Consultations in general practice: a comparison of patients' and doctors' satisfaction.

OBJECTIVE--To provide an objective means of assessing patients'' and doctors'' satisfaction with a consultation. DESIGN--Questionnaire study of patients and general practitioners after consultations. SETTING--Urban general practice. SUBJECTS--250 Patients attending consecutive consultations conducted by five general practitioners. MAIN OUTCOME MEASURE--Identification of deficiencies within a consultation as perceived by both doctors and patients. RESULTS--The doctor''s and patient''s questionnaires for each consultation were matched and the results analysed on a group basis. The response rate for individual questions was high (81-89%). The doctors and patients significantly disagreed about the doctors'' ability to assess and put patients at ease, to offer explanations and advice on treatment, and to allow expression of emotional feelings and about the overall benefit that the patients gained from the consultation. In all cases of disagreement the doctor had a more negative view of the consultation than the patient. CONCLUSIONS--The results of giving structured questionnaires on consultations to both patients and doctors could be a useful teaching tool for established doctors or those in training to improve the quality and sensitivity of care they provide.     

Out of hours service: the Danish solution examined.

In Denmark the provision of out of hours care by general practitioners came under increasing pressure in the 1980s because of growing demand for services by the public and increasing complaints from rural doctors about their heavy workload and disproportionately low remuneration in comparison with urban doctors. As a result, the out of hours service was reformed at the start of 1992: locally negotiated rota systems were replaced with county based services. Each county now has a coordination centre, where all patients'' calls are received by a team of doctors. The doctors may give a telephone consultation, advise the patient to attend one of the emergency clinics strategically placed about the county, or arrange for a home visit. Doctors on home visiting duty are located at bases throughout the county and keep in touch with the coordination centre with mobile telephones. Graded fees mean that doctors are encouraged to give telephone consultations rather than arrange for clinic consultations or home visits. The reforms have reduced doctors'' out of hours workload and the number of home visits made and have proved acceptable to patients, doctors, and administrators.     

Misunderstandings in prescribing decisions in general practice: qualitative study

ObjectivesTo identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice.DesignQualitative study.Setting20 general practices in the West Midlands and south east England.Participants20 general practitioners and 35 consulting patients.Results14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor''s decision, and relationship factors. All the misunderstandings were associated with lack of patients'' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors'' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients'' ideas about medicines for successful prescribing.ConclusionsPatients'' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.     

General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey.

OBJECTIVES: To evaluate general practitioners'' knowledge of a range of psychosocial problems among their patients and to explore whether doctors'' recognition of psychosocial problems depends on previous general knowledge about the patient or the type of problem or on certain characteristics of the doctor or the patient. DESIGN: Multipractice survey of consecutive adult patients consulting general practitioners. Doctors and patients answered written questions. SETTING: Buskerud county, Norway. SUBJECTS: 1401 adults attending 89 general practitioners during one regular working day in March 1995. MAIN OUTCOME MEASURES: Doctors'' knowledge of nine predefined psychosocial problems in patients; these problems were assessed by the patients as affecting their health on the day of consultation; odds ratios for the doctor''s recognition of each problem, adjusted for characteristics of patients, doctors, and practices; and the doctor''s assessment of previous general knowledge about the patient. RESULTS: Doctors'' knowledge of the problems ranged from 53% (108/203) of "stressful working conditions" to 19% (12/63) of a history of "violence or threats." Good previous knowledge of the patient increased the odds for the doctor''s recognition of "sorrow," "violence or threats," "substance misuse in close friend or relative," and "difficult conflict with close friend or relative." Age and sex of doctor and patient, patient''s educational level and living situation, and location of practice influenced the doctor''s awareness. CONCLUSIONS: Variation in the patients'' communication abilities, the need for confidence in the doctor-patient relationship before revealing intimate problems, and a tendency for the doctors to be entrapped by their expectations may explain these findings.     

Questioning behaviour in general practice: a pragmatic study.

