Doctor-patient communication in different European health care systems: relevance and performance from the patients' perspective

Physicians' Self-Perceived Competence on Breaking Bad News to Parents of Children with Neurodisabilities

Delivering difficult news to parents of children with neurodisabilities, often involving new diagnoses, prognosis changes, or declines in function or health, presents a complex task. Our aim was to assess physicians' self-perceived competence in breaking bad news (BBN) within this context. An online survey was administered to neuropediatricians and developmental and rehabilitation pediatricians in Switzerland. Among 247 invited physicians, 62 (25.1%) responded (age of 51 ± 11 years; M/F ratio of 2:3). They rated their BBN competence at 7.5 ± 1.6 out of 10. Factors significantly associated with self-perceived competence in uni- and multivariate analyses included years of professional experience (≤10 years: 6.2 ± 1.8; >10 years: 8.2 ± 0.8), and region of pregraduate training (Switzerland: 7.3 ± 1.6; European Union: 8.3 ± 0.9). The respondents highlighted the positive roles of professional and personal experience, quality relationships with families, and empathy in BBN. In summary, physicians generally expressed a sense of competence in delivering difficult news to parents of children with neurodisabilities. They underscored the significance of life experiences and certain individual qualities in their effectiveness. These findings provide valuable insights into enhancing professional training and support in this crucial yet underexplored aspect of medical practice.

Litigations in orthopedics and trauma surgery: reasons, dynamics, and profiles

BACKGROUND

In recent literature, the increasing number of medical litigations, both in terms of the number of cases being filed and the substantive costs associated with lawsuits, has been described. This study aims to provide an overview of the profile of litigation for orthopedic and trauma surgery to describe the differences and the development of the number of cases over time.

PATIENTS AND MATERIALS

A retrospective review of all litigations between 2000 and 2017 was conducted using the institutional legal database. The causes of litigation were documented and classified into seven major categories. In addition to plaintiff characteristics, the litigation outcomes and the differences between emergency and elective surgery were analyzed.

RESULTS

A total of 230 cases were evaluated. The mean age of the plaintiffs was 44.6 ± 20.1 years, and 56.8% were female. The main reasons for litigation were claimed inappropriate management (46.1%), misdiagnosis (22.6), and poor nursing care (8.3%). Significantly more litigations were filed against surgeons of the orthopedic subspecialty compared with trauma surgeons (78%; p ≤ 0.0001). There were significantly fewer litigations per 1000 cases filed overall in 2009-2017 (65% less; p = 0.003) than in 2000-2008.

CONCLUSION

Our results could not confirm the often-stated trend of having more litigations against orthopedic and trauma surgeons. Although the absolute numbers increased, the number of litigations per 1000 patients treated declined. Patients who underwent elective surgery were more likely to file complaints than emergency patients.

Validity of data collection methods for time spent, professional involvement and treatment volume for the purpose of cost-effectiveness studies in dentistry

OBJECTIVES

Economic evaluations can support provision of adequate and affordable oral care, requiring valid information on costs. The aim was to assess the validity of (a) patients' self-report (PS) and routine electronic patient records (EPR) regarding time spent per visit and (b) PS regarding types of treatment and type of dental professionals involved.

METHODS

Data were collected in four dental clinics regarding time spent using PS and EPR, on types of treatment and dental professionals involved using PS. As reference standard for time spent, independent research assistants (RA) collected data on time per visit using stopwatches. As reference standard for types of treatment and of dental professionals involved, we used the dental clinic's Electronic Patient Files (DEPF). The two one-sided tests (TOST) equivalence procedure for the difference between paired means for time and kappa statistics for treatment and professional were used to assess agreement of data collection methods with the reference standards.

RESULTS

Equivalence and agreement was good between (a) PS and RA registration concerning waiting time, appointment time and total time spent and (b) EPR and DEPF concerning appointment time. Agreement between PS and DEPF concerning types of treatment was moderate to fair (kappa values between 0.49 and 0.56 for preventive consultation, restoration, radiographs and extractions and between 0.15 and 0.26 for fluoride applications and sealants). Agreement between PS and DEPF for dental professional involved was fair (kappa = 0.41).

CONCLUSIONS

Data collection regarding time using PS and EPR was valid. Data collection via PS on treatment and professionals involved were not sufficiently valid and should occur via DEPF.

Unemployed individuals contact GPs more frequently but report lower satisfaction: results of the population-based DEGS1 and the GPCare-1 patient survey

Unemployment is associated with a variety of adverse health-related outcomes, yet little data on primary care services for this risk group exist. Using data from two surveys, we analyzed the frequency of GP contacts and patients' experiences with GPs comparing unemployed with employed individuals. Data of the German Health Interview and Examination Survey for Adults (DEGS1), a nationwide cross-sectional study (n = 8151), were analyzed regarding associations between employment status and the number of GP visits. The General Practice Care-1 study (GPCare-1), a cross-sectional questionnaire survey (n = 813), evaluated patients' communication with their GP. Data were collected from June to August 2020 in 12 teaching practices affiliated with our university. The statistical analysis included individuals of working age (18-64 years old) (DEGS1 n = 5659, GPCare-1 n = 587). In both studies, working age subpopulations were analyzed (DEGS1: n = 5659 of 8151, GPCare-1: n = 587 of 813). In DEGS1, the prevalence of unemployment was 6.5% (n = 372). Unemployed individuals had more GP contacts in the last 12 months (4.50 vs. 2.86, p < 0.001). In the GPCare-1 study, unemployed individuals (6.6%, n = 39) were significantly less satisfied with GP communication: enough space in consultations (42.9% vs. 60.3%, p = 0.043), feeling comfortable to address sensitive topics (44.1% vs. 65.9%, p = 0.010), problems taken very seriously by GP (48.6% vs. 70.6%, p = 0.007). Yet, they were more willing to accept GPs' help for psychosocial burdens (67.6% vs. 47.6%, p = 0.024). GPs should be aware that patients with unemployment wish more support to cope with their burdening situation.

First Systematic Review on Health Communication Using the CiteSpace Software in China: Exploring Its Research Hotspots and Frontiers

Since the 1970s, health communication (HC) has attracted widespread attention from practitioners and researchers in various fields in China, leading to the production of a vast array of literature. In order to reveal the current state, popular themes, and research frontiers of HC research, this study employed the CiteSpace software to conduct a comprehensive review based on 1505 HC publications from 1992 to 2021 retrieved from the China National Knowledge Infrastructure (CNKI) database. The results demonstrated that (1) the number of HC publications has experienced an annual increase over the past 20 years, albeit with certain inverted S-shaped fluctuations and (2) the most prolific authors mainly included Wang L.Y., Zhang Z.L., and Wang Y.L., while well-known universities played a leading role in HC research in China. A significant finding was that a stable core group of authors or institutional has been not formed in the HC field. Furthermore, (3) research hotspots included health education, new media, health literacy, health information, animal husbandry and veterinary medicine (AHVM), the doctor-patient relationship, and public health emergencies. Additionally, the development of the field could be divided into four stages, indicating a significant shift in HC research from focusing on medicine and public health issues towards communication issues. Finally, (4) new research frontiers have mainly included the WeChat official account and Health China.

