Children seen frequently out of hours in one general practice.

OBJECTIVE--To identify reasons why some children receive more out of hours visits than most. DESIGN--A one year prospective study to identify the study group. This was followed by a case-control study involving a record search and personal interviews. SETTING--One three doctor urban general practice in West Lothian with 4812 patients. SUBJECTS--40 children aged under 10 years identified as high users of the out of hours service (more than two visits a year) and 40 age and sex matched controls. MAIN OUTCOME MEASURES--Numbers of visits; social factors such as lone motherhood, low educational attainment; score for management response to clinical vignette. RESULTS--147/756 (19%) out of hours visits in the study year were to children aged under 10 years; 109 (74%) to 41 children (6%). Problems seen were mainly minor, and little active management was required. Family and social factors which were significantly more common for the cases than for the controls included a lone mother (15 v 4), low educational attainment by the mother (25 v 14), receipt of income support (22 v 7), and non-ownership of the home (45 v 22) or a car (19 v 9). Mothers of the cases were more likely to choose to contact a doctor when presented with vignettes describing common childhood illnesses (median score for 16 vignettes 16.5 for cases v 14.5 for controls, Wilcoxon signed rank test, p = 0.01). CONCLUSIONS--Children seen more frequently than expected out of hours came from more socially disadvantaged families and their mothers were more likely to seek medical advice about minor childhood illness. Maternal education, to promote confidence in managing minor illness, may reduce their use of the out of hours service.     

Evaluation of peak flow and symptoms only self management plans for control of asthma in general practice.

OBJECTIVE--To compare a peak flow self management plan for asthma with a symptoms only plan. DESIGN--Randomisation to one of the self management plans and follow up for a year. SETTING--Four partner, rural training practice in Norfolk. SUBJECTS--115 Patients (46 children and 69 adults) with asthma who were having prophylactic treatment for asthma and attending a nurse run asthma clinic. MAIN OUTCOME MEASURES--The number of doctor consultations, courses of oral steroids, and short term nebulised salbutamol treatments and the number of patients who required doctor consultations, courses of oral steroids, and short term nebulised salbutamol. RESULTS--Both self management plans produced significant reductions in the outcome measures but there were no significant differences in the degree of improvement between the groups. The results were similar for children and adults. The proportions of patients requiring a doctor consultation fell from 98% (50/51) to 66% (34/51) in the peak flow group and from 97% (62/64) to 53% (34/64) in the symptoms only group and the proportions requiring oral steroids from 73% (34/46) to 47% (21/46) and 52% (31/60) to 12% (7/60). The median number of doctor consultations was reduced from 8.0 to 2.0 in the peak flow group and from 4.5 to 1.0 in the symptoms only group. CONCLUSIONS--The peak flow meter was not the crucial ingredient in the improved illness of the two groups. Teaching patients the importance of their symptoms and the appropriate action to take when their asthma deteriorates is the key to effective management of asthma. Simply prescribing peak flow meters without a system of self management and regular review will be unlikely to improve patient care.     

Illness among holidaymakers and the effect on a seaside practice.

Between 1 May and 30 September 1983 a practice of three doctors in the centre of Scarborough conducted 1772 consultations with 1472 temporary residents, 967 (55%) of which were during July and August. The pattern of illness differed considerably from that usually found in general practice, with an excess of minor infections, gastrointestinal upsets, and skin problems comprising 46% of the consultations. Practitioners who care for appreciable numbers of temporary residents should plan their services to match the special needs of holidaymakers. The task of doctors in areas with many visitors would be made easier if patients who are on regular medication or are under surveillance brought with them not only enough drugs for their needs but also a summary of their medical history.     

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.     

Quality and the use of time in general practice: widening the discussion.

