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.     

Computer assisted screening: effect on the patient and his consultation.

The initial impact of computer assisted preventive screening in general practice consultations has been monitored. The technology has not been found stressful by patients, and the power of the consultation to alleviate low arousal has been increased by computer use. No appreciable increase in the durations of consultation was detected, despite an average computer initiated input of two minutes eight seconds. The computer has successfully prompted preventive screening and health education with a sixfold increase in the number of potentially relevant procedures being mentioned. The actual information presented by the computer has been shown to be crucial, with the terminal''s mere presence an ineffective reminder. The computer terminal was used in 65% of the consultations for which it was available, which, if sustained, represents an effective screening programme for attending patients.     

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.     

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.     

Screening for psychosocial problems among primary care patients: a pilot study.

The symptoms that a patient presents to the doctor are often not the underlying concern that prompted the consultation. The success of consultations involving a hidden diagnosis depends on how well the patient can express his or her concerns to the doctor and on how skilfully the doctor can encourage this. This study tested the feasibility and acceptability of having patients complete a brief health index questionnaire designed to help them describe their underlying concerns to the doctor. In two family medicine centres 996 patients were asked to complete a questionnaire while waiting to see the doctor; 724 (73%) did so. An evaluation of their responses showed the method to be acceptable to most. The doctors judged that it added valuable information in 41% of all consultations and in 73% of consultations in which the patient presented with psychologic complaints. There was, nevertheless, considerable variation among the physicians in their acceptance of the approach. This variability is discussed in the light of alternative models of how, in practical terms, to treat the psychosocial dimensions of a patient''s complaint.     

Off the cuff consultations.

Over six months I recorded 198 off the cuff consultations that occurred at social gatherings, at chance meetings, and in medical settings outside my surgery. More men than women made such consultations, roughly two thirds were a request for health information, and just under half of consultations were with other doctors'' patients. It seemed that many patients were seeking a second medical opinion.     

How much personal care in four group practices?

OBJECTIVE--To establish the degree of continuity of care in general practice. DESIGN--Retrospective study of the records of all eligible patients attending the surgery at randomly selected sessions. SETTING--Four large group practices in the Southampton Health District, one of which operated a strict system of personal lists. PATIENTS--776 Patients who had been registered for at least two years and had consulted at least 12 times over six years or less. MAIN OUTCOME MEASURES--Continuity score for each patient calculated from the number of consultations (out of the past 12) with his or her usual doctor. Number of the times the patients had consulted the doctor with whom they were registered. RESULTS--In the practice with personal lists a mean of 10 of the 12 consultations had been with the same doctor (83% of consultations), but in the three practices with combined lists the means were 5.9 (49%), 6.2 (52%), and 6.9 (58%). Continuity was associated with increased age and with the recording of a major problem. In the practices with combined lists 63 of 72 children consulted at least five different doctors. Only 140 of 489 patients currently in the practice who were identified as being registered with a doctor had most usually consulted that doctor in the practices with combined lists. CONCLUSIONS--Personal continuity of care may be fairly low in group practice, especially for younger and healthier patients registered at practices with combined lists. These findings support the Department of Health''s recent decision to make "target payments" (for cervical smears and childhood immunisations) to groups rather than to individual principals but pose a question for the future of individual clinical responsibility.     

Influence of patient characteristics on test ordering in general practice.

Information regarding all consultations was collected in seven general practices for one year. From these data we report on the use of laboratory tests and its association with patient characteristics--including social class, age, sex, and diagnosis--and with which doctor was consulted. Most of the requests were for technically simple tests of low cost. There was a noticeable variation in the use of tests with regard to all patient characteristics. Diagnosis, identity of doctor, age of patient, and social class were each shown by multivariate techniques to be independently related to use of tests. Whereas fewer tests were used per consultation for social classes III-V compared with other social classes, more were used per patient per year for these same groups, reflecting in part the higher consultation rates of social classes III-V. Variation in diagnoses fully accounted for the greater test ordering for women. Nearly two thirds of all tests were ordered for 10% of all patients who consulted and 7% of all registered patients. The results of our analysis suggest that this concentration is determined primarily by those patient characteristics most indicative of medical need and by which doctor is providing care.     

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.     

Usefulness of letters from hospitals to general practitioners.

In an investigation of the communication between specialist hospital departments and general practitioners 97 general practitioners were asked to say how important selected items of information that the hospital could pass on would be for management of a patient receiving chemotherapy. In addition, the records of 68 patients were examined for coverage of these topics. General practitioners considered technical topics to be more important than social ones. Hospital letters covered technical topics well, apart from details of possible side effects, but did not do the same even for the two social topics that most doctors considered to be essential--namely, what patients have been told about their diagnosis and prognosis. Letters from hospitals to general practitioners cover technical topics well but should include more information relating to the social aspects of the patient''s disease.     

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.     

Comparison of criteria derived by government and patients for evaluating general practitioner services.