The patient satisfaction in primary care consultation-Questionnaire (PiC): An instrument to assess the impact of patient-centred communication on patient satisfaction

Background

Primary care consultation is significantly influenced by communication between the General Practitioner (GP) and their patients. Hypothesising that patient satisfaction can be tested based on an expectation-experience comparison, the aim of this article is to discuss the influence of communication on patient satisfaction.

Methods

A standardised questionnaire was developed striving for a universal primary care survey tool that focuses on patient satisfaction in the context of patient-centred-communication. The sample consisted of 14 German GPs with 80 patients each (n = 1120). Due to the inclusion in an overarching cluster-randomised-study (CRT), the medical practices to be examined were divided into intervention and control groups. The intervention was developed as a reflective training on patient-centred communication.

Results

The results in the present sample show no correlation between patient-centred-communication and patient satisfaction. There are also no significant differences between the intervention and control group.

Discussion

The results raise the question to what extent patient satisfaction can be shaped significantly through patient-centred-communication. The presented project represents part of the basic research in general medical care research and contributes to the transparent processing of theoretical assumptions. With the results described here, communication models with a focus on patient centredness can be evaluated with regard to their practical relevance and transferability.

Communication and empathy skills: Essential requisites for patient-centered radiology care

PURPOSE

To investigate how patients value radiologists, using data from the Dutch healthcare assessment website.

METHOD

The Dutch healthcare assessment website was searched for patient reviews about radiologists in The Netherlands. The scores (scale of 1-10) assigned to the most recent review of each radiologist were extracted. All written reviews were assessed using standardized coding taxonomy, in the domains "clinical competencies" (including quality and safety of clinical care) and "relationships" (including communication with patients and humaneness/caring). For each category, it was assessed whether the review was positive or negative with regard to the performance of the radiologist.

RESULTS

217 of 941 radiologists (23 %) had been reviewed between 2017 and 2021. The total number of institutions to which these radiologists were affiliated was 75 (6 academic and 69 non-academic institutions). Median score assigned to each review was 9.6 (interquartile range 1.3, range 1-10). 74 of 217 radiologists (34 %) were given a maximum review score of 10. 29 of 217 radiologists (13 %) were given a review score of 5 or lower. The far majority of reviews concerned the categories communication (36 % of all positive patient reviews and 30 % of all negative patient reviews) and humaneness/caring (45 % of all positive patient reviews and 49 % of all negative patient reviews).

CONCLUSION

Radiologists are generally highly valued by patients, although there is room for improvement to decrease the number of negative patient experiences. Communication and empathy appear to be the most important skills on which radiologists are judged from a patient's perspective.

Development and evaluation of a tailored e-self-management intervention (dr. Bart app) for knee and/or hip osteoarthritis: study protocol

Background

This paper describes (the development of) an eHealth tool (dr. Bart app) to enhance self-management and to optimize non-surgical health care utilization in patients with knee and/or hip osteoarthritis (OA) and presents a study aiming 1) to study the effectiveness of the dr. Bart app on health care use 2) to explore differences in use, usability and the clinical outcomes of the dr. Bart app between the Netherlands and Germany.

Methods

The dr. Bart app is a fully automated eHealth application and is based on the Fogg model for behavioural change, augmented with reminders, rewards and self-monitoring to reinforce app engagement and health behaviour. The dr. Bart app propose goals to a healthier lifestyle based on machine learning techniques fed by data collected in a personal profile and choosing behaviour of the app user. Patients ≥50 years with self-reported knee and/or hip OA will be eligible to participate. Participants will be recruited in the community through advertisements in local newspapers and campaigns on social media. This protocol presents a study with three arms, aiming to include 161 patients in each arm. In the Netherlands, patients are randomly allocated to usual care or dr. Bart app and in Germany all patients receive the dr. Bart app. The primary outcome of the first research question is the number of self-reported consultations in secondary health care. The primary outcome of the second research question (comparison between the Netherlands and Germany) is self-management behaviour assessed by the patient activation measure (PAM-13) questionnaire. Secondary outcomes are costs, health-related quality of life, physical functioning and activity, pain, use and usability of the dr. Bart app. Data will be collected through three online questionnaires (at baseline and after 3 and 6 months after inclusion).

Discussion

This study will gain insight into the effectiveness of the dr. Bart app in the (conservative) treatment of patients with knee and/or hip OA and differences in the use and usability of the dr. Bart app between the Netherlands and Germany.

Trial registration

Dutch Trial Register (Trial Number NTR6693 / NL6505). Registration date: 4 September 2017.

Training residents in patient-centred communication and empathy: evaluation from patients, observers and residents

BACKGROUND

Patient-centred communication and empathy are key enablers for patient-centred care. However, several studies suggest a downward trend regarding the empathic communication skills of physicians during medical residency. It is known that communication training can have a positive effect on patient-centred communication, empathy and relational skills. Training residents in patient-centred communication and empathy can be an opportunity to improve the patient-centred care. To evaluate the training a tri-focal perspective will be used.

METHODS

A 3-day training was developed to improve residents' patient-centred communication and empathy skills at an academic medical health centre, in the Netherlands. The training included: (1) the basics of patient-centred communication and empathy (through presentations, scientific literature), (2) practicing with actors, and (3) reflecting on residents' video recorded consultations (by themselves and communication experts). A pilot study with a pre-post design was conducted to evaluate the training from patient and observer perspectives. Semi-structured interviews were used to get insight into residents' perspective. Nine residents from different specialities followed the training and enrolled in the pilot study. During two random days consultations between residents and patients were video recorded. Patients were asked to fill in two questionnaires, indicating their perspective on residents' empathy and communication skills before as well as after the consultation. All video recorded consultations were coded to rate residents' communication skills, empathy, computer use and agenda-setting. Statistical analysis were performed using multilevel analysis.

RESULTS

A total of 137 eligible patients took part in the pilot study. Trained residents showed significant improvement in patient-rated empathy scores. According to observers, residents' computer use improved significantly after the training. The communication skills of trained residents did not improve significantly. Agenda setting by residents showed a downward trend. Almost all residents were satisfied with the training, especially with the video-feedback.

