved (142 out of 250), with 139 being appropriate for analysis. The current knowledge and awareness of stroke and stroke risk was relatively good. Almost 90% knew that stroke occurs in the brain and most correctly identified the causes as related to impaired blood supply to the brain. Further, upon recognizing signs of stroke, 96% thought it was 'extremely important' to get immediate treatment for someone who may be having a stroke. Seventy-eight percent of respondents stated that they would like further information about stroke. The most popular sources of information identified were: their general practice (51%); television and radio (36%); and friends and family (33%). CONCLUSION: The consumers' involvement has essentially allowed lay people to consult other members of the general public about health issues of national priority with specific local relevance. The involvement of consumers in research needs to be considered as worthwhile if it is to have any lasting impact on local or national services. Future research using consumer involvement will need to decide upon the balance between scientific integrity and the level of consumer direction.

Adult↗
PubMed1990

The role of nonphysician consultants as health-care educators in postgraduate programs of anesthesiology.

Many physicians believe that the tasks of postgraduate medical education and faculty development are best carried out by senior physicians trained in the appropriate specialty. However, many also will admit that, as physicians, they have received too little training for such an educational role, and that the practical demands of medical practice, scientific research, and administration make it difficult if not impossible to allocate time to continuing medical education program development, curriculum design for residency training, teacher training, and other key aspects of postgraduate medical education. Many medical disciplines have attempted to alleviate this problem by using nonphysician health-care educational consultants in their training programs. However, little attention has been paid to the possibilities of using such consultants in anesthesiology residency education and faculty development. Such consultants in postgraduate medical education and training programs in anesthesiology could perform a wide variety of functions and roles because they possess skills and technical expertise in teaching, training, curriculum design, evaluation, program planning, and interpersonal communications that faculty members often lack. The successful use of a nonphysician consultant in the Department of Anesthesiology at Hahnemann University in Philadelphia, Pennsylvania, is described.

Allied Health Personnel↗
PubMed1999

Assessment of practicing family physicians: comparison of observation in a multiple-station examination using standardized patients with observation of consultations in daily practice.

PURPOSE: Looking for a valid, reliable, and feasible method to collect data on the performances of practicing family physicians, the authors compare the measurement characteristics of a multiple-station examination (MSE) using standardized patients with those of a video assessment of regular consultations in daily practice (practice video assessment, PVA). METHOD: In a cross-sectional study, consultations of 90 family physicians were videotaped both in an MSE and in their daily practices. Peer-observers used a validated instrument (MAAS-Global) to assess the physicians' communication with patients and their medical performances. The physicians were randomly divided into two groups, comparable for demographic characteristics, and half underwent the assessments in reverse order to test for time-order effects. Content validity, criterion validity, reliability, and feasibility of the two methods were compared. RESULTS: Content validity of the PVA was superior to that of the MSE, since the domain of general family practice care was better covered. Observed participants judged the videotaped practice consultations to be "natural," whereas hardly any family physician, after reviewing the videotaped consultations of the MSE, recognized his or her usual working style. Specific criteria made it possible to standardize real practice. Concerning criterion validity, only the medical-performance components of the two methods correlated. No correlation was found for the communication components. Real-practice performance proved to be less influenced by observation than was performance during the MSE. The reliabilities of the two methods, expected to be better in the controlled MSE, were comparable. The administration of the PVA was more flexible, less costly, and better accepted by the family physicians than was that of the MSE. CONCLUSION: Assessment for quality improvement of family physicians' practices by video observation in daily practice is superior to video assessment in a simulated setting using standardized patients.

Adult↗
PubMed1989

Why do people seek medical advice for back pain: a comparison of consulters and nonconsulters.

Respondents with back pain who had answered affirmatively to the question about back pain in a population study were divided into two groups depending on whether they had consulted or had not consulted a physician due to their back pain. There were 17 nonconsulters and 37 consulters. The subjects participated in a stringent physical examination and in the following psychological tests: the Eysenck Personality Inventory (EPI), the rod and frame test (RFT), and the metacontrast technique (MCT). They also answered a pain questionnaire. Based on the results, we found that the nonconsulters differed from the consulters on many issues but had nevertheless rated their constant level of pain on two different occasions as being equally severe on a graphic rating scale (GRS). The groups differed as follows: The nonconsulters rated their work to be more stressful; had less frequently a spouse suffering or having suffered from chronic pain; had fewer abnormal pain drawings; woke up less frequently during the night; used sleeping pills less frequently; participated more often in sports; and had a higher frequency of repression on the MCT compared to a group of painless subjects.

Adult↗
PubMed1992

Ethical dilemmas in child and adolescent consultation psychiatry.

Ethical issues in child and adolescent psychiatry consultation arise frequently but seldom are discussed in a public setting. This case of an adolescent victim of a surgical accident illustrates many aspects of consultation psychiatry. The consult question itself, of behavior management, is not unusual, although in this case the question is complicated by the sequelae of trauma, psychosocial chaos, and the staff's angry feelings toward the patient. In addition, potential surgical wrongdoing at the referring hospital brings up the more difficult ethical questions of the consultant's responsibilities, which must be to the patient and his family, as well as to the attending and referring physicians.

