Domains of consultation research in primary care

An overview of general practitioner consultations in China: a direct observational study

BACKGROUND

General practitioner (GP) consultation has long been considered an important component of general practice, but few studies have focused on its characteristics in China.

OBJECTIVE

This study aimed to explore the content and elucidate the characteristics of GP consultations in general practice in China.

METHODS

A multimethod investigation of GP consultations in eight community health centres in Guangzhou and Shenzhen, China was conducted between July 2018 and January 2019. Data from 445 GP consultations were collected by direct observation and audio tape and analysed by a modified Davis Observation Code with indicators for frequencies and detailed time durations. GP and patient characteristics were collected by post-visit surveys.

RESULTS

The mean visit duration was approximately 5.4 minutes. GPs spent the most time on treatment planning, history taking, negotiating, notetaking and physical examination and less time on health promotion, family information collecting, discussing substance use, procedures and counselling. The time spent on procedures ranked first (66 seconds), followed by history taking (65 seconds) and treatment planning (63 seconds). Besides, patients were very active in the consultation, specifically for topics related to medicine ordering and drug costs.

CONCLUSIONS

This study described the profile of GP consultations and illustrated the complexity of care provided by GPs in China. As patient activation in GP consultations becomes increasingly important, future studies need to explore how to promote the engagement of patients in the whole consultation process other than just requesting for medicine.

Understanding the body-mind in primary care

Patients' experience of symptoms does not follow the body-mind divide that characterizes the classification of disease in the health care system. Therefore, understanding patients in their entirety rather than in parts demands a different theoretical approach. Attempts have been made to formulate such approaches but many of these, such as the biopsychosocial model, are still basically dualistic or methodologically reductionist. In primary care, patients often present with diffuse symptoms, making primary care the ideal environment for understanding patients' undifferentiated symptoms and disease patterns which could readily fit both bodily and mental categories. In this article we discuss theoretical models that have attempted to overcome this challenge: The psychosomatic approach could be called holistic in the sense of taking an anti-dualistic stance. Primary care theorists have formulated integrative views but these have not gained a foothold in primary care medicine. McWhinney introduced a new metaphor, 'the body-mind', and Rudebeck advocated cultivating 'bodily empathy'. These views have much in common with both phenomenological thinking and mentalization, a psychological concept for understanding others. In the process of understanding patients there is a need for the physician to enter an intersubjectivity that aims at understanding the patient's experiences and sensations without initially jumping to diagnostic conclusions or into a division into mental and physical phenomena. Mentalization theory could form the basis of an approach to a more comprehensive understanding of patients. The success of such an approach is, however, dependent upon structural and organizational conditions that do not counteract it.

Learning to listen in primary care: some educational challenges

Effective clinician listening and communicating directly affects patients' health, satisfaction with healthcare, and complaints. This influences healthcare policy and clinician training/assessment. Listening skills and consultation frameworks underpin training but are often poorly used in everyday clinical work. Primary care doctors provide continuity of care using listening skills to develop long term relationships. Additionally, they listen to patients and colleagues in other ways such as surveys, participation groups, and significant event reviews. All these factors challenge educators to offer systematic training which ensures that future primary care clinicians/leaders develop conscious competence in listening at different levels and in differing contexts.

Reading Balint group work through Lacan's theory of the four discourses

In Balint groups, (para)medical professionals explore difficult interactions with patients by means of case presentations and discussions. As the process of Balint group work is not well understood, this article investigates Balint group meetings by making use of Lacan's theory of the four discourses. Five Balint group case presentations and their subsequent group discussion were studied, resulting in the observation of five crucial aspects of Balint group work. First, Balint group participants brought puzzlement to the group, which is indicative of the structural impossibility Lacan situates at the basis of all discourse (1). As for the group discussion, we emphasize 'hysterization' as a crucial process in Balint group work (2), the supporting role of the discourse of the analyst (3) and the centrality of discourse interactions (4). Finally, the potential transformation of the initial puzzlement is discussed (5). We conclude by putting forth the uniqueness of Balint group work as well as the potential usefulness of our analysis as a framework for Balint group leaders and professionals in charge of continuing medical education.