OBJECTIVE: To study the extent to which general practitioners'' questioning behaviour in routine practice is likely to encourage the adoption of evidence based medicine. DESIGN: Self recording of questions by doctors during consultations immediately followed by semistructured interview. SETTING: Urban Australian general practice. SUBJECTS: Random sample of 27 general practitioners followed over a half day of consultations. MAIN OUTCOME MEASURES: Rate of recording of clinical questions about patients'' care which doctors would like answered; frequency with which doctors found answers to their questions. RESULTS: Doctors asked a total of 85 clinical questions, at a rate of 2.4 for every 10 patients seen. They found satisfactory answers to 67 (79%) of these questions. Doctors who worked in small practices (of one or two doctors) had a significantly lower rate of questioning than did those in larger practices (1.6 questions per 10 patients v 3.0 patients, P = 0.049). No other factors were significantly related to rate of questioning. CONCLUSIONS: These results do not support the view that doctors routinely generate a large number of unanswered clinical questions. It may be necessary to promote questioning behaviour in routine practice if evidence based medicine and other forms of self directed learning are to be successfully introduced.     

Should general practitioners call patients by their first names?

OBJECTIVE--To assess the acceptability to patients of the use of patients'' first names by doctors and doctors'' first names by patients in general practice. DESIGN--An administered questionnaire survey. SETTING--5 General practices in Lothian. PATIENTS--475 Patients consulting 30 general practitioners. MAIN OUTCOME MEASURE--Response by patients to questionnaire on attitude to use of first names. RESULTS--Most of the patients either liked (223) or did not mind (175) being called by their first names. Only 77 disliked it, most of whom were aged over 65. Most patients (324) did not, however, want to call the doctor by his or her first name. CONCLUSIONS--General practitioners should consider using patients'' first names more often, particularly with younger patients.     

An instrument for assessment of videotapes of general practitioners' performance.

OBJECTIVES--To identify those important characteristics of doctors'' and patients'' behaviour that distinguish between "good" and "bad" consultations when viewed on videotape; to use these characteristics to develop a reliable instrument for assessing general practitioners'' performance in their own consultations. DESIGN--Questionnaires completed by patients, general practitioner trainers, and general practitioner trainees. Reliability of draft instrument tested by general practitioner trainers. SETTING--All vocational training schemes for general practice in the Northern region of England. SUBJECTS--First stage: 76 patients in seven groups, 108 general practice trainers in 12 groups, and 122 general practice trainees in 10 groups. Second stage: 85 general practice trainers in 12 groups. MAIN OUTCOME MEASURES--Trainers'' ratings of importance; alpha coefficients of draft instrument by trainee, group, and consultation. RESULTS--6890 characteristics of good and bad consultations were consolidated into a draft assessment instrument consisting of 46 pairs of definitions separated by six point bipolar scales. Nine statement pairs given low importance ratings by trainers were eliminated, reducing the instrument to 37 statement pairs. To test reliability, general practitioner trainers used the instrument to assess three consultations. With the exception of one group of trainers, all alpha coefficients exceeded the acceptable level of 0.80. CONCLUSION--The instrument produced is reliable for assessing general practitioners'' performance in their own consultations.     

Assessment of patients aged over 75 in general practice.

OBJECTIVES--To evaluate the assessment scheme for people aged 75, to establish doctors'' and nurses'' views on the value of the assessment scheme, and to seek patients'' opinions on elderly assessments. DESIGN--Data on the assessment process were collected from individual practices. Questionnaires were sent to doctors and practice nurses undertaking assessments and to a sample of elderly patients. SUBJECTS--31,565 patients aged 75 and over and all doctors registered with Wiltshire Family Health Services Authority, as well as practice nurses assessing elderly patients. A 2% random sample of elderly patients was selected to answer questions on patient satisfaction. MAIN OUTCOME MEASURES--Numbers of patients accepting the invitation for assessment, who carried out the assessments and where, what unmet needs were identified, and by whom. RESULTS--20,192 patients (64%) accepted the assessment offer. Doctors carried out 8786 assessments and nurses 10,779. Although 12,317 (61%) were carried out in the home, nurses did most domiciliary assessments (7122/11,883). Nurses with extra qualifications identified the highest number of unmet needs (400/1000 visits). 155 of 228 (68%) doctors thought assessments unnecessary whereas 25 of 48 (52%) of nurses thought them important. 93% of patients found assessment useful. CONCLUSIONS--Doctors see no merit in the scheme; most undertake assessments opportunistically and pick up few new problems. Nurses who see it as important require further training to fit them to do home visits confidently. Patients who were assessed found it worth while. The case for developing a specialist community nurse for elderly people should be investigated.     