Adolescent↗
PubMed2001

Adherence to antibiotics prescribed in an accident and emergency department: the influence of consultation factors.

The objective of this study was to investigate the extent of non-adherence to prescribed antibiotics and the relationship of non-adherence to consultation and attitudinal factors. Self-completion postal questionnaires were sent to 202 consecutive adult attenders to an accident and emergency (A&E) department who had been given antibiotics to take home, within a week of the A&E attendance. The questionnaire included a detailed log of dosing, two sections of eight questions each on the patients' perceptions of the consultation and of their attitudes to medicines in general, which were marked on Likert scales; and questions inviting free text answers. Efforts were made to maximize the response rate, and to contact a random sample of 10 non-responders to assess any non-response bias. The response rate was 56%. The non-responders sampled reported similar non-adherence to that of the responders. Of the 113 responders, 10 (9%) indicated that they had taken none of their prescribed medicines, and 25 (22%) that they had taken less than 80%. The most common pattern of non-adherence was early cessation. Two aspects of the consultation (expectations about a prescription, and that there were too many tablets) were related to adherence. In conclusion, this study suggests that the effectiveness of some A&E consultations is reduced by inadequate exploration of patients' concerns and expectations.

Adolescent↗
PubMed2005

Gender, age, and ethnicity in HIV vaccine-related research and clinical trials: report from a WHO-UNAIDS consultation, 26-28 August 2004. Lausanne, Switzerland.

This report summarizes the presentations and recommendations from a consultation held in Lausanne, Switzerland (26-28 August 2004) organized by the joint World Health Organization (WHO) - United Nations Programme on HIV/AIDS (UNAIDS) HIV Vaccine Initiative. The consultation discussed issues related to gender, ethnicity, and age in HIV vaccine research and clinical trial recruitment. A special focus of the meeting was the participation of women and adolescents in clinical trials. Also discussed were the experiences and lessons from various research programs, trials, and studies in different countries. Implementing the recommendations from this meeting will require prioritization and active participation from the research community, funders of research, local and national governments, non-governmental organizations, and industry, as well as the individuals and communities participating in clinical trials. This report contains the collective views of an international group of experts, and does not necessarily represent the decisions or the stated policy of the WHO. The contribution of the co-chairs (R. Macklin and F. Mhalu) and the rapporteurs (H. Lasher, M. Klein, M. Ackers, N. Barsdorf, A. Smith Rogers, E. Levendal, T. Villafana and M. Warren) during the consultation and in the preparation of this report is much appreciated. S. Labelle and J. Otani are also acknowledged and thanked for their efficient assistance in the preparation of the consultation and the report.

AIDS Vaccines↗
PubMed2005

Surgical and radiological management of uterine fibroids--a UK survey of current consultant practice.

BACKGROUND: The aim of this study was to determine the current surgical and radiological management of uterine fibroids by consultants working in the UK. METHODS: A structured questionnaire was posted to all 1439 UK consultants. Non-responders were sent one reminder. The main outcome measures were surgical route and technique used for myomectomy, and the use and availability of uterine artery embolization (UAE). RESULTS: Eight hundred fifty-two (59%) consultants replied. Seven hundred thirty-five (86%) admitted to regular sessions of gynecologic surgery, and 75% of this group performed open myomectomy, 16% laparoscopic myomectomy, and 66% hysteroscopic myomectomy. Open myomectomy: Forty-one percent of consultants performed open surgery on uteri equivalent to 12-week gestational age or less, 87% prescribed preoperative gonadotrophin-releasing hormone agonists (GnRHa) in order to reduce surgical bleeding, with 35% using myomectomy clamps, 23% tourniquets, and 19% vasoconstrictors. Laparoscopic myomectomy: The largest uterine size the majority would attempt was equivalent to a 12-week gestation, 58.6% used preoperative GnRHa, 21% used intraoperative vasoconstrictors, and 1.4% tourniquets in order to minimize bleeding. Hysteroscopic myomectomy: As with laparoscopic myomectomy, the largest uterine size the majority would attempt was equivalent to a 12-week pregnancy. Blood transfusion: Twenty per cent, 10%, and 7% reported the need for blood transfusion in up to 10% of patients undergoing open, laparoscopic, or hysteroscopic myomectomy, respectively. UAE: Fifty-one percent have access to UAE and 40% have referred at least one patient in 2001. CONCLUSIONS: Open and hysteroscopic myomectomy are frequently utilized in contrast to laparoscopic myomectomy. The reported rate of blood transfusion appears low. Although UAE is widely available, the majority of patients are still managed surgically.

Female↗
PubMed2005

Misunderstandings: a qualitative study of primary care consultations in multilingual settings, and educational implications.

