Consumerism and the consultation: the doctor's view

Computers and the general practice consultation

The introduction of desktop computing into primary healthcare over the past 30 years has been founded on the assumption that it would be accompanied by a clearly demonstrable benefit both to direct patient care, and to the development of administrative systems. While advances in primary care administration may be related to computerization, the evidence for improvements in direct patient care is more mixed. In this paper we critically discuss issues raised by the existing research literature in primary care computing, and especially note the difficulties posed by the absence of portable generic electronic patient records.

[Sociodemographic factors and satisfaction related to the care received by women with breast cancer. Multicentre study]

OBJECTIVES

Evaluate the level of satisfaction in the Medical Oncology Services in our Community of women with breast cancer, and analyse the influence of sociodemographic and clinical factors on their satisfaction.

MATERIAL AND METHODS

Cross-sectional multicentre study using an anonymous and voluntary questionnaire completed by 225 women diagnosed with breast cancer. The tool used was the modified SERVQHOS, adapted to our context. We collected demographic and clinical data. To determine the reliability of the tool after the adjustments, a Cronbach's alpha analysis was performed. A descriptive analysis was also performed, as well as non-parametric statistics to study the influence of demographic variables on satisfaction.

RESULTS

The best evaluated aspects were the kindness of the staff [4.30±0.83 (2-5)], the confidence transmitted by them [4.23±0.79 (2-5)] and personal treatment [4.12±0.88 (2-5)]. The worst evaluated was the ease of getting to the hospital [3.06±0.99 (1-5)], waiting time [3.16±1.00 (1-5)], state of consultations rooms [3.38±0.99 (1-5)] and punctuality of the sessions [3.38±1.05 (1-5)]. The overall satisfaction was 4.04±0.82 (1-5). Age influenced their assessment of the personal appearance of the staff (P=.04), the state of consultations rooms (P<00), the ease of getting to the hospital, and the quantity and quality of information received (P=01). Educational level influenced their satisfaction with personal appearance of the staff (P =03) and the state of consultations rooms (P=03). Women who worked and those who were temporary disabled women evaluated the appearance of personnel worst (P=02). The time from the diagnosis affected the satisfaction with the staff willingness to help (P<00) and therapy attendance, and the satisfaction with the ability to understand their needs (P=03).

CONCLUSIONS

The individual characteristics of the participants influence their satisfaction. We have been able to identify deficient areas from their point of view, identifying important improvement opportunities in several aspects of care to work on in order to increase the quality of care.

Alignment of nephrology training with workforce, patient, and educational needs: an evidence based proposal

BACKGROUND AND OBJECTIVES

Competency-based training programs focus on the product of training rather than the process with the desired attributes and skills set of the specialist directing the training program. These ideal skills and qualities have yet to be formally identified for nephrology training. The objectives of our study were: (1) to define the attributes of a "high quality" nephrologist from the perspectives of the trainer (nephrologist), trainee, and renal patient and (2) identify components and relative frequencies of nephrologists' work practice.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Four substudies were undertaken, utilizing a combined quantitative and qualitative approach: (1) a national nephrology workforce study, (2) in-depth interviews of nephrology patients, (3) in-depth interviews of nephrology trainees, and (4) in-depth interviews of practicing nephrologists.

RESULTS

Patients value good communication skills above other attributes. Nephrologists and trainees identify particular personal attributes, a holistic and evidence-based approach to patient care, and good clinical skills as paramount. Although nephrologists spend most of their time in clinical practice, substantial time is also spent in research, teaching, and administrative work.

CONCLUSIONS

For the first time, an evidence-based approach has been used to help define qualities desired in a practicing nephrologist. Along with training and assessment in clinical practice, this research supports nephrology training programs incorporating training in basic interventions, research skill acquisition, administration, and teaching. Training toward high standards in advanced communication and the maintenance of a holistic approach to patient care are necessary.