Attitudes among NHS doctors to requests for euthanasia.

OBJECTIVES--To explore NHS doctors'' attitudes to competent patients'' requests for euthanasia and to estimate the proportion of doctors who have taken active steps to hasten a patient''s death. DESIGN--Anonymous postal questionnaire, with no possibility of follow up. The survey was conducted from December 1992 to March 1993. SUBJECTS--All (221) general practitioners and 203 hospital consultants in one area of England. RESULTS--273 doctors responded to a question on whether a patient had ever asked them to hasten death. Of these, 163 had been asked to; 124 of these had been asked to take active steps to hasten death; 38 of 119 (32%) of these had complied with such a request (95% confidence interval 23% to 40%). This proportion represented 12% of all those who returned a completed questionnaire and 9% of all those who had been sent a questionnaire (95% confidence interval 6.3% to 11.7%). A larger proportion of the respondents (142/307 (46%)), however, would consider taking active steps to bring about the death of a patient if it was legal to do so. CONCLUSIONS--Many doctors face difficult decisions about euthanasia. For the benefit of both patients and doctors euthanasia should be discussed more openly.     

Effect of computer use in the consultation on the delivery of care.

The effects of the use of a computer on the delivery of care in consultations in general practice were examined. In this trial a computer system provided for the review and update of patients'' medical histories, notes on doctor-patient contacts, and information on repeat prescribing. Thirty consultations in which the computer system was used and 30 consultations in which no computer was used were matched individually for the doctor consulted, the sex and age of the patient, and the presenting problem(s). Six independent general practitioners blind rated each consultation for the standard of care attained. A minor negative effect of computer use on the doctors'' clinical performance was found. We suggest, however, that this small effect would disappear if a computer system was used routinely.     

Retrospective study of doctors' "end of life decisions" in caring for mentally handicapped people in institutions in The Netherlands.

OBJECTIVES: To gain insight into the reasons behind and the prevalence of doctors'' decisions at the end of life that might hasten a patient''s death ("end of life decisions") in institutions caring for mentally handicapped people in the Netherlands, and to describe important aspects of the decisions making process. DESIGN: Survey of random sample of doctors caring for mentally handicapped people by means of self completed questionnaires and structured interviews. SUBJECTS: 89 of the 101 selected doctors completed the questionnaire. 67 doctors had taken an end of life decision and were interviewed about their most recent case. MAIN OUTCOME MEASURES: Prevalence of end of life decisions; types of decisions; characteristics of patients; reasons why the decision was taken; and the decision making process. RESULTS: The 89 doctors reported 222 deaths for 1995. An end of life decision was taken in 97 cases (44%); in 75 the decision was to withdraw or withhold treatment, and in 22 it was to relieve pain or symptoms with opiates in dosages that may have shortened life. In the 67 most recent cases with an end of life decision the patients were mostly incompetent (63) and under 65 years old (51). Only two patients explicitly asked to die, but in 23 cases there had been some communication with the patient. In 60 cases the doctors discussed the decision with nursing staff and in 46 with a colleague. CONCLUSIONS: End of life decisions are an important aspect of the institutionalised care of mentally handicapped people. The proportion of such decisions in the total number of deaths is similar to that in other specialties. However, the discussion of such decisions is less open in the care of mental handicap than in other specialties. Because of distinctive features of care in this specialty an open debate about end of life decisions should not be postponed.     

Submitting articles to the BMJ

ObjectiveTo investigate how doctors engage with patients with psychotic illness in routine consultations.DesignConversation analysis of 32 consultations between psychiatrists and patients with schizophrenia or schizoaffective disorder.SettingTwo psychiatric outpatient clinics in east London and south west London.Participants7 psychiatrists and 32 patients with schizophrenia or schizoaffective disorder.ResultsPatients actively attempted to talk about the content of their psychotic symptoms in consultations by asking direct questions, repeating their questions and utterances, and producing these utterances in the concluding part of the consultation. In response, doctors hesitated, responded with a question rather than with an answer, and smiled or laughed (when informal carers were present), indicating that they were reluctant to engage with patients'' concerns about their psychotic symptoms.ConclusionsPatients repeatedly attempted to talk about the content of their psychotic symptoms, which was a source of noticeable interactional tension and difficulty. Addressing patients'' concerns about their illness may lead to a more satisfactory outcome of the consultation and improve engagement of such patients in the health services.