CONCLUSIONS

A brief training significantly increased residents' empathy scores according to patients and significantly decreased residents' computer use according to observers. These findings indicate that the quality of patient-centred care can be improved by integrating patient-centred communication into residency programs, at an academic medical health centre. The ultimate goal is to structurally embed the training in residents' education program.

Determinants of physician-patient communication: The role of language, education and ethnicity

AIM

The value of patient-centredness, of which effective physician-patient communication is one key element, has been established within medicine. However, research shows social differences in medical communication according to the patient's social background. This study examines the role of the patient's ethnicity, educational background and language proficiency in relation to physician-patient interaction in 31 countries.

METHOD

More than fifty thousand patients were given a standardized questionnaire to gain insights into the professional behaviour of their family physician and their own expectations and actions.

RESULTS

While no effect of ethnicity was found, there was a significant effect of patients' language proficiency and educational level. Patients with lower language proficiencies were more likely to experience more negative interactions with their physicians. Second-generation migrants who did not fill in the questionnaire in an official language were more negative about the patient-physician interaction. Patients who had a greater chance of having a positive patient-physician interaction were more likely to be higher educated.

CONCLUSION

Despite the shift towards patient-centred care in medicine, physician-patient communication is still determined by the patient's educational background and language proficiency.

PRACTICE IMPLICATION

GPs should primarily be trained to tailor their communication styles to match patients' backgrounds.

Perceptions regarding the scope of practice of family doctors amongst patients in primary care settings in Nairobi

Background

Primary care (PC) is the foundation of the Kenyan health care system, providing comprehensive care, health promotion and managing all illnesses across the lifecycle. In the private sector in Nairobi, PC is principally offered by the general practitioners, also known as family doctors (FDs). The majority have no postgraduate training. Little is known about how patients perceive their capability.

Aim

To assess patients’ perceptions of the scope of practice of FDs working in private sector PC clinics in Nairobi and their awareness of the new category of family physicians (FPs) and the discipline of family medicine.

Setting

Private sector PC clinics in Nairobi.

Methods

A descriptive survey using a structured, self-administered questionnaire. Simple random sampling was used to recruit 162 patient participants.

Results

Of the participants, 30% knew the difference between FPs and FDs. There was a high to moderate confidence that FDs could treat common illnesses; provide lifestyle advice; family planning (66%) and childhood immunisations (64%). In adolescents and adults, low confidence was expressed in their ability to manage tuberculosis (58%), human immunodeficiency virus (55%) and cancer (33%). In the elderly, there was low confidence in their ability to manage depression (55%), anxiety (57%), urinary incontinence (57%) and diabetes (59%). There was low confidence in their ability to provide antenatal care (55%) and Pap smears (42%).

Conclusion

Patients did not perceive that FDs could offer fully comprehensive PC services. These perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing FPs.

Which patient and doctor behaviours make a medical consultation more effective from a patient point of view. Results from a European multicentre study in 31 countries

OBJECTIVE

To assess European patients' preferences regarding seven aspects of doctor-patient communication.

METHODS

6049 patients from 31 European countries evaluated 21 doctor and 12 patient behaviours, through a patient-generated questionnaire (PCVq). Multilevel models explored the effects of patient characteristics, contextual and cultural dimensions on preferences.

RESULTS

Patients attributed more responsibility to doctors, by giving greater importance to doctor than to patient factors, in particular to Treating the patient as a partner and as a person and Continuity of care. Gender, age, education, the presence of chronic illness and two of Hofstede's cultural dimensions, Individualism and Indulgence, showed differential evaluations among patients. Women gave greater importance to all seven communication aspects, older patients to being prepared for the consultation, lower educated patients to Treating patient as a person and Thoughtful planning. Patients from countries with an indulgent background rated all seven communication aspects of greater importance. A more individualistic orientation was related to lower importance regarding the four doctor's factors and the patient factor Open and Honest.

CONCLUSIONS

Treating the patient as a person and providing continuity of care emerged as universal values.

PRACTICE IMPLICATIONS

The findings should represent a landmark for the adaptation of patient-generated communication guidelines and programs in Europe.

Measuring therapeutic relationship in the care of patients with haemophilia: A scoping review

OBJECTIVE

We conducted a scoping review of the tools used to measure therapeutic relationship in patients with haemophilia.

BACKGROUND

Haemophilia is an inherited bleeding disorder caused by a deficiency of a clotting factor in the blood. Therapeutic relationship is foundational to the management of patients with chronic diseases like haemophilia. A reliable and valid measurement tool for assessing therapeutic relationship is needed to evaluate the quality of care received by these patients, and to rigorously study the association between therapeutic relationship and the outcomes of treatment.

METHODS

We adopted the Arksey and O'Malley framework for scoping studies. The following electronic databases were searched for studies that measured a construct related to therapeutic relationships in haemophilia care: MEDLINE, EMBASE, CINAHL, PsycINFO and Scopus. We inventoried these studies, identified the measurement tools used, and described each tool by purpose, content, measurement properties and target population. We identified gaps in the current evidence and directions for future research.

RESULTS

There were 253 unique records retrieved in the search, and twenty studies were deemed relevant. Ten measurement tools were identified. None of the tools measured therapeutic relationship as a single entity; however, six tools measured constructs considered part of patient-provider relationship (eg trust, communication, working alliance). There has been little validation testing of these tools in haemophilia patient populations.

CONCLUSIONS

There is a need for a validated tool for measuring therapeutic relationship in the care of patients with haemophilia. This review provides a foundation for future research in this area.

Exploring the training and scope of practice of GPs in England, Germany and Spain

OBJECTIVE

To explore general practitioner (GP) training, continuing professional development, scope of practice, ethical issues and challenges in the working environment in three European countries.

METHOD

Qualitative study of 35 GPs from England, Germany and Spain working in urban primary care practices. Participants were recruited using convenience and snowball sampling techniques. Semi-structured interviews were recorded, transcribed and analysed by four independent researchers adopting a thematic approach.

RESULTS

Entrance to and length of GP training differ between the three countries, while continuing professional development is required in all three, although with different characteristics. Key variations in the scope of practice include whether there is a gatekeeping role, whether GPs work in multidisciplinary teams or singlehandedly, the existence of appraisal processes, and the balance between administrative and clinical tasks. However, similar challenges, including the need to adapt to an ageing population, end-of-life care, ethical dilemmas, the impact of austerity measures, limited time for patients and gaps in coordination between primary and secondary care are experienced by GPs in all three countries.