A study was carried out to see whether patients'' criteria of good health care in general practice were different from those of the government and doctors. A total of 711 patients in a semirural group practice evaluated the importance of 20 criteria describing different facets of care. Half the criteria were derived from Promoting Better Health (health education, easy to change doctors, all children vaccinated, health checks for adults and children under 5, regular screening for cancer, woman doctor available, doctor goes on courses, well decorated premises, convenient surgery times); the other 10 were taken from a preliminary interview study of 24 patients (staff friendly and know me, doctor listens and sorts out problems, same doctor for consultations, nurse on premises, appointments available within 48 hours, waiting time less than 20 minutes, small surgery premises, tests available at surgery). Questionnaires containing 10 pairs of criteria assigned by computer were drawn up and patients asked to give their preference in each pair. The number of times each criterion was preferred was scored and its comparative importance ranked. The three criteria most highly ranked by all patients were having a doctor who listens, having a doctor who sorts out problems, and usually seeing the same doctor (all criteria originated by patients). The three least highly valued were health education, being able to change doctor easily, and well decorated and convenient premises (all criteria originated by the government). The criteria originated by patients as a group scored significantly more highly than those originated by government as a group. In a more competitive general practice environment, in which doctors will be more inclined to satisfy the wishes of patients, officially supported indicators of good quality care might not get the encouragement that the government and doctors think that they deserve.     

Internet based consultations to transfer knowledge for patients requiring specialised care: retrospective case review

ObjectiveTo assess whether transferring knowledge from specialists at centres of excellence to referring doctors through online consultations can improve the management of patients requiring specialised care.DesignRetrospective case review of the first year of internet based patient initiated consultations between referring doctors and consulting specialists.SettingUS teaching hospitals affiliated with an organisation providing internet based consultations.ParticipantsDoctors in various settings around the world engaging in internet based consultations with specialists.Results79 consultations took place. 90% (n=71) of consultations were for services related to oncology. 90% of consultations involved new recommendations for treatment. The most common recommendation was a new chemotherapeutic regimen (68%, n=54). Diagnosis changed in 5% (n=4) of cases. The average turnaround time was 6.8 working days compared with an average of 19 working days to see a comparable specialist.ConclusionsInternet based consultations between specialists at centres of excellence and referring doctors contribute to patient care through recommendations for new treatment and timely access to specialist knowledge. Although change in diagnosis occurred in only a few cases, the prognostic and therapeutic implications for these patients may be profound.

What is already known on this topic

Telemedicine could improve health care by transferring knowledge from centres of excellence to patients'' doctorsFew studies have systematically assessed the value of such internet based specialty consultations

What this study adds

Patients can benefit from internet based consultations between their doctor and consulting specialistsNew recommendations for treatment were discussed in 90% of cases, and change in diagnosis occurred in 5% of casesPatients can access a specialist''s opinion more quickly than waiting to see a specialist     

Taking medical histories through interpreters: practice in a Nigerian outpatient department.

Consultations through interpreters in the medical outpatient department of a Nigerian hospital were tape-recorded. These recordings were translated completely into English and transcribed, and the performance of the interpreters was analysed. The interpreters often did not provide word-for-word translations of what the doctor or patient had said. Some of these deviations were helpful, but others were confusing or incorrect. In particular, interpreters were inclined to conduct much of the consultations themselves. Hospitals using interpreters should ensure that they have no conflicting duties during consultations and that they have some training in language and interpretation. The quality of interpretation should be checked by native-speaking doctors and by using recordings. Doctors using interpreters should try to make sure that everything said is translated and check the patient''s answers by asking questions in several ways.     

Detection of renal allograft rejection by computer.

A computer program incorporating an adaptation of a statistical method, the multiprocess Kalman filter, was used to detect changes in trends of plasma creatinine and urea concentrations. In 28 recipients of renal allografts a definite deterioration in renal function was identified retrospectively on 32 occasions by an experienced renal physician independently of the statistical analysis. The computer identified 31 of these 32 episodes using creatinine and urea results, and 29 using creatinine alone. Dysfunction was identified by the computer significantly earlier (p less than 0.05) than by the clinician and a median of one day earlier (p less than 0.02) than treatment was actually initiated. The computer identified dysfunction on 11 out of 1259 days when the clinician did not suspect rejection. These 11 episodes may have had a pathological importance, though no clinical diagnosis was made. This computer method is useful for immediate analysis of incoming results and for timing events either prospectively or retrospectively.     

Do personal computers make doctors less personal?

Ten months after the installation of a computer in a general practice surgery a postal survey (piloted questionnaire) was sent to 390 patients. The patients'' views of their relationship with their doctor after the computer was introduced were compared with their view of their relationship before the installation of the computer. More than 96% of the patients (n=263) stated that contact with their doctor was as easy and as personal as before. Most stated that the computer did not influence the duration of the consultation. Eighty one patients (30%) stated, however, that they thought that their privacy was reduced.Unlike studies of patients'' attitudes performed before any actual experience of use of a computer in general practice, this study found that patients have little difficulty in accepting the presence of a computer in the consultation room. Nevertheless, doctors should inform their patients about any connections between their computer and other, external computers to allay fears about a decrease in privacy.     

Who undertakes the consultations in the outpatient department?

In a study of all 4275 outpatient consultations over one month in a district general hospital it was found that the clinics in surgical specialties had the largest numbers of patients. In general surgery less than half of new patients and only one third of all patients attending the clinic were seen by a consultant. (Nine months later about a third of all new patients had still not seen a consultant in the clinic.) In the medical clinics just over a quarter of patients were seen by doctors who had less than six months'' experience in their present specialty after registration. Overall, doctors had been on continuous duty for at least 24 hours before a third of consultations. Doctors in training had actually worked during the previous night before attending a quarter of the clinics.Much of the large volume of work is performed by tired, incompletely trained doctors. It is suggested that a greater proportion of the work should be performed by fully trained staff. The workload might be reduced by modifying the pattern of the consultation.