What is already known on this topic

Patients with psychotic illness are difficult to engage in the health servicesNo research has been published on how doctors engage with these patients in consultations

What this study adds

Patients actively attempt to talk about the content of their psychotic symptomsDoctors'' reluctance and discomfort in engaging with this topic is apparentAddressing patients'' concerns may lead to a more satisfactory outcome of the consultation and improve engagement with services     

基于马尔科夫链的医疗决策

在临床实践中,医生和患者均面临决策,由于医生和患者个体知识经验的局限性,仅依赖个人经验的决策判断难以全面评估治疗方案的好坏,而通过马尔科夫链模型可以帮助医生和患者对复杂疾病建立抽象模型,便于对疾病的各治疗效果进行决策分析。马尔科夫链模型是处理离散事件的随机过程,通过当前设定的信息,预测将来的情况。本文总结了马尔科夫链在医疗决策中的应用的基本原理,梳理了在医疗决策领域常用的马尔科夫链模型的分类,针对医疗决策的特点探讨不同类型马尔科夫链的矩阵法、队列法以及蒙特卡洛模拟分析方法的适用范围和优缺点。针对疾病进展的三状态模型以及是否使用某药物的实际决策案例,分析比较队列法与蒙特卡洛模拟法的具体应用,总结归纳队列法与蒙特卡洛模拟法的优缺点。     

Sartorial eloquence: does it exist in the paediatrician-patient relationship?

OBJECTIVE--To evaluate children''s and parents'' perceptions of hospital doctors'' attire. DESIGN--Questionnaire study asking children and parents to assign positive and negative attributes to five photographs of a male or female doctor dressed formally and informally. SETTING--Outpatient department, Children''s Hospital, Birmingham. SUBJECTS--203 consecutive child-parent pairs attending outpatient clinics over three months. MAIN OUTCOME MEASURES--Children''s and parents'' preferences, assessed by comparing proportions. RESULTS--70% (286/406) of children and parents rated doctors'' dress as important; more children rated it "very important" (27% (54/203) v 14% (29/203), P < 0.01, 95% confidence interval for difference 5% to 21%). Of the 99 children responding, 44 regarded the man in white coat as most competent (44% v 20% expected by chance, P < 0.01, 34% to 54%) and most concerned (32% v 20%, P < 0.01, 23% to 41%). Children also regarded the woman in white coat as most competent; however, male and female doctors in white coats rated lower for friendliness. Asians and regular surgical attenders preferred doctors in white coats. The man in polo shirt and trousers was rated as most friendly (40% v 20% expected by chance, P < 0.01, 30% to 50%) and most gentle (37% v 20%, P < 0.01, 27% to 46%). The woman in tee shirt and slacks also rated most friendly and gentle; however, both casually dressed doctors rated lower for competence. Parents preferred more casual dress but expressed preferences less strongly, and they poorly predicted which outfits their children preferred. CONCLUSIONS--Children regard formally dressed doctors as competent but not friendly; they regard casual dress as friendly but not competent.     

Implications of managed care for health systems,clinicians, and patients.

The rhetoric and realities of managed care are easily confused. The rapid growth of managed care in the United States has had many implications for patients, doctors, employers, state and federal programmes, the health insurance industry, major medical institutions, medical research, and vulnerable patient populations. It has restricted patients'' choice of doctors and limited access to specialists, reduced the professional autonomy and earnings of doctors, shifted power from the non-profit to the for-profit sectors and from hospitals and doctors to private corporations. It has also raised issues about the future structuring and financing of medical education and research and about practice ethics. However, managed care has also accorded greater prominence to the assessment of patient satisfaction, profiling and monitoring of doctors'' work, the use of clinical guidelines and quality assurance procedures and indicated the potential to improve the integration and outcome of care.