CONCLUSION

Primary health care variations have strong historical roots, derived from the different national experiences and the range of clinical services delivered by GPs. There is a need for an accessible source of information for GPs themselves and those responsible for safety and quality standards of the healthcare workforce. This paper maps out the current situation before Brexit is being implemented in the UK which could see many of the current EU arrangements and legislation to assure professional mobility between the UK and the rest of Europe dismantled.

Patient-perceived responsiveness of primary care systems across Europe and the relationship with the health expenditure and remuneration systems of primary care doctors

BACKGROUND

Health systems are expected to be responsive, that is to provide services that are user-oriented and respectful of people. Several surveys have tried to measure all or some of the dimensions of the responsiveness (e.g. autonomy, choice, clarity of communication, confidentiality, dignity, prompt attention, quality of basic amenities, and access to family and community support), however there is little evidence regarding the level of responsiveness of primary care (PC) systems.

METHODS

This work analyses the capacity of primary care systems to be responsive. Data collected from 32 PC systems were used to investigate whether a relationship exists between the responsiveness of PC systems and the PC doctor remuneration systems and domestic health expenditure.

RESULTS

There appears to be a higher responsiveness of PC when doctors are paid via capitation than when they only receive a fee for services or a mixed payment method. In addition, countries that spend more on health services are associated with higher levels of dignity and autonomy.

CONCLUSION

Quality, as measured from the patient's perspective, does not necessarily overlap with PC performance based on structure and process indicators. The results could also stimulate a new debate on the role of economic resources and PC workforce payment mechanisms in the achievement of quality goals, in this case related to the capacity of PC systems to be responsive.

Communication during haematological consultations; patients' preferences and professionals' performances

Many patients with haematological malignancies experience barriers in clinical communication. Reaching effective communication is of great importance as it has been linked to a range of improved patient outcomes such as satisfaction, compliance to treatment, perceived quality of life and physical and mental health. To get a better understanding how communication in haematological consultations can be improved, the current study focussed on patients' preferences and perceived performances regarding the communicative behaviour of their health care professional. Secondly, the mediation of an online communication tool for patients was analysed. Within a controlled pre- post-test design, 78 datasets of clinical consultations could be analysed. Patients considered both affective and instrumental communication aspects important. The affective communication behaviour of the health care professional met the patients' pre-visit preferences well. In the information exchange, more variability and discrepancies were found. Overall, the online intervention did not seem to influence the patients' perceived communication performance of their health care professional much. To further improve the communication during clinical consultations, health care professionals should inquire about patients' expectations, especially during the exchange of information and advices. At the same time, patients should be supported to express their preferences at the start of the consultation. The study was registered in the Netherlands Trial Register, number 3779.

How do national cultures influence lay people's preferences toward doctors' style of communication? A comparison of 35 focus groups from an European cross national research

Background

The evidence that inspires and fosters communication skills, teaching programmes and clinical recommendations are often based on national studies which assume, implicitly, that patients’ preferences towards doctors’ communication style are not significantly affected by their cultural background. The cross-cultural validity of national results has been recognized as a potential limitation on how generally applicable they are in a wider context. Using 35 country-specific focus group discussions from four European countries, the aim of the present study is to test whether or not national cultures influence lay people’s preferences towards doctors’ style of communication.

Methods

Lay people preferences on doctor’s communication style have been collected in Belgium, the Netherlands, the United Kingdom and Italy. Each centre organized between eight and nine focus groups, where participants (n = 259) were asked to comment on a video of a simulated medical interview. The discussions were audiotaped, transcribed and coded using a common framework (Guliver Coding System) that allowed for the identification of different themes.

Results

The frequency distribution of the topics discussed highlights lay people’s generally positive views towards most part of doctors interventions. The regression model applied to the Guliver categories highlighted slight national differences and the existence of a cross-cultural appreciation, in particular, of five types of intervention: Doctors attitudes (both Task-Oriented and Affective/Emotional), Summarizing, Structuring and Providing solution.

Conclusion

Lay panels valued doctors’ communication style in a similar manner in the countries selected. This highlights the existence of a common background, which in the process of internationalization of heath care, might foster the implementation of cross-national teaching programmes and clinical guidelines.

Changes in general practitioners' sensitivity to patients' distress in low back pain consultations

OBJECTIVE

We aim to study GPs' sensitivity to patients' distress and communication on psychosocial factors prior to and after the introduction of the clinical guideline for low back pain.

METHODS

Consultations from previous studies on doctor-patient communication in the Netherlands were available for secondary analyses. We selected consultations in which patients presented low back pain complaints (N=168; 25 from 1989, 6 from 1995, 116 from 2001, 21 from 2008) and analyzed these consultations using the Roter Interaction Analysis System (RIAS) and the Verona Coding Definitions of Emotional Sequences (VR-CoDES).

RESULTS

GPs more often acknowledged psychosocial factors during consultations after implementation of the guideline for non-specific low back pain. Moreover, patients more often voiced their worries, while GPs put more emphasis on providing biomedical information and counseling during these consultations.

CONCLUSIONS

GPs tend to emphasize biomedical factors rather than supporting their patients emotionally. Patients are likely to voice their worries implicitly, indicating they have a need for emotional support from their GPs.

PRACTICE IMPLICATIONS

GPs now face the challenge of not only recognizing psychosocial aspects during consultations with low back pain, but also actively eliciting concerns regarding these psychosocial aspects.

Assessing the potential for improvement of primary care in 34 countries: a cross-sectional survey

Objective

To investigate patients’ perceptions of improvement potential in primary care in 34 countries.

Methods

We did a cross-sectional survey of 69 201 patients who had just visited general practitioners at primary-care facilities. Patients rated five features of person-focused primary care – accessibility/availability, continuity, comprehensiveness, patient involvement and doctor–patient communication. One tenth of the patients ranked the importance of each feature on a scale of one to four, and nine tenths of patients scored their experiences of care received. We calculated the potential for improvement by multiplying the proportion of negative patient experiences with the mean importance score in each country. Scores were divided into low, medium and high improvement potential. Pair-wise correlations were made between improvement scores and three dimensions of the structure of primary care – governance, economic conditions and workforce development.

Findings

In 26 countries, one or more features of primary care had medium or high improvement potentials. Comprehensiveness of care had medium to high improvement potential in 23 of 34 countries. In all countries, doctor–patient communication had low improvement potential. An overall stronger structure of primary care was correlated with a lower potential for improvement of continuity and comprehensiveness of care. In countries with stronger primary care governance patients perceived less potential to improve the continuity of care. Countries with better economic conditions for primary care had less potential for improvement of all features of person-focused care.

Conclusion

In countries with a stronger primary care structure, patients perceived that primary care had less potential for improvement.