BACKGROUND: Patients in inner-city areas come from increasingly diverse language and cultural backgrounds. Neither communications training modelled on local English speakers nor the provision of interpreters offer adequate solutions. AIM: To identify how patients with limited English and culturally different communication styles consult with general practitioners (GPs) in English, and to develop training strategies from both good practice and observed misunderstandings. METHODS: Randomly selected routine and emergency surgeries in 19 inner London general practices were video-recorded. The videos were viewed independently by 2 discourse analysts. Key consultations, across a wide range of English language ability, were selected and transcribed to analyse misunderstandings resulting from language/cultural differences. RESULTS: Of the 232 video recordings that were made, 20% were with patients with limited English and contained major and often extended misunderstandings. QUALITATIVE ANALYSIS: Four main categories of patient 'talk' contributing to misunderstandings are identified: (1) pronunciation and word stress; (2) intonation and speech delivery; (3) grammar, vocabulary and lack of contextual information; and (4) style of presentation. The importance of different styles of self-presentation by patients as the reason for misunderstandings is highlighted. On only 3 occasions were culturally specific health beliefs raised. CONCLUSION: It is routine for GPs in inner London practices to manage consultations with patients with culturally different communicative styles from their own. Specific training in identifying these problems and preventing/repairing them in the consultation is essential. This level of awareness-raising is more crucial than general discussions of culturally different health belief models.

Communication↗
PubMed2006

Knowing a medical doctor is associated with reduced mortality among sick children consulting a paediatric ward in Guinea-Bissau, West Africa.

BACKGROUND: To examine equity in access to public health services in Guinea-Bissau. METHODS: The study was conducted in 2000-2001 at the emergency clinic of the only paediatric ward in Bissau. Mothers of all children from the study area were interviewed about previous care seeking and relations with anybody working in the health sector. All management actions in the emergency clinic were registered. In-hospital and subsequent community mortality was ascertained through community surveillance. The measured outcome was mortality risk within 30 days of first consultation. RESULTS: We followed 1572 children with a first consultation. Of these, 8.2% died within 30 days. Acquaintance with a physician reduced 30-day mortality risk by 48% (95% CI: 18-66). The effect was strongest among post-neonatal children (54%; 95% CI: 18-74). Mortality within 30 days of consultation was also independently predicted by consultation after 7 PM, nurse team on duty, day of week and young mother. In a multivariate model, socioeconomic status and school education were not associated with 30-day mortality when acquaintance with a medical doctor was taken into account. CONCLUSION: Favouritism may be a significant factor for quality of care and child mortality in developing countries. Interventions to improve hospital and health worker performance should be given high priority.

Adolescent↗
PubMed2005

Evaluation of a programme of group visits and computer-assisted consultations in the treatment of adolescents with Type 1 diabetes.

AIM: To examine the effects of group visits and computer-assisted consultations on quality of life and glycaemic control in adolescents with Type 1 diabetes. METHODS: A total of 116 adolescents, aged 11-17 years, and their parents were randomly assigned to an intervention (n = 62) or a control group (n = 54). The intervention group was invited to a 15-month programme comprising group visits and computer-assisted consultations. The control group was offered traditional out-patient consultations. Outcomes included changes in HbA(1c) and the adolescents' assessment of generic and disease-specific health-related quality of life measured by the Child Health Questionnaire (CHQ-CF87) and the Diabetes Quality of Life Questionnaire (DQOL), respectively. RESULTS: One hundred and one adolescents (55/46) agreed to participate, mean age 14.2 years (sd 1.5), mean diabetes duration 6.5 years (sd 3.6, range 1-16 years), mean HbA(1c) 9.3% (sd 1.4, range 6.1-12.8%). Eighty-three (72%) completed the questionnaires at follow-up (intervention/control 45/38). There were significant age by randomization group interactions for diabetes-related impact (P = 0.018), diabetes-related worries (P = 0.004), mental health (P = 0.046) and general behaviour (P = 0.029), implying that the intervention was effective in older adolescents (above 13-14 years). No significant effects on mean HbA(1c) were identified. CONCLUSIONS: Group visits and computer-assisted consultations had beneficial effects on health-related quality of life in older adolescents, the role of this intervention being questionable in younger adolescents.

Adolescent↗
PubMed2004

Women's experiences of student presence in consultations for problematic uterine bleeding.

Research suggests that although a high proportion of patients accept the presence of students in gynaecological consultations, issues of consent, privacy and comfort are important. This study considers women's views on the impact of student presence on communication in the consultation. Our research suggests that student presence may distort the flow of communication in the gynaecological consultation. There are implications for both patient satisfaction and clinician training. If students are introduced into the consultation, clinical tutors should take special care to maintain dedicated communication with the patient.

Adult↗
PubMed2000

Computer imaging versus conventional esthetic consultation: a prospective clinical study.

Computer imaging can be helpful in demonstrating to patients the potential outcome of esthetic dental procedures. The current clinical study assesses the effectiveness of computer imaging by comparing the reactions of patient and dentist to conventional consultations versus the use of computer imaging. The responses from 35 subjects show that computer imaging consultations are more effective in helping patients decide to accept treatment. Patient satisfaction was higher (93.75%) with computer consultations than with conventional methods (83.3%). Computer imaging consultations were easier to conduct but significantly (p < .05) more time consuming.

Adult↗