Over-the-counter medicines: professional expertise and consumer discourses

Ideas of participation and partnership in health care consultations have attracted increasing attention in recent years; however the consequences in terms of the necessary shifts in existing relationships are often overlooked. We examine how pharmacists work to maintain their professional expertise against the rise of health-care consumerism. We draw on the following data from a UK study of consultations for over-the-counter (OTC) medicines in two pharmacies: (i) an outline of the pharmacy owners' views of their practice model, (ii) data from observations and tape recorded consultations (iii) interviews with customers and pharmacists and (iv) views expressed in two feedback sessions discussing vignettes developed from observational and interview-based fieldwork. There was no suggestion that attempts to engage customers in discussions about their treatment necessitated a diminution of the importance of pharmaceutical expertise. Indeed, both pharmacists and customers acknowledged the importance of the asymmetry of knowledge between pharmacists and customers. Pharmaceutical expertise was however not always perceived to be necessary and transactions in pharmacies may be treated like those in any other retail environment. Further research using a larger dataset to investigate problems in interactions resulting from tensions between pharmaceutical expertise and consumerism is indicated.

A patient decision aid to support shared decision-making on anti-thrombotic treatment of patients with atrial fibrillation: randomised controlled trial

OBJECTIVE

To determine the efficacy of a computerised decision aid in patients with atrial fibrillation making decisions on whether to take warfarin or aspirin therapy.

DESIGN

Two-armed open exploratory randomised controlled trial.

SETTING

Two research clinics deriving participants from general practices in Northeast England.

PARTICIPANTS

109 patients with atrial fibrillation aged over 60.

INTERVENTIONS

Computerised decision aid applied in shared decision-making clinic compared to evidence-based paper guidelines applied as direct advice.

MAIN OUTCOME MEASURES

Primary outcome measure was the decision conflict scale. Secondary outcome measures included anxiety, knowledge, decision-making preference, treatment decision, use of primary and secondary care services and health outcomes.

RESULTS

Decision conflict was lower in the computerised decision aid group immediately after the clinic; mean difference -0.18 (95% CI -0.34 to -0.01). Participants in this group not already on warfarin were much less likely to start warfarin than those in the guidelines arm (4/16, 25% compared to the guidelines group 15/16, 93.8%, RR 0.27, 95% CI 0.11 to 0.63).

CONCLUSIONS

Decision conflict was lower immediately following the use of a computerised decision aid in a shared decision-making consultation than immediately following direct doctor-led advice based on paper guidelines. Furthermore, participants in the computerised decision aid group were significantly much less likely to start warfarin than those in the guidelines arm. The results show that such an approach has a positive impact on decision conflict comparable to other studies of decision aids, but also reduces the uptake of a clinically effective treatment that may have important implications for health outcomes.

Satisfaction with the outpatient encounter: a comparison of patients' and physicians' views

OBJECTIVE

To compare patients' and physicians' visit-specific satisfaction in an internal medicine outpatient setting, and to explain their respective views.

DESIGN

Patients' and physicians' background characteristics were assessed prior to outpatient encounters. Immediately after the encounter, both patients and physicians completed a questionnaire assessing satisfaction with the visit.

SETTING

The outpatient division of an academic teaching hospital.

PARTICIPANTS

Thirty residents and specialists in general internal medicine, rheumatology, and gastroenterology, and 330 patients having a follow-up appointment with one of these physicians.

MEASUREMENTS AND MAIN RESULTS

Patients' and physicians' visit-specific satisfaction was assessed using 5 Visual Analogue Scales (0 to 100). Patients' overall satisfaction was higher than physicians' satisfaction (mean 81 vs. 66), and correlation of patients' and physicians' overall satisfaction with the specific visit was medium sized (r= .28, P < .001). Patients' satisfaction ratings were associated with their previsit self-efficacy in communicating with their physician (P < .001) and with visiting a female physician (P < .01). Physicians' satisfaction was associated with patients' higher educational level (P < .05), primary language being Dutch (P < .001), better mental health (P < .05), and preference for receiving less than full information (P < .05).

CONCLUSIONS

In an outpatient setting, patients' visit-specific satisfaction ratings were substantially higher than, and only moderately associated with, physicians' ratings of the same visit. The dissimilar predictors explaining patients' and physicians' satisfaction suggest that patients and physicians form their opinion about a consultation in different ways. Hence, when evaluating outpatient encounters, physicians' satisfaction has additional value to patients' satisfaction in establishing quality of care.

Mothers' evolving relationships with doctors and nurses during the chronic childhood illness trajectory

AIMS

In this paper the evolution of mothers' relationships with doctors and nurses during the chronic childhood illness trajectory is explored and discussed and the implications for child health care are considered. The discussion reports one aspect of a qualitative study that sought to determine whether time of diagnosis influenced mothers' coping across the illness trajectory.

