Timer: a new objective measure of consultation content and its application to computer assisted consultations.

As part of the research into the effect in the consultation of the use of a computer to prompt opportunistic preventive care a valid, objective, and practical measure of the consultation process was required. After a review of the alternative methods the Time Interval Medical Event Recorder (Timer) was developed, its reliability tested, and applied to 93 control consultations and 49 computer assisted consultations. Timer records, every five seconds, four consultation events: the problems being dealt with, the physical activity, the verbal activity, and the secondary tasks being attempted. Timer showed that control consultations lasted an average of 6 minutes 58 seconds. The doctors spent 35% of their time on administration, and patients and doctors were both conversational for just 33% of the consultation. Giving information was the most common verbal activity (48% of the duration of the consultation) with silence accounting for 21% of the time. When the computer was used the average consultation was longer, at 7 minutes and 46 seconds. The doctor''s contribution to the consultation appeared to have increased. Patient centred speech fell from 36% in controls to 28% of the duration of the consultation when the computer was used, while doctor centred speech rose from 30% to 34.5%. Secondary tasks (exploring patient concepts, education, management sharing, and prevention) were attempted during 28% of the control consultations and 40% of the computer consultations. This was accounted for by the increase in prevention (p less than 0.001). Timer is a reliable and practical tool for researching the consultation, and though it has shown validity in detecting differences between consultations that use a computer and those that do not, further applications are required to establish its full value.     

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.     

Has general practitioner computing made a difference to patient care? A systematic review of published reports.

OBJECTIVE--To review findings from studies of the influence of desktop computers on primary care consultations. DESIGN--Systematic review of world reports from 1984 to 1994. SETTING--The computerised catalogues of Medline, BIDS, and GPlit were searched, as well as conference proceedings, books, bibliographies, and references in books and journal articles. SUBJECTS--30 papers met the inclusion criteria and were included for detailed review. INTERVENTIONS--A validated scheme for assessing methodological adequacy was used to score each paper. MAIN OUTCOME MEASURES--Papers were rated on sample formation, baseline differences, unit of allocation, outcome measures, and follow up. Differences in outcomes were also recorded. RESULTS--Four of the six papers dealing with the consultation process showed that consultations took longer. Doctor initiated and "medical" content of consultations increased at the expense of a reduction in patient initiated and "social" content. Each of the 21 studies which looked at clinician performance showed an improvement when a computer was used (from 8% to 50%, with better results for single preventive measures). Only one of the three studies looking at patient outcomes showed an improvement (diastolic blood pressure control 5 mm Hg better after one year, with fewer doctor-patient consultations). CONCLUSIONS--Using a computer in the consultation may help improve clinician performance but may increase the length of the consultation. More studies are needed to assess the effects on patient outcomes of using a computer in consultations.     

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.     

Reactions of patients to video recording of consultations in general practice.

The potential value of video recording for examining medical consultations depends on the extent to which recordings are representative of unfilmed consultations. This paper examines the views of 295 patients in two general practices whose consultations were filmed and compares them with the views of a control group of 185 patients. Most of those who were filmed reported that the consultation was not directly affected, and no overall effect of filming was discovered when patients rated their stress after the consultations, their rapport with the doctor, or other aspects of the consultation. At one practice, however, filming was significantly associated with lower ratings of rapport between doctor and patient among those patients who reported some direct effect of filming. Patient refusal rates from other studies are also examined and shown to vary systematically--the more opportunity patients are given to decline the more likely they are to take it. Consideration of doctors'' responses to being filmed would usefully complement the emphasis on the views of patients.     

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     

Topic analysis: an objective measure of the consultation and its application to computer assisted consultations.

A simple method has been developed to classify the verbal interaction during medical consultations in terms of the relative proportions of medical and social content and the initiator of conversational topics discussed. The method has been applied to video tape recordings of three doctors'' consultations with and without a computer present to classify and compare the items discussed. Actual computer use has been shown to have a medical effect on the consultations (p less than 0.05) and to increase the proportion of topics initiated by the doctor (p less than 0.001). Although this was largely accounted for by the massive increase in doctor initiated medical items resulting directly from computer use, there was evidence that, for two of the doctors, these topics were replacing some of the normal social and patient initiated medical exchanges.     

Continuity of care in general practice: effect on patient satisfaction.

OBJECTIVE--To evaluate the influence of continuity of care on patient satisfaction with consultations. DESIGN--Direct and episodic specific evaluation of patient satisfaction with recent consultation. SETTING AND SUBJECTS--A representative sample of 3918 Norwegian primary care patients were asked to evaluate their consultations by filling in a questionnaire. The response rate was 78%. MAIN OUTCOME MEASURES--The patient''s overall satisfaction with the consultation was rated on a six point scale. Continuity of care was recorded as the duration and intensity of the present patient-doctor relationship and as patients'' perception of the present doctor being their personal doctor or not. RESULTS--The multivariate analysis indicated that an overall personal patient-doctor relationship increased the odds of the patient being satisfied with the consultation sevenfold (95% confidence interval 4.9 to 9.9) as compared with consultations where no such relationships existed. The duration of the patient-doctor relationship had a weak but significant association with patient satisfaction, while the intensity of contacts showed no such association. CONCLUSION--Personal, continuous care is linked with patient satisfaction. If patient satisfaction is accepted as an integral part of quality health care, reinforcing personal care may be one way of increasing this quality.     