Concerns voiced by patients and GPs' responses during psychosocial visits in primary care: a historical cross-sectional study

Background

In a recent study comparing psychosocial consultations prior to and after the implementation of national clinical guidelines in the Netherlands, we found that general practitioners (GPs) showed less empathy in the more recent consultations. As a consequence, patients possibly have less scope to express their worries. The objective is to investigate whether patients have become more reluctant to open up about their concerns during psychosocial consultations and how GPs respond.

Methods

Consultations from previous study samples videotaped between 1977 and 2008 and categorized by GPs as ‘completely psychosocial’ were selected for the present study. These consultations were observed using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to capture cues and concerns expressed by patients and GPs’ immediate responses. We compared consultations prior to (N = 121) and after (N = 391) introduction of national clinical guidelines in the 1990s.

Results

In 92% of the consultations, patients presented at least one worry. These were most often expressed implicitly. However, the proportion of consultations containing at least one explicit concern changed from 24% to 37% over time. The increased number of expressed cues and concerns was partly explained by a change in GP characteristics; the latter sample contained more female and more experienced GPs. Furthermore, cues and concerns were more often expressed during later phases of consultations in recent years.

Conclusions

Our study shows that patients have become somewhat more explicit in expressing their worries. However, GPs need to be aware that, still, most worries are expressed implicitly and that new concerns may appear towards the end of consultations.

Talking about psychosocial problems: an observational study on changes in doctor-patient communication in general practice between 1977 and 2008

OBJECTIVE

To examine whether GPs' communication styles have changed since the introduction and implementation of clinical guidelines for psychosocial problems in Dutch general practice in the 1990s.

METHODS

From a database of 5184 consultations videotaped between 1977 and 2008, 512 consultations assessed by GPs as 'completely psychosocial' were coded with RIAS (Roter Interaction Analysis System). The 121 consultations prior to and 391 consultations after implementation of guidelines were analyzed whether communication styles have changed over time.

RESULTS

We found that GPs were more likely to consider consultations to be mainly (17%) or completely (12%) psychosocial after the implementation of guidelines. They gave more biomedical and psychosocial information and advice in the second period compared to the first period. We also found that empathy decreased over time (frequency of empathic statements by GPs changed from 2.9-3.2 to 1.4-1.6 between periods).

CONCLUSION

Communication in psychosocial consultations has changed; GPs have become more focused on task-oriented communication (asking questions, giving information and advice) and less on showing empathy.

PRACTICE IMPLICATIONS

GPs face the challenge of integrating an evidence-based approach of applying guidelines that promote active symptom exploration with understanding patients' personal contexts and giving room to their emotions.

Does the Cultural Formulation Interview for the fifth revision of the diagnostic and statistical manual of mental disorders (DSM-5) affect medical communication? A qualitative exploratory study from the New York site

OBJECTIVES

Cross-cultural mental health researchers often analyze patient explanatory models of illness to optimize service provision. The Cultural Formulation Interview (CFI) is a cross-cultural assessment tool released in May 2013 with DSM-5 to revise shortcomings from the DSM-IV Outline for Cultural Formulation (OCF). The CFI field trial took place in 6 countries, 14 sites, and with 321 patients to explore its feasibility, acceptability, and clinical utility with patients and clinicians. We sought to analyze if and how CFI feasibility, acceptability, and clinical utility were related to patient-clinician communication.

DESIGN

We report data from the New York site which enrolled 7 clinicians and 32 patients in 32 patient-clinician dyads. We undertook a data analysis independent of the parent field trial by conducting content analyses of debriefing interviews with all participants (n = 64) based on codebooks derived from frameworks for medical communication and implementation outcomes. Three coders created codebooks, coded independently, established inter-rater coding reliability, and analyzed if the CFI affects medical communication with respect to feasibility, acceptability, and clinical utility.

RESULTS

Despite racial, ethnical, cultural, and professional differences within our group of patients and clinicians, we found that promoting satisfaction through the interview, eliciting data, eliciting the patient's perspective, and perceiving data at multiple levels were common codes that explained how the CFI affected medical communication. We also found that all but two codes fell under the implementation outcome of clinical utility, two fell under acceptability, and none fell under feasibility.

CONCLUSION

Our study offers new directions for research on how a cultural interview affects patient-clinician communication. Future research can analyze how the CFI and other cultural interviews impact medical communication in clinical settings with subsequent effects on outcomes such as medication adherence, appointment retention, and health condition.

Older cancer patients' information and communication needs: what they want is what they get?

OBJECTIVE

To evaluate what information and communication aspects older cancer patients (≥65) consider important in preparing for chemotherapy treatment (CT), the extent to which this corresponds with what oncology nurses consider important, and the extent to which nurses attend to these aspects during real-life educational visits in oncology.

METHODS

The QUOTE(chemo) was used to have patients (n=116) and nurses (n=123) rate the importance of 66 aspects of patient education. Subsequently, the implementation of these 66 aspects during videotaped nursing visits (n=155) with older cancer patients receiving CT for the first time was examined.

RESULTS

Older cancer patients attached most importance to 'treatment-related information', 'rehabilitation information', 'affective communication' and discussing 'realistic expectations'. Nurses placed great importance to almost all aspects except to discussing 'realistic expectations'. Discrepancies were found between expressed importance and the actual performance during the videotaped consultations, particularly in discussing realistic expectations, coping information, interpersonal communication, and tailored communication.

CONCLUSION

Results pointed to aspects that need improvement to ensure high quality patient education tailored to the patients' needs.

PRACTICE IMPLICATIONS

To make sure older cancer patients' needs are met, more attention should be paid to the development of interventions supporting both needs assessment and fulfillment.

How patients want their doctor to communicate. A literature review on primary care patients' perspective

OBJECTIVE

To review the literature on the communicative behaviours primary care patients want from a "good" physician.

METHODS

An electronic search used the key words doctor-patient relation AND patient desires OR patient expectations OR patient preferences (from now on referred to as expectations). The qualitative and quantitative articles meeting the selection criteria were analysed separately, comparing methods, definitions, measures and outcomes. The physician behaviours desirable from a patient perspective were grouped by linking them to the communicative functions of an effective medical encounter as defined from a professional perspective.

RESULTS

Twenty-seven studies were included. Critical issues were the heterogeneity of definitions and measures and the lack of integration between quantitative and qualitative findings. Most of the expectations in qualitative studies were related to the function "Fostering the relationship". Similar expectations arose less often in quantitative studies.

CONCLUSIONS

Patients do have concrete expectations regarding each of the functions to be met in the medical encounters. The research approach tends to bias the results.

