Why patients consult and what happens when they do

OBJECTIVE

To study patients' perceptions of why they consulted the doctor, how ill they thought they were, and what happened in the consultation. To compare patients' perceptions before and after the consultation and to compare these perceptions with those of the doctor.

DESIGN

Patients filled in a questionnaire before and after the consultation. The doctor filled a questionnaire in after the consultation.

SETTING

Three general practices in Bedfordshire and one in Hertfordshire.

PATIENTS

500 consecutive patients consulting in each practice.

MAIN OUTCOME MEASURES

Changes in patients' perceptions and differences between the perceptions of patients and doctors.

RESULTS

Doctors perceived patients to be less ill than the patients themselves did. Patients from social classes IV and V and children perceived themselves to be more ill than the average. Patients perceived themselves to be less ill after the consultation. A third of patients attended because doctors had told them to, and a quarter of patients had already tried to treat their problem themselves when they attended the consultation. Doctors' perceptions of the consultation emphasised listening, supporting, and giving advice. Patients' perceptions emphasised prescribing, reassuring, and referring to a consultant. Doctors perceived that they listened, examined, and gave advice less to social classes IV and V than to social classes I, II, and III and gave explanations more often to men than to women. Patients perceived external factors rather than lifestyle factors as being more important in causing their problems.

CONCLUSION

Doctors' perceptions of patients' problems differed from those of patients expressed both before and after their consultation. Doctors' and patients' perceptions also differed about the consultation itself. The consultation reassured some patients.

Patients' views of the consultation: comparison of a prison and general practice population

Prisoners' perceptions of why they consulted the doctor, how ill they thought they were and what happened during the consultation were studied in Bedford prison using a questionnaire. Patients' perceptions were compared before and after the consultation and with the perception of the doctor. The figures from this study were compared with comparable groups in a similar general practice survey. Prisoners perceived themselves to be more ill than comparable groups living in the community and both doctor and prisoners perceived that the prisoners received less reassurance. Prisoners were less likely to attend the doctor because their treatment had not worked, or because the doctor had asked them to return than comparable groups living in the community. The perception of the doctor and the prisoners about what occurred in the consultation diverged. The doctors perceived that they provided more advice and support than the prisoners felt they received. These perceptions may reflect a more difficult doctor-patient relationship and poorer continuity of care in prison medicine. These problems might be overcome if the prison medical service were run by the National Health Service and prison doctors had no role in the management of prisoners.

Acetate catabolism in the dissimilatory iron-reducing isolate GS-15

Acetate-grown GS-15 whole-cell suspensions were disrupted with detergent and assayed for enzymes associated with acetate catabolism. Carbon monoxide dehydrogenase and formate dehydrogenase were not observed in GS-15. Catabolic levels of acetokinase and phosphotransacetylase were observed. Enzyme activities of the citric acid cycle, i.e., isocitrate dehydrogenase, 2-oxoglutarate sythase, succinate dehydrogenase, fumarase, and malate dehydrogenase, were observed.

Children with special needs in England and Wales: the care of hearing impairment, myelomeningocele, and adolescent pregnancy

Services for children with special needs in England and Wales are described briefly, with attention to the services provided by the National Health Service, local authorities, the social security system, and voluntary organizations. For illustrative purposes, particular reference is made to children with hearing impairments and myelomeningoceles. A separate account is given of the provision for pregnant adolescents, again addressing services provided by all major sources of assistance.

Preventive care for children: immunization in England and Wales

Immunization rates against common, notifiable diseases of childhood have improved steadily in England and Wales, although the 90% target rates for 1990 have not been achieved. The organization of the immunization program is described, with attention to service delivery, mechanisms of assurance, and consideration of the remaining barriers to further improvement in coverage.

Child health services in England and Wales: an overview

Child health services in England and Wales are rendered largely through the National Health Service and Social Security. The activities of local authorities are also important to child health. The structure and scope of services offered children by each of these is presented and discussed, with special attention to changes anticipated during the next 2 years. The care of children is integrated into the system serving all ages, so that services are difficult to evaluate and resources are shared with other groups. Health policy for children is fragmentary, although encouraging trends are visible in the evolution of existing policy. The impact of impending changes in hospital, community, and general practitioner services on the care of children is unclear at this time.

