Presentation of patients' problems during triage in emergency medicine

Is Solicitation of Problem Presentations Always Normative? How Chinese Patients Get to Present Their Reasons for Medical Visits

Research based on recordings made across numerous specialties and geographical locations has characterized doctors' solicitations of patients' reasons for the visit as normative. However, in our dataset of 132 audio-recordings of consultations in Chinese primary and secondary care, it was as common for patients to self-initiate giving the reason for their visit as it was for doctors to solicit these (n = 65 vs. n = 67 respectively). Based on a conversation analytic examination of our dataset, we show that doctors do not treat patient-initiated problem presentations as deviant. Whilst there are some contextual contingencies (related, for example, to the queuing-system) that might account for this novel finding, these are only partly explanatory. Instead, we argue that, relative to Western contexts, the participants in our data treat the medical consultation as akin to a service-encounter in which patients are entitled to ask for what they want. Implications for understanding medical openings and health outcomes are discussed.

Negotiating 'the problem' in GP home visits to people with dementia

People with dementia are often marginalised in health care due to the effects of the condition on short term memory and communication. The problem presentation is a key area of primary care consultations where patients 'have the floor', and hence are able to direct the trajectory of the consultation to achieve certain ends. An exploration of how patients with advanced dementia participate in this stage of the consultation can thus demonstrate their participation and subsequent engagement. We used conversation analysis to describe how healthcare professionals (HCPs), people with dementia, and their carers establish the presenting problem in 17 out-of-hours primary care home visit consultations. In all cases, the carer had called the out of hours service on behalf of the patient. Rather than traditional "what can I help you with?" problem solicits, HCPs instead stated their reason-for-visit using information provided by the carer. All the patients showed some misalignment with this presented reason-for-visit, by denying the existence of current symptoms and/or their involvement in the decision to call the doctor. Carers appeared to show respect for the patient's ownership of their experience, only providing input on invitation from doctors or patients. Patient acknowledgement and willingness to engage in examination were needed for progressivity, but agreement with the reason-for-visit was not. In two consultations, the reason-for-visit was not explained to patients, and in both cases this resulted in the person with dementia showing frustration and resistance to examination. People with dementia may resist doctor home visits for many reasons, such as embarrassment for not remembering symptoms, or stoicism in the face of medical ailments. These findings show how the balance of progressivity and intersubjectivity tips towards progressivity in consultations with people with dementia, but this is reversed when the patient is not engaged in the reason-for-visit.

Antibiotic Prescribing and Doctor-Patient Communication During Consultations for Respiratory Tract Infections: A Video Observation Study in Out-of-Hours Primary Care

Objective: Communication skills can reduce inappropriate antibiotic prescribing, which could help to tackle antibiotic resistance. General practitioners often overestimate patient expectations for an antibiotic. In this study, we describe how general practitioners and patients with respiratory tract infections (RTI) communicate about their problem, including the reason for encounter and ideas, concerns, and expectations (ICE), and how this relates to (non-)antibiotic prescribing in out-of-hours (OOH) primary care.

Methods: A qualitative descriptive framework analysis of video-recorded consultations during OOH primary care focusing on doctor-patient communication.

Results: We analyzed 77 videos from 19 general practitioners. General practitioners using patient-centered communication skills received more information on the perspective of the patients on the illness period. For some patients, the reason for the encounter was motivated by their belief that a general practitioner (GP) visit will alter the course of their illness. The ideas, concerns, and expectations often remained implicit, but the concerns were expressed by the choice of words, tone of voice, repetition of words, etc. Delayed prescribing was sometimes used to respond to implicit patient expectations for an antibiotic. Patients accepted a non-antibiotic management plan well.

Conclusion: Not addressing the ICE of patients, or their reason to consult the GP OOH, could drive assumptions about patient expectations for antibiotics early on and antibiotic prescribing later in the consultation.