PRACTICE IMPLICATIONS

The collected expectations suggest how physicians may perform each of their tasks according to the patient perspective. Future research on patients' communicative expectations needs to overcome the gap between qualitative and quantitative findings.

Are GP patients' needs being met? Unfulfilled information needs among native-Dutch and Turkish-Dutch patients

OBJECTIVE

This study aims to assess unfulfilled information needs of native-Dutch and Turkish-Dutch general practitioner (GP) patients in the Netherlands. In addition, the relation between perceived and recorded information provision by GPs is studied.

METHODS

Unfulfilled information needs of native-Dutch (N=117) and Turkish-Dutch patients (N=74) were assessed through pre- and post-consultation questionnaires. Audiotapes of GP consultations were made to code GPs' information provision.

RESULTS

Turkish-Dutch patients experience more unfulfilled information needs than native-Dutch patients, in particular those who identify equally with Dutch and Turkish culture. Overall, perceived information provision is hardly related to recorded information provision.

CONCLUSION

GPs insufficiently provide Turkish-Dutch patients and, to a lesser extent, native-Dutch patients as well, the information they need.

PRACTICE IMPLICATIONS

GPs should be trained in giving adequate, tailored information to patients with various ethnic and cultural backgrounds.

Shared medical appointments for children and adolescents with type 1 diabetes: perspectives and experiences of patients, parents, and health care providers

Aims

This study examined the perspectives and experiences of patients, parents, and health care providers with shared medical appointments (SMAs) for children and adolescents with type 1 diabetes. Specifically studied were reasons to attend SMAs, perceived differences between SMAs and individual medical appointments, patient-valued health care aspects, and providers’ performance.

Methods

Fifty-two patients, 8 parents, and 36 health care providers participated. Perspectives on SMAs were assessed with questionnaires and an online focus group. Data was analyzed using descriptive statistics.

Results

Health care providers had work-related reasons to conduct SMAs. Patients and parents primarily valued the presence of other patients during SMAs. According to health care providers and patients, a higher or similar amount of information was discussed during SMAs as opposed to individual appointments, respectively. SMAs did contain more discussion about lifestyle. Most consultation aspects considered important by the patients were performed by their health care providers. Patient satisfaction with SMAs did tend to decrease after 3 months. Parents were somewhat more critical about SMAs.

Conclusions

Health care providers, patients, and parents were generally positive about SMAs. Future studies should examine the impact of the presence of parents and different health care providers during SMAs, and that of differences in patient age, type of insulin treatment, and disease-related problems.

GULiVER--travelling into the heart of good doctor-patient communication from a patient perspective: study protocol of an international multicentre study

BACKGROUND

The project GULiVer explores how lay people in Belgium (Gent), the Netherlands (Utrecht), the UK (Liverpool) and Italy (Verona) evaluate physicians' communicative skills. The aims are to present the study design and to assess the quality of collected data.

METHODS

In each centre one out of two sets of four videotaped consultations involving medical students with varying communication skills were shown to eight lay panels of six to nine participants each (n = 259). The selection of lay participants was stratified by gender and age in order to obtain a heterogeneous sample. Background characteristics included socio-demographics, participants' general physical (COOP-WONCA) and mental health (GHQ), communication preferences (QUOTE-com) and trust in doctors (TMP). Participants were asked to give quantitative and qualitative evaluations of the student doctors' performance in a mixed-methods design. Quality assessment of the collected data and protocol adherence of the four centres was carried out by Generalized Linear Model (GLM).

RESULTS

The overall sample comprised 259 participants. Participants were equally distributed among the centres and balanced in terms of age, gender and OSCE scenario, confirming the quality of collected data.

CONCLUSION

The study design and the applied procedures will ensure a great richness of data allowing a wider European perspective on lay persons' views, assessed both individually and through focus group discussion.

Discussing patient's lifestyle choices in the consulting room: analysis of GP-patient consultations between 1975 and 2008

BACKGROUND

The increasing prevalence of chronic diseases and the growing understanding that lifestyle behaviour plays an essential role in improving overall health suggest a need for increased attention to lifestyle choices in the consulting room.This study aims to examine whether or not healthy and unhealthy lifestyle choices of patients are currently being discussed more often in primary care consultations than in former decades. Furthermore, we are interested in GPs' approach to lifestyle behaviour during consultations. Lastly, we examine whether lifestyle behaviour is discussed more with certain patients during consultations, depending on gender, age and educational background.

METHOD

We analysed video-recordings of medical consultations, collected between 1975 and 2008 in Dutch GP practices. Data were analysed using logistic regression.

RESULTS

This study shows that discussion of smoking behaviour and physical activity has increased somewhat over time. A change in discussion of nutrition and alcohol is, however, less clear. Overall, alcohol use is the least discussed and physical activity the most discussed during consultations. GPs mainly refer to lifestyle when it is relevant to the patient's complaints (symptom approach). GPs' approach to lifestyle behaviour did not change over time. In general, lifestyle behaviour is discussed more with older, male patients (except for nutrition). GPs talk about lifestyle behaviour with patients from different educational backgrounds equally (except for physical activity).

CONCLUSION

In recent years there is greater awareness of a healthy lifestyle, which is reflected to a limited extent in this study. Still, lifestyle behaviour is discussed in only a minority of consultations. GPs do not refer to lifestyle behaviour as a routine procedure, i.e. do not include it in primary prevention. This highlights the importance of the introduction of prevention consultations, where GPs can discuss lifestyle issues with patients who do not (yet) have risk symptoms.

What happened? GPs' perceptions of consultation outcomes and a comparison with the experiences of their patients

OBJECTIVE

To investigate GPs' perceptions of consultation outcomes and to investigate the associations between these and outcomes perceived by the patients.

DESIGN

25 GPs and 10 patients for each GP filled in a questionnaire about the outcome of the same consultation. The questions in the questionnaires were formulated from concepts found in preceding qualitative studies. Their answers were analysed and compared.

SETTING

GPs and patients from 16 group practices in Norrbotten, Sweden.

RESULTS

The GPs had the apprehension that their consultations would lead to cure/symptom relief in half of their consultations. They believed that their patients were satisfied up to 90% and that up to 75% had been reassured, understood more or could cope better. The GPs were satisfied themselves with up to 95% of the consultations, they enhanced their relationship to their patient up to 70%. Their affirmative concordance with their patients was high regarding satisfaction, intermediate regarding patient reassurance and patient understanding and lowest regarding cure/symptom relief.

CONCLUSION

The GPs' were lacking in their ability to assess the patients' increased understanding and the concordance between their own and the patients' expectation of cure/symptom relief was low.

Can dimensions of national culture predict cross-national differences in medical communication?