Bone mineral mass associated with postmenopausal vertebral deformities

Vertebral morphometry on thoracic and lumbar spine radiographs and bone mass measurements were carried out on 215 patients investigated for postmenopausal osteoporosis. Bone mineral mass was measured on the central third of the skeleton by neutron activation analysis and the result, normalized for body size, expressed as a calcium bone index (CaBI). The normal CaBI value for females (20-40 years) is 0.97 (0.11) with a lower limit for these young, normal women, of 0.75. Vertebral compression deformity was defined as a mean height more than 15% lower than adjacent normal vertebrae. Thoracic and lumbar anterior wedge deformities and central compression were defined as anterior/posterior (A/P) or mid/posterior (M/P) height ratios of less than 0.75. For the 129 patients without vertebral deformities, the mean CaBI was 0.80 (0.12) (1 SD) and 32% of these patients had CaBI values below the normal young adult range (CaBI less than 0.75). In 20 patients, vertebral deformities were limited to 1 or 2 mid-thoracic vertebrae, and the mean CaBI values for these 20 patients was 0.81 (0.15), equal to that for patients without any vertebral deformity. For the remaining 67 patients, (i.e., patients with one or more vertebral deformities involving at least one distal thoracic or one lumbar vertebra) the mean CaBI value was 0.66 (0.10), 17% below the value for patients without vertebral deformities. Low CaBI values (CaBI less than 0.75) were observed in 87% of these patients, consistent with the diagnosis of osteoporotic fractures. Based on our CaBI results, however, mid-thoracic deformity was not associated with significant osteopenia and is not, therefore, diagnostic of osteoporotic fracture.

Fluoride-induced fractures: relation to osteogenic effect

The possible effects of fluoride in inducing fractures were studied in 61 patients treated with sodium fluoride (NaF), 40-60 mg daily in combination with calcium and vitamin D. Nine patients developed the fluoride-(F) related lower extremity pain syndrome. Four other patients had stress fractures associated with trauma. Seven of the 61 patients had 10 upper femur fractures of which 5 were stress fractures. The bone mineral mass of the central skeleton including the hips was measured by neutron activation and the results expressed as a calcium bone index (CaBI) which normalizes the results to that of young adults of the same body size (normal range 0.75-1.2). At the time of hip fracture, 4 patients with a minimal increase in bone mass (mean delta CaBI 0.01) had 4 femur fractures and 3 patients with a marked increase (mean delta CaBI 0.24) had 6. The 7 patients with upper femur fractures at 4 years had a significantly higher bone fluoride retention, 30 mg/g Ca compared with 23.9 mg/g Ca for the other 54 (p less than 0.02) and were older, 73.1 versus 64.2 years (p less than 0.01). Using all 61 fluoride-treated patients, femur fractures/patient were significantly correlated to bone fluoride (p less than 0.05) and to age (p less than 0.05). By partial correlation, only the correlation between hip fractures/patient and bone fluoride remained significant after controlling for the effect of age (p less than 0.05). These results suggest that fluoride therapy may be implicated in the pathogenesis of hip fractures which may occur in treated patients despite a rapid, marked increase in bone mass. The lower extremity pain syndrome is not frequently associated with stress fractures in this study.

The long-term treatment of steroid osteoporosis with fluoride

Twenty-two patients with steroid-induced osteoporosis were studied retrospectively to assess the effects on bone mass of fluoride therapy over 4 years. Thirteen of 19 patients with miscellaneous disorders and 2 with Cushing's syndrome received 1 g calcium/day, 50,000 IU vitamin D (D) weekly, and 40-60 mg/day sodium fluoride (F). Six patients with miscellaneous disorders and one with Cushing's syndrome received only Ca and vitamin D. The mean (+/- SD) cumulative dose of prednisone for fluoride-treated patients at the beginning of the study was 42 +/- 25 g, and for those patients treated with only Ca and vitamin D, 45 +/- 47 g, and during the study the cumulative dose was comparable in both groups. The bone mineral mass of the central skeleton was measured by neutron activation analysis and the results expressed as the calcium bone index (CaBI) which normalizes the results to that of young adults of the same body size (normal range 0.75-1.2). In the 13 patients with miscellaneous disorders treated with fluoride, the mean +/- SD CaBI rose from 0.65 +/- .03 to 0.75 +/- .03 after 3 years p less than 0.001) and to 0.81 +/- .11 at 4 years. Patients without fluoride had an initial mean CaBI of 0.70 +/- .08 and it was not significantly changed over 3 years, 0.68 +/- .09 and 4 years, 0.71 +/- .09. The rise in CaBI in fluoride-treated patients with steroid-induced osteoporosis including Cushing's syndrome was comparable to that of 61 patients with postmenopausal osteoporosis treated with fluoride.(ABSTRACT TRUNCATED AT 250 WORDS)