Comparison of patient questionnaire,medical record,and audio tape in assessment of health promotion in general practice consultations.

OBJECTIVE--To determine what proportion of health promotion activities reported by the patient is recorded in the general practice notes and to compare these methods of assessing health promotion with audio tape analysis. DESIGN--Secondary analysis of data obtained in a controlled trial of differing appointment lengths. After each consultation the medical record was examined and the patient invited to completed a questionnaire. A subsample of consultations was audio taped. SETTING--Nottinghamshire. SUBJECTS--16 general practitioners from 10 practices. This report includes 3324 consultations with patients aged > or = 17, with data on measurement of blood pressure and advice about smoking and alcohol. RESULTS--Data from questionnaire and medical notes were available for 2281 consultations. Advice on smoking was recorded in the notes in 30.9% of cases in which a patient reported it (for alcohol and measurement of blood pressure, 44.4% and 82.7% of cases respectively). In 516 cases analysis of audio tape and review of records was performed. Advice on smoking was recorded in the patient''s notes in 28.6% of cases in which it was detected on audio tape (for alcohol, 31.1% of cases). In 335 consultations data from audio tape and questionnaire were available. Advice on smoking was reported by patients in 73.9% of cases in which it was detected on audio tape (for alcohol, 75.0% of cases). CONCLUSIONS--Review of the medical record is a reasonably accurate method of assessing measurement of blood pressure in the consultation but would lead to significant underestimation of advice about smoking and alcohol.     

Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes

ObjectiveTo determine patients'' preferences for a shared or directed style of consultation in the decision making part of the general practice consultation.DesignStructured interview, with video vignettes of acted consultations.Setting5 practices in Lothian, Scotland.Participants410 patients (adults and adults accompanying children) attending surgery appointments.ResultsPatients varied in their preference for involvement in decision making in the consultation. Under multiple regression analysis, patients'' preference was found to be independently predicted by the problem viewed (patients presented with physical problems preferred a directed approach), patients'' age (patients aged 61 or older were more likely to prefer the directed approach), social class (social classes I and II were more likely to prefer the shared approach), and smoking status (smokers more likely to prefer the shared approach). Those patients who were able to answer (or who thought their doctor''s style similar to those in the vignettes) were more likely to describe their own doctor''s style as similar to their preferred style. No major association in preference was found with sex, frequency of attendance, or perceived chronic ill health.ConclusionPatients may vary in their desire for involvement in decision making in consultations. Although this variation seems to depend on the presenting problem, age, social class, and smoking status, these associations are not absolute, with large minorities in each group. Doctors need the skills, knowledge of their patients, and the time to determine on which occasions, with which illnesses, and at which level their patients wish to be involved in decision making.     

Age,pattern of consultation,and functional disability in elderly patients in one general practice.

OBJECTIVE--To examine how functional disability varies with sex, age, and other variables in patients aged 75 and over living in the community and to ascertain whether a statistical model derived from the variables in this population usefully predicted functional disability in another of similar age. DESIGN--Retrospective study of data collected by interview and by examination of medical records. SETTING--An urban general practice with five partners and a list of 15,000 patients, very few of whom belonged to ethnic minorities. PATIENTS--775 Patients (252 men, 523 women) aged 75 and over living in the community between September 1985 and August 1986; 13 other patients considered to be unsuitable and 14 who declined an interview were excluded. Also 94 patients who became 75 or joined the practice after August 1986. MAIN OUTCOME MEASURE--The proportions of fit, partially disabled, and severely disabled (housebound) patients. RESULTS--90 Men (35.7%) and 128 women (24.5%) were fit, and 27 men (10.7%) and 116 women (22.2%) were housebound; in all age groups women were significantly more likely to be disabled than men. A significant trend towards greater disability was shown with increasing age and, more noticeably, with pattern of consultation when patients were divided into three categories based on the number of times they had attended the surgery and been visited at home over about two years. Statistical models gave the forecast percentage of fit and severely disabled patients for each sex, age group, and pattern of consultation, and a simple scheme was derived to identify from information wholly contained in medical records most of those patients most prone to severe disability. The scheme was verified applying it to a population of 94 elderly patients in 1988-9. CONCLUSION--Sex, age, and pattern of consultation together provide a quick indication of elderly patients'' tendency to severe disability, which can help in screening and in day to day consultations.     

Evaluating care of patients reporting pain in fundholding practices.

OBJECTIVE--To compare quality of care between 1990 and 1992 in patients with self diagnosed joint pain. DESIGN--Questionnaire and record based study. SUBJECTS--Patients identified at consecutive consultations during two weeks in 1990, 1991, and 1992. SETTING--Six practice groups in pilot fundholding scheme in Scotland. MAIN OUTCOME MEASURES--Length of consultation; numbers referred or investigated or prescribed drugs; responses to questions about enablement and satisfaction. RESULTS--About 15% of patients consulted with joint pain each year. 25% (316) of them had social problems in 1990 and 37% (370) in 1992; about a fifth wanted to discuss their social problems. Social problems were associated with a raised general health questionnaire score. The mean length of consultation for patients with pain was 7.6 min in 1990 and 7.7 min in 1992. Patients wishing to discuss social problems received longer consultations (8.5 min 1990; 10.4 min 1992); but other patients with social problems received shorter consultations (7.4 min; 7.2 min). The level of prescribing was stable but the proportion of patients having investigations or attending hospital fell significantly from 1990 to 1992 (31% to 24%; 31% to 13% respectively). Fewer patients responded "much better" to six questions about enablement in 1992 than in 1990. Enablement was better after longer than shorter consultations for patients with social problems. CONCLUSIONS--Quality of care for patients with pain has been broadly maintained in terms of consultation times. The effects of lower rates of investigation and referral need to be investigated further.     

Narrowing the health gap between a deprived and an endowed community

A 15 month campaign by a primary health care team in Stockton on Tees raised the uptake of preventive care of its patients in a severely deprived area to a level generally exceeding that of a more endowed neighbouring community. This was achieved by opportunistic attention after unrelated consultations, writing twice to each household with a list of its outstanding items necessary for preventive care, using health visitors to encourage attendance, and occasionally undertaking preventive care in patients'' homes. Extra clerical staff were needed to implement the new recording and monitoring procedures introduced.With rigorous monitoring and organisation general practitioners may improve the uptake of preventive health care by their more deprived patients.     

Assessing the consultation: methods of observing trainees in general practice.

We compared two different methods of observing trainees at work in general practice: the traditional one of a senior or training general practitioner sitting in during selected surgeries and the more modern video recording, with the patients'' written consent. Patients who had experienced the presence of a second doctor during the consultation were less likely to show an increase in arousal after their consultations than those who had been recorded on video. Patients who refused consent to be recorded were more highly stressed than those who agreed and showed smaller decreases in stress after consultations. The presence of two doctors generated fewer reductions in stress after the consultation than video recording did, but this was a non-significant trend. The group that was recorded on video did not differ appreciably from a control group in changes in stress or arousal.     

How can good general practitioner care be achieved?

It has been shown that to provide a high standard of care general practitioners probably need to book consultations at intervals of at least 10 minutes. In this study the maximum list size for which a general practitioner might be expected to provide a high standard of care was determined from calculations of the time spent consulting, based on various consultation rates and list sizes and assuming that consultations were 10 minutes long. If good quality care is to be provided and is to include the range of services suggested in the government''s recent green paper average list sizes should probably be no more than 1750, and lower in areas of high demand and high need. In addition to this, minimum standards could be determined for such measures as facilities available in surgeries, practice records, and accessibility of doctors to ensure that basic services were offered by all general practitioners.     

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.     

Health promotion in the general practice consultation: a minute makes a difference.

OBJECTIVE--To see whether extending appointment length from seven and a half minutes or less to 10 minutes per patient would increase health promotion in general practice consultations. DESIGN--Controlled trial of 10 minute appointments. Consultations were compared with control surgeries in which the same doctors booked patients at their normal rate (median six minutes per patient). SETTING--10 general practices in Nottinghamshire. SUBJECTS--16 general practitioners were recruited. Entry criteria were a booking rate of eight or more patients an hour, a wish for longer consultations, and plans to increase appointment length. MAIN OUTCOME MEASURES--Duration of consultations; recording of blood pressure, weight, and cervical cytology in the medical record; recording of advice about smoking, alcohol, diet, exercise, and immunisation in the medical record; reporting of the above activities by patients. RESULTS--Mean consultation times were 8.25 minutes in the experimental sessions and 7.04 and 7.16 minutes in the control sessions. Recording of blood pressure, smoking, alcohol consumption, and advice about immunisation was significantly more frequent in the experimental sessions, and the proportion of consultations in which one or more items of health education were recorded in the medical notes increased by an average of over 6% in these sessions. Patients more often reported discussion of smoking and alcohol consumption and coverage of previous health problems in the experimental sessions. There was little change in discussion of exercise, diet, and weight or cervical cytology activity. CONCLUSIONS--Shortage of time is a major factor in general practitioners'' failure to realise their potential in health promotion. General practice should be organised so that doctors can run 10 minute appointment sessions.