OBJECTIVE

This study investigated at a country level how cross-national differences in medical communication can be understood from the first four of Hofstede's cultural dimensions, i.e. power distance, uncertainty avoidance, individualism/collectivism and masculinity/femininity, together with national wealth.

METHODS

A total of 307 general practitioners (GPs) and 5820 patients from Belgium, Estonia, Germany, Great Britain, the Netherlands, Poland, Romania, Spain, Sweden and Switzerland participated in the study. Medical communication was videotaped and assessed using Roter's interaction analysis system (RIAS). Additional context information of physicians (gender, job satisfaction, risk-taking and belief of psychological influence on diseases) and patients (gender, health condition, diagnosis and medical encounter expectations) was gathered by using questionnaires.

RESULTS

Countries differ considerably form each other in terms of culture dimensions. The larger a nation's power distance, the less room there is for unexpected information exchange and the shorter the consultations are. Roles are clearly described and fixed. The higher the level of uncertainty avoidance, the less attention is given to rapport building, e.g. less eye contact. In 'masculine' countries there is less instrumental communication in the medical interaction, which was contrary to expectations. In wealthy countries, more attention is given to psychosocial communication.

CONCLUSION

The four culture dimensions, together with countries' wealth, contribute importantly to the understanding of differences in European countries' styles of medical communication. Their predictive power reaches much further than explanations along the north/south or east/west division of Europe.

PRACTICE IMPLICATIONS

The understanding of these cross-national differences is a precondition for the prevention of intercultural miscommunication. Improved understanding may occur at microlevel in the medical encounter, as well as on macrolevel in pursuing more effective cooperation and integration of European health care policies.

Does training general practitioners to elicit patients' illness representations and action plans influence their communication as a whole?

OBJECTIVE

To examine whether the discussion of illness representations and action plans during medical encounters affects the way patients and general practitioners (GPs) communicate.

METHODS

In a quasi-experimental design, 10 GPs first performed care-as-usual conversations with patients. After a 6 h training they performed consultations either emphasizing patients' illness representations or action plans. Data were collected from 70 videotaped consultations with hypertensive patients, which were analyzed using the Roter Interaction Analysis System.

RESULTS

Compared with care-as-usual consultations, communication in the action plan condition resulted in an increased discussion of lifestyle issues whereas communication in the illness representation condition resulted in more discussion of patient concerns. In both experimental conditions the proportion of affective GP utterances was higher while patients contributed more to the conversation. When GPs changed their communication style, patients did accordingly.

CONCLUSION

The explicit address of illness representations or action plans during consultations results in more attention to patient concerns and lifestyle issues and an overall improvement in patient-GP communication in terms of affective atmosphere and patient involvement.

PRACTICE IMPLICATIONS

These findings show that after a brief training GPs are able to change their communication style in a way that allows for a more thorough consideration of patient self-management.

Has patients' involvement in the decision-making process changed over time?

OBJECTIVE

To get insight into the changes over time of patients' involvement in the decision-making process, and into the factors contributing to patients' involvement and general practitioners' (GPs) communication related to the Medical Treatment Act (MTA) issues: information about treatment, other available treatments and side-effects; informed decision making; asking consent for treatment.

BACKGROUND

Societal developments have changed the doctor-patient relationship recently. Informed decision making has become a central topic. Patients' informed consent was legalized by the MTA (1995).

DESIGN

Data of two cross-sectional studies, the First (1987) and Second (2001) Dutch National Survey of General Practice, were compared.

SETTING AND PARTICIPANTS

General practice consultations; 16 GPs and 442 patients in 1987; 142 GPs and 2784 patients in 2001.

METHODS

Consultations were videotaped and rated using Roter's Interaction Analysis System and observer questionnaires; pre- and post-consultation patient questionnaires; and GP questionnaires. Descriptive analyses and multivariate, multilevel analysis were applied.

MAIN RESULTS

Most patients reported to have received the information they had considered as important prior to the consultation. There were discrepancies in involvement in treatment decisions and in giving information about other available treatments, side-effects and risks. GPs who were more affective and gave more information, more often involved their patients, especially younger patients, in decision making. In 2001, more informed decision making was observed and the GPs asked consent for a treatment more often, but they less often asked for the patients' understanding.

CONCLUSION

Patients' involvement in decision making has increased over time, but not in every respect. However, this does not apply for all patients, especially the older ones. It should be questioned whether they are willing or capable to be involved and if so, how they could be encouraged.

Cultural differences in medical communication: a review of the literature

OBJECTIVE

Culture and ethnicity have often been cited as barriers in establishing an effective and satisfying doctor-patient relationship. The aim of this paper is to gain more insight in intercultural medical communication difficulties by reviewing observational studies on intercultural doctor-patient communication. In addition, a research model for studying this topic in future research is proposed.

METHODS

A literature review using online databases (Pubmed, Psychlit) was performed.

RESULTS

Findings reveal major differences in doctor-patient communication as a consequence of patients' ethnic backgrounds. Doctors behave less affectively when interacting with ethnic minority patients compared to White patients. Ethnic minority patients themselves are also less verbally expressive; they seem to be less assertive and affective during the medical encounter than White patients.

CONCLUSION

Most reviewed studies did not relate communication behaviour to possible antecedent culture-related variables, nor did they assess the effect of cultural variations in doctor-patient communication on outcomes, leaving us in the dark about reasons for and consequences of differences in intercultural medical communication. Five key predictors of culture-related communication problems are identified in the literature: (1) cultural differences in explanatory models of health and illness; (2) differences in cultural values; (3) cultural differences in patients' preferences for doctor-patient relationships; (4) racism/perceptual biases; (5) linguistic barriers. It is concluded that by incorporating these variables into a research model future research on this topic can be enhanced, both from a theoretical and a methodological perspective.

PRACTICE IMPLICATIONS

Using a cultural sensitive approach in medical communication is recommended.

Attitudes and practices of physicians and nurses regarding physical activity promotion in the Catalan primary health-care system

BACKGROUND

In Catalonia a high percentage of the population remains inactive. General practices are an ideal setting to advise on physical activity (PA). However, there is a lack of evidence regarding practices, barriers and predictors of such promotion in the Catalan primary health-care system. This study set out to establish descriptive baseline data for PA promotion in Catalan general practices, and to explore the experiences of doctors/nurses in promoting PA in their day-to-day professional lives.

METHODS

A mixed-method approach was adopted. A survey was conducted with 245 physicians/nurses (58% response rate). Subsequently, focus groups (n = 5) and semi-structured interviews (n = 7) were conducted with 18 physicians and 15 nurses. After coding for important themes, the final interpretation was confirmed by contributors.