Lesbians on Medical Encounters: Tales of Heteronormativity, Deception, and Expectations

The experiences of lesbian women in medical encounters prove particularly relevant for understanding their difficulties in their relationship with professionals and health services. We carried out semistructured interviews with 30 women aged 21 to 63 years, who define themselves as lesbian. The analysis highlights the difficulties experienced in disclosure of sexuality in medical encounters, the tendency for doctors to come across as heteronormative, and also medical practices experienced as appropriate by interviewees. Analysis of participant experiences demonstrates the need for reflection and decision making to promote the recognition of the sexual citizenship of lesbian women and their empowerment.

Understanding "revolving door" patients in general practice: a qualitative study

BACKGROUND

'Revolving door' patients in general practice are repeatedly removed from general practitioners' (GP) lists. This paper reports a qualitative portion of the first mixed methods study of these marginalised patients.

METHODS

We conducted qualitative semi-structured interviews with six practitioner services staff and six GPs in Scotland, utilizing Charmazian grounded theory to characterise 'revolving door' patients and their impact from professionals' perspectives.

RESULTS

'Revolving door' patients were reported as having three necessary characteristics; they had unreasonable expectations, exhibited inappropriate behaviours and had unmet health needs. A range of boundary breaches were reported too when 'revolving door' patients interacted with NHS staff.

CONCLUSIONS

We utilise the 'sensitising concepts' of legitimacy by drawing on literature about 'good and bad' patients and 'dirty work designations.' We relate these to the core work of general practice and explore the role that medical and moral schemas have in how health service professionals understand and work with 'revolving door' patients. We suggest this may have wider relevance for the problem doctor patient relationship literature.

Bringing self-management into clinical view: a qualitative study of long-term condition management in primary care consultations

OBJECTIVES

To understand social processes underpinning support for self-management of long-term conditions in primary care.

METHODS

Comparative analysis of observational and interview data concerning the management of long-term conditions in UK primary-care consultations. Analysis of recordings of primary care consultations (n = 86) was conducted in conjunction with analysis of semi-structured interviews with health professionals (n = 17) and patients (n = 12) living with a long-term condition.

RESULTS

A key finding was the infrequency with which self-management topics became legitimate objects for discussion in consultations. Analysis suggested that the maintenance of self-other relations was a prime objective for both patients and professionals, and the introduction of self-management topics threatened this process. Technology and the division of labour among primary-care professionals reinforced this tension.

DISCUSSION

In order for self-management support to become embedded and integrated into primary care, interventions concerning long-term condition management need to take into account this tension underpinning care.

The ethics of everyday practice in primary medical care: responding to social health inequities

BACKGROUND

Social and structural inequities shape health and illness; they are an everyday presence within the doctor-patient encounter yet, there is limited ethical guidance on what individual physicians should do. This paper draws on a study that explored how doctors and their professional associations ought to respond to the issue of social health inequities.

RESULTS

Some see doctors as bound by a notion of care that is blind to a patient's social position, while others respond to this issue through invoking notions of justice and human rights where access to care is a prime focus. Both care and justice orientations however conceal important tensions linked to the presence of bioethical principles underpinning these. Other normative ethical theories like deontology, virtue ethics and utilitarianism do not provide adequate guidance on the problem of social health inequities either.

CONCLUSION

This paper explores if Bauman's notion of "forms of togetherness" provides the basis of a relational ethical theory that can help to develop a response to social health inequities of relevance to individual physicians. This theory goes beyond silence on the influence of social position of health and avoids amoral regulatory approaches to monitoring equity of care provision.

How does the general practitioner understand the patient? A qualitative study about psychological interventions in general practice

OBJECTIVES

General practitioners (GPs) treat more than 90% of common mental disorders. However, the content of their interventions remains undefined. The present study aimed to explore GPs' processes of understanding the patients with emotional problems.

DESIGN

The study was qualitative using semi-structured interviews with 14 general practitioners sampled purposively. Observation was done in the surgeries of four of the GPs.