BACKGROUND

The quality of relationships between mothers, who are usually the primary carers, and nursing and medical staff is central to the experience of coping with chronic childhood illness. Mothers need to develop expertise in a wide range of technical skills and knowledge of complex health care issues, while also coming to terms with the uncertainty of a condition with an unpredictable trajectory. Attempts to understand the significance of relationships between those living with chronic illness and staff have highlighted a number of factors that may influence the degree to which they are viewed as satisfactory. The way staff communicate with families has been identified as one of the mediating processes through which the quality of such is determined.

DESIGN

Mothers of 15 children diagnosed presymptomatically and 14 children diagnosed postsymptomatically with the chronic illness Vesicoureteric Reflux (VUR) were interviewed to assess and compare coping strategies across the trajectory. Mothers' written consent was obtained and interviews were tape-recorded, transcribed and analysed using the 'Framework Technique'.

FINDINGS AND CONCLUSION

The need to develop and sustain trusting relationships with staff was reported as a continual source of stress for mothers. The formation of satisfactory alliances, based on mutual respect and good communication early in the trajectory, in particular during the prediagnostic phase, was found to be instrumental in coping and competence development during the later chronic phase of the trajectory. Further research is needed to map prospectively the evolution of relationships between mothers and staff across the trajectory.

Domains of consultation research in primary care

The consultation is increasingly viewed as a crucial aspect of general practice medicine, but a variety of methods of conceptualising, describing and modifying its structure and content have been described. This article describes the historical background to the current interest in the consultation, and describes four qualitatively distinct approaches (or 'domains') to understanding the consultation: the psychodynamic; clinical-observational; social-psychological; and sociological. Four key dimensions along which the domains can be differentiated are described. These concern whether the critique of medical practice inherent in the domain is internal or external to the discipline of general practice; whether the focus of the domain is on the consultation participants' identities or activities; whether the key research methodology is quantitative or qualitative in character; and the degree to which the objective of research within the domain is to describe current practice or prescribe ways of conducting the consultation. Methods of encouraging work across domains are discussed.

Knowing patients and knowledge about patients: evidence of modes of reasoning in the consultation?

BACKGROUND

The idea that the patient is in some way known to the doctor is an important one in general practice. The thrust towards patient-centred medicine, the promotion of open and negotiative consultation skills and the development of a biopsychosocial model of primary care medicine all rely on the patient providing a history composed of more than a list of facts.

OBJECTIVE

Our aim was to explore the nature and importance of doctors' knowledge about patients.

METHODS

Fifteen GPs audio-recorded 25-30 consultations with consecutive consenting patients. They scored each consultation according to how satisfying they found it. Semi-structured interviews based on a selection of consultations were conducted to draw out the doctor's views on the factors that were important to their satisfaction. The interviews were transcribed verbatim. Qualitative analysis was inductive and iterative.

RESULTS

Within doctors' narratives, we found accounts of two ways of 'knowing' the patient. The first was a deductive mode of reasoning derived from facts about the patient. The facts that were known were specific to the context of the general practice consultation and led to biomedical and biographical knowledge. The second was an inductive mode of reasoning derived from a contextual interpretation of the facts about the patient which resulted in knowledge of their behaviour and cognitions. Both modes of reasoning gave the doctor knowledge of the patient and permitted action by the doctor in the consultation but led to different interpretations of the patient and different experiences of the consultation.

CONCLUSION

'Knowing the patient' is important to the way GPs attribute meaning to their work. Doctors were more likely to identify as 'known' those patients with whom they adopted an inductive mode of reasoning. In addition, their experience of the consultation was more likely to be positive.

The strategies used by general practitioners when providing information about medicines

Changes both inside and outside the consultation increase the chances that patients may gain information from sources other than their general practitioner (GP). Data from nine interviews and one focus group with British GPs were used to explore GPs' rationale for the information they provide when prescribing oral steroids and their perceptions of patients' expectations. GPs' communication strategies were associated with the type of relationship they sought to perpetuate with patients. Some GPs reported that decisions about the provision of information were based on their own judgements of what patients needed to know (paternalistic approach), while others reported attempts to take account of patients' existing knowledge and beliefs (mutualistic approach). All the GPs were aware of the availability of information about medical matters, and most believed that patients' expectations had increased. The communication strategies of some GPs may not be appropriate given the availability of medical information outside the consultation.