To examine the association between different consulting styles in general practice (defined according to the average length of doctor-patient contact time in surgery consultations) and the process of care for those patients presenting with new episodes of respiratory illness, 1787 consultations conducted by 85 general practitioner principals in Lothian from November 1987 to May 1988 were analysed. Short as against long consultations resulted in less attention being given to psychosocial issues that the doctor recognised as relevant. When psychosocial problems were dealt with prescribing of antibiotics decreased. In this volunteer sample of doctors the process of care seemed to reflect decisions as to how time was allocated rather than inherently different patterns of clinical behavior. Organisational and contractual changes will shift the mix of financial and professional incentives for general practitioners in ways that could lead to doctors reallocating their time toward shorter consultations; such a reallocation could have important implications for patient 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.     

Risk factors for lower respiratory complications of rhinovirus infections in elderly people living in the community: prospective cohort study.

OBJECTIVE: To assess the role of rhinoviruses in elderly people living in the community. DESIGN: Prospective community based surveillance of elderly people, without intervention. Subjects were telephoned weekly to identify symptomatic upper respiratory tract infections. Symptoms and impact of illnesses were monitored, and specimens were collected for diagnostic serology and human rhinovirus polymerase chain reaction. SETTING: Leicestershire, England. SUBJECTS: 533 subjects aged 60 to 90. MAIN OUTCOME MEASURES: Symptoms, restriction of activity, medical consultations, and antibiotic use during 96 rhinovirus infections. Adjusted odds ratios for lower respiratory syndromes with respect to smoking and health status. RESULTS: A viral cause was established in 211 (43%) of 497 respiratory illnesses; rhinoviruses were identified in 121 (24%) and as single pathogens in 107. The median duration of the first or only rhinovirus infection in the 96 people with 107 rhinovirus infections was 16 days; 18 of the 96 patients were confined to bed and 25 were unable to cope with routine household activities. Overall, 60 patients with rhinovirus infections had lower respiratory tract syndromes; 41 patients consulted their doctor, 31 of them (76%) receiving antibiotics. One patient died. Logistic regression analysis showed that chronic medical conditions increased the estimated probability of lower respiratory rhinovirus illness by 40% (95% confidence interval 17% to 68%) and smoking by 47% (14% to 90%). There were almost six times as many symptomatic rhinovirus infections as influenza A and B infections. CONCLUSIONS: Rhinoviruses are an important cause of debility and lower respiratory illness among elderly people in the community. Chronic ill health and smoking increase the likelihood of lower respiratory complications from such infections. The overall burden of rhinovirus infections in elderly people may approach that of influenza.     

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.     

Nurse practitioners in accident and emergency departments: what do they do?

OBJECTIVE--To determine the distribution and scope of nurse practitioner schemes in accident and emergency departments in England and Wales; to describe the caseloads of doctors and nurse practitioners on two representative days; and to estimate the number of patients managed by nurse practitioners in the year to 31 March 1991. DESIGN--A postal survey of accident and emergency departments and a content analysis of case notes of new patients attending a representative sample of accident and emergency departments on two days. SETTING--All accident and emergency departments in England and Wales. PARTICIPANTS--Survey: 560 nurses in charge of accident and emergency departments. Census: case notes of 5814 patients in 37 accident and emergency departments. MAIN OUTCOME MEASURES--Survey: number of accident and emergency departments with nurse practitioner schemes. Census: demographic and clinical characteristics of new patients attending and whether nurse practitioner or doctor made diagnoses and ordered investigations, treatments, referrals, discharges. RESULTS--513 replies (92%) from 465 surveyed functioning accident and emergency departments and 48 departments recently closed. 27 (6%) departments used designated nurse practitioners and 159 (34%) "unofficial" nurse practitioners. Only 530 (9%) of the 5814 patients in the census were managed entirely or mainly by nurse practitioners, with higher proportions in ophthalmic departments (nearly 30%) and minor casualty departments (over 40%) than in major departments (3%). Most patients managed by nurse practitioners (86%) had minor trauma. In the year ending 31 March 1991 an estimated 390,000 (95% confidence interval 260,000 to 520,000) patients out of a total of 12.5 million (3.1%, 2.1% to 4.1%) were clinically managed by a nurse practitioner. CONCLUSIONS--Designated nurse practitioner schemes are rare. The volume and range of nurse practitioner work in major general accident and emergency departments is small compared with those in specialised and minor accident and emergency departments.     