METHODS

Analysis of the interviews was made by Interpretative Phenomenological Analysis (IPA). Observation notes were analysed from a hermeneutic-phenomenological perspective, inspired by IPA.

RESULTS

GPs had very different approaches to patients with emotional problems. Physical symptoms were the usual reason for consulting the GP. Understanding patients' perception of the meaning of their bodily symptoms in their complex life-situation was considered important by some of the participants. Arriving at this understanding often occurred through the narrative delivered in different narrative styles mirroring the patients' mental state. Awareness of relational factors and self-awareness and self-reflexivity on the part of the GP influenced this process. Other participants did not enter this process of understanding patients' emotional problems.

CONCLUSIONS

The concept of mentalization could be used to describe GPs' processes of understanding their patients when making psychosocial interventions and could form an important ingredient in a general practice theory in this field. Only some participants had a mentalizing approach. The study calls attention to the advantage of training this capacity for promoting professional treatment of patients and a professional dialogue across sector borders.

Experiences of carrying out talking therapy in general practice: a qualitative interview study

OBJECTIVE

To explore GPs' experience of carrying out 'talking therapy'.

METHODS

Qualitative study using semi-structured interviews with 11 Danish GPs sampled purposively. The material was analysed by Interpretative Phenomenological Analysis.

RESULTS

The participants expressed difficulty in explaining how they carried out talking therapy. However, from their description of individual therapies their perception of important aspects of methodology could be obtained: (1) their own open receptiveness, e.g. attentive listening, not limited by time; (2) relational factors including trust and empathy developed over time, or more active therapeutic use of the relationship; (3) knowledge of the patient's life story, told or written, used to form a model of the patient's problems, thoughts and feelings. The sessions were not offered if the GPs lacked time.

CONCLUSION

Participants were mostly self-taught and did not use specific methods systematically despite having learnt them. GPs knew the patients beforehand; talking therapy developed from other treatment, and methodology had to fit into this. Specific methods are possibly not relevant in general practice.

PRACTICE IMPLICATIONS

Formulation of a theory of talking therapy based on the views and experience of GPs and including non-specific factors could professionalize the field.

Evaluation of a family support service: short-term outcome

The aim of this study was to evaluate the short-term impact of two types of family support services (FSS) for children with behavioural problems (N = 51 and 49 respectively). These were compared with children (N = 40) matched for presenting problems and referred to specialist CAMHS in a locality without FSS. Pre and postintervention measures were the Health of the Nation Outcome Scales (HoNOSCA), the Strengths and Difficulties Questionnaire (SDQ), and a service utilization checklist. Although all three groups were associated with decrease of child behavioural scores, the two family support services provided an earlier response and resulted in significantly higher reduction of HoNOSCA and SDQ scores. The two FSS types implemented different 'levels' of interventions, as FSS-B resulted in a more favourable short-term outcome and appeared to operate more closely to specialist services, while FSS-A appeared to adopt a more preventive role. Family support services have an important role within a comprehensive child mental health service, but the specificity of their interventions for different target client groups requires further investigation.

Doctor–patient interaction in a randomised controlled trial of decision-support tools

In this paper, we draw on the analytic perspectives of ethnomethodology to explore doctor-patient encounters in an experimental trial of a complex intervention: an efficacy randomised controlled trial (RCT) of decision-support tools in the UK. We show how the experimental context in which these encounters take place pervades the interactions within them. We argue that two interactional orders were at work in the encounters that we observed: (i) the ceremonial order of the consultation and (ii) the assemblage of the decision-support tool trial. We demonstrate how doctors in the trial oscillate between positions as authoritative clinician and neutralistic decision-support tool-implementer, and patients move between positions as passive recipients of clinical knowledge and as active subjects required to render their experience as calculable in terms of the demands of the decision-support tools and the broader trial they are embedded in. We demonstrate how the RCT coordinates the world of the clinical environment and the world of experimental evidence.

Technogovernance: Evidence, subjectivity, and the clinical encounter in primary care medicine

Technological solutions to problems of knowledge and practice in health care are routinely advocated. This paper explores the ways that new systems of practice are being deployed as intermediaries in interactions between clinicians and their patients. Central to this analysis is the apparent conflict between two important ways of organizing ideas about practice in primary care. First, a shift away from the medical objectification of the patient, towards patient-centred clinical practice in which patients'heterogeneous experiences and narratives of ill-health are qualitatively engaged and enrolled in decisions about the management of illness trajectories. Second the mobilization of evidence about large populations of experimental subjects revealed through an impetus towards evidence-based medicine, in which quantitative knowledge is engaged and enrolled to guide the management of illness, and is mediated through clinical guidelines. The tension between these two ways of organizing ideas about clinical practice is a strong one, but both impulses are embodied in new 'technological' solutions to the management of heterogeneity in the clinical encounter. Technological solutions themselves, we argue, embody and enact these tensions, but may also be opening up a new array of practices--technogovernance--in which the heterogeneous narratives of the patient-centred encounter can be resituated and guided.

Does the achievement of medical identity limit the ability of primary care practitioners to be patient-centred? A qualitative study

OBJECTIVE

To explore primary care practitioners approach to and management of menstrual disorders using a sociological perspective.

METHODS

Semi-structured interviews of primary care practitioners with an iterative approach to recruitment and analysis informed by grounded theory.

RESULTS

Two broad approaches to patient care were described-a biomedical approach, which concentrated on medical history taking and the search for disease, and a patient-as-person approach where a patient's individual ideas and concerns were elicited. Practitioners believed they had a role in integrating these approaches. Activities intrinsic to the biomedical approach such as the performance of examinations, the ordering of tests and making decisions about biomedical aspects of care were however not available for shared decision-making. The exercise of these decisions by medical practitioners was necessary for them to achieve their professional identity.

CONCLUSION

While practitioners accepted the ideology of patient-centred care the biomedical approach had the advantage of providing practitioners with a professional identity, which protected their status in relation to patients and colleagues.

PRACTICE IMPLICATIONS

The adoption of shared decision-making by medically qualified primary care practitioners is limited by practitioners need to achieve their medical identity. At present, this identity does not involve significant sharing of power and responsibility. A shift in perception of medical identity is required before more shared decision-making is seen in practice.

Framing the doctor-patient relationship in chronic illness: a comparative study of general practitioners' accounts

How family doctors conceptualise chronic illness in the consultation has important implications for both the delivery of medical care, and its experience by patients. In this paper, we present the results of a re-analysis of qualitative data collected in a series of studies of British family doctors between 1995 and 2001, to explore the ways in which the legitimacy and authority of medical knowledge and practice are organised and worked out in relation to three kinds of chronic illness (menorrhagia; depression; and chronic low back pain/medically unexplained symptoms). We present a comparative analysis of (a). the moral evaluation of the patient (and judgements about the legitimacy of symptom presentation); (b). the possibilities of disposal; and (c). doctors' empathic responses to the patient, in each of these clinical cases. Our analysis defines some of the fundamental conditions through which general practitioners frame their relationships with patients presenting complex but sometimes diffuse combinations of 'social', 'psychological' and 'medical' symptoms. These are fundamental to, yet barely touched by, the increasingly voluminous literature on how doctors should interact with patients. Moving beyond the individual studies from which our data are drawn, we have outlined some of the highly complex and demanding features of what is often seen as routine and unrewarding medical work, and some of the key requirements for the local negotiation of patients' problems and their meanings (for both patients and doctors) in everyday general practice.

Challenging heteronormativity in the consultation: a focus group study among general practitioners

OBJECTIVE

To reflect on and further understand mechanisms of heteronormativity in the consultation, with special focus on the relative invisibility of lesbian women.

DESIGN

Tape-recorded focus group interviews transcribed verbatim and analysed using qualitative methods.

SETTING

General practitioners (GPs) from the city of Göteborg, Sweden, who had formerly answered a postal questionnaire about lesbian women in the consultation, were invited to take part in subsequent focus groups.

SUBJECTS