RESULTS

Eighty-eight percent of physicians/nurses promoted PA at least infrequently. However, work conditions were perceived as unfavourable, with the main barriers being lack of (i) time, (ii) training and (iii) protocols. Qualitative data showed that PA promotion was opportunistic, focused on selected patients, used generalized messages and was highly dependent on personal interests. Regular promotion was encouraged by direct experiences of the benefits of regular exercising, knowing patients well, being supported by medical colleagues and creating links with other community institutions. PA promotion was especially hindered by seeing PA promotion as a secondary task, and patients ignoring recommendations.

CONCLUSIONS

PA promotion in Catalonia remains to be integrated into practice consultations. Therefore, strategies should be developed within public health. Using a mixed-method approach provided a broader range of evidence than most studies, which rely on quantitative methods.

When talking to the patient is difficult: the physician's perspective

The aim of the study was to analyze the difficult doctor-patient relationship from a doctor's perspective. A qualitative-interpretative approach was employed to analyze representations of difficult visits collected by means of written narrations. Two main scenarios were identified: (i) a 'personal scenario' in which the doctor had difficulties from a purely personal perspective; and (ii) a 'professional scenario' in which the doctor had difficulties as a professional when the 'other' resists or in facing the 'other' who resists. A further scenario was identified in which problems were generated by the family of the patient. Results suggest that the relation between doctor and patient may be very complex. Difficulties may be internal to the doctor, hence intra-psychic, depending on being both a professional and a human being. Difficulties may also be external between two psychological subjects (labeled as inter-psychic), where interaction of the 'you' and the 'other' becomes a battleground, a wall of opposition, or alternatively a place of experimentation with relationships. Furthermore, external difficulties may also be between more than two persons (labeled as inter-personal), by the possible multiplicity of the 'other'. This happens in particular when the 'other' is represented by the family.

The unexpected in primary care: a multicenter study on the emergence of unvoiced patient agenda

PURPOSE

Within the time constraints of a typical physician-patient encounter, the full patient agenda will rarely be voiced. Unexpectedly revealed issues that were neither on the patient's list of items for discussion nor anticipated by the physician constitute an emerging agenda. We aimed to quantify the occurrence rate of emerging agendas in primary care practices and to explain the variation between patients and practices.

METHODS

This observational cross-sectional study involved 182 primary care practices in 9 European cultural regions. Consecutive primary care consultations were videotaped and rated. Patients completed preconsultation and postconsultation questionnaires assessing their expectations and perceived care. Emerging agenda, determined by using 11-item preconsultation and postconsultation questionnaires, was defined as care perceived by the patient to be in addition to expected care, after adjustment for cultural variations of patient expectations.

RESULTS

For consultations involving 2,243 patients (mean age, 44.8 years, 58.4% women), every sixth (15.8%) consultation revealed emerging psychosocial agenda. Biomedical agenda emerged in 14.5% of the consultations. Rates for unmet expectations were 13.6% and 10.3%, respectively, for psychosocial and biomedical problems. Practices showed considerable heterogeneity of occurrence of emerging agenda (biomedical, median 13%, range 0%-67%; psychosocial, median 14%, range 0%-53%). After controlling for region and patient baseline characteristics, variables significantly related to emerging agenda were patient expectations and biomedical or psychosocial discourse content, but not consultation time or sex of the patient. A large proportion of the variance attributable to physicians remained concealed in a practice dummy variable (explaining up to 8% of the variance).

CONCLUSION

Unexpected agenda emerges in every sixth to seventh consultation in outpatient primary care visits.

Is the communicative behavior of GPs during the consultation related to the diagnosis? A cross-sectional study in six European countries

This study explores the relation between the diagnosis made by the general practitioner (GP) and his or her communicative behavior within a consultation, by means of the analysis of 2095 videotaped consultations of 168 GPs from six countries participating in the Eurocommunication study. The doctors' diagnoses were coded into ICPC chapters and merged into seven clinically relevant diagnostic clusters. The communicative behavior was gauged by means of the Roter interaction analysis system (RIAS). We found the most important differences for consultations about psychosocial problems as compared to all other diagnostic categories. In these consultations, doctors show more affective behavior, are more concerned about having a good relationship with their patients, ask more questions and give less information than in other consultations. The percentages of utterances in the other diagnostic categories were pretty similar. The communicative behavior of doctors reflects a global pattern in every consultation. This pattern is the most stable for affective behavior (social talk, agreement, rapport building and facilitation). Within instrumental behavior (the other categories), the directions and the information the doctor gives are adapted to the problems presented.

Impact of national health care systems on patient evaluations of general practice in Europe

OBJECTIVE

To examine associations between patient evaluations of general practice and characteristics of national health care systems.

METHODS

International comparative study in 17 countries, using international patient survey data (n= 25052) and data-bases for health care system characteristics. Dependent variable was patients' evaluation of general practice care. Five independent factors were examined: GP density, physician density, fee for service reimbursement, gatekeeper role, and first-contact role.

RESULTS

None of the associations were statistically significant.

CONCLUSIONS

Patients were highly satisfied with general practice in different national health care systems. Descriptive tables on international variations may lead to misleading conclusions.

Quality assessment of health counseling: performance of health advisors in cardiovascular prevention

Quality assessments of interventions are seen as essential in optimizing their implementation, interpreting their effectiveness, and illuminating their underlying processes. In Hartslag Limburg, a cardiovascular prevention project, the quality of a health counseling intervention was assessed as part of the process evaluation. Four health advisors each video-taped 16 counseling sessions, all of which were assessed by three independent observers. Health counseling was found to be a very difficult skill, but, all things considered, the overall quality was evaluated as rather encouraging. No indication was found of quality improvement over time. The interpretation of the findings was complicated by limited absolute interobserver agreement, but reliable relative distinctions could be made between the health advisors' performance and their application of various counseling skills. Future quality investigators are advised to carefully match study goals with study methods, and practitioners planning a health counseling project should take the complexity of the task into account.

The experience of gatekeeping: a psychiatric nurse in an emergency department

Emergency departments are increasingly identified as the entry point to mental health services. In the hope of facilitating the flow of psychiatric patients through a general hospital's emergency department, experienced psychiatric nurses were asked to participate in a pilot project in a general hospital in Canada. This paper is a reflection of one emergency psychiatric nurse's (EPN) experience of her role being transformed into that of a gatekeeper. The notion of "gatekeeper" as a metaphor highlights "keeping psychiatric patients out" of an already strained emergency system. As a means to balance fiscal demands with patient care, the EPN inadvertently served to obscure entry for patients with mental illness who were seeking emergency services.