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.     

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.     

'Well doctor, it is all about how life is lived': cues as a tool in the medical consultation

Introduction During consultations, the perspective of the patient and the family physician come together. In order to reach a shared view about the symptoms it is important to know the agenda of the patient. Cues (i.e. non-explicit remarks that can enclose a special meaning) can serve as a tool to clarify the agenda.Case report In this article, we describe a patient with unexplained palpitations during vacuuming. During one of the following consultations she provided an important psychosocial cue which changed my perspective on her palpitations, resulting in a deeper understanding of her symptoms.Discussion Recognition and exploration of cues is important for reaching mutual understanding of doctors and patients about the symptoms. Moreover, it enhances the therapeutic relationship and improves illness outcomes and patient satisfaction.Conclusion Noticing cues in the medical consultation helps the doctor to understand the patient's real worries. It gives us, as doctors, a better understanding of the patient's perspective.     

The Practice Nurse—A New Look

A nurse has been employed by three general practitioners in a semi-rural practice of 9,000 patients since April 1968. Of her 1,360 home visits, 838 were primary visits, of which only 87 required follow-up by the doctor and 484 were requested directly to the nurse. More advanced procedures carried out by the nurse included electrocardiography, pregnancy diagnosis, blood sampling, and cytology. This study suggests that the work of a practice nurse improves the medical service already provided and reduces the work-load of the doctors, particularly by primary screening by the nurse both at home and in the surgery.     

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.     

Patterns of medical drug use - a community focus.

The pattern and extent of medical use of drugs was examined by survey in a rural Ontario community (Smithville) and a suburban (Burlington) family practice. Changes in established patterns of drug use that occur after the introduction of a nurse practitioner were also examined in the suburban practice. In both surveys 60% of respondents were using at least one medication and 30% were taking at least one medication prescribed or suggested by a doctor. There were consistently high rates of use of nonprescribed drugs at all ages, especially among females. Vitamins and tonics were the most commonly used drugs, and were taken by 25 to 28% of the respondents, 40% of whom used them on the advice of a physician. From 8.8 to 10.5% of respondents used sedatives or tranquillizers, and reduction in the prescribed use of these drugs was found among patients managed by the nurse practitioners. Self-medication is apparently unrelated to the frequency of medical consultation.     

Psychiatric Illness in General Practice: A Detailed Study Using a New Method of Case Identification

A self-administered questionary (the General Health Questionnaire) aimed at detecting current psychiatric disturbance was given to 553 consecutive attenders to a general practitioner''s surgery. A sample of 200 of these patients was given an independent assessment of their mental state by a psychiatrist using a standardized psychiatric interview. Over 90% of the patients were correctly classified as “well” or “ill” by the questionary, and the correlation between questionary score and the clinical assessment of severity of disturbance was found to be +0·80.The “conspicuous psychiatric morbidity” of a suburban general practice assessed by a general practitioner who was himself a psychiatrist and validated against independent psychiatric assessment was found to be 20%. “Hidden psychiatric morbidity” was found to account for one-third of all disturbed patients. These patients were similar to patients with “conspicuous illnesses” in terms both of degree of disturbance and the course of their illnesses at six-month follow-up, but were distinguished by their attitude to their illness and by usually presenting a physical symptom to the general practitioner.When 87 patients who had been assessed as psychiatric cases at the index consultation were called back for follow-up six months later, two-thirds of them were functioning in the normal range. Frequency of attendance at the surgery in the six months following index consultation was found to have only a modest relationship to severity of psychiatric disturbance.It is argued that minor affective illnesses and physical complaints often accompany each other and usually have a good prognosis.     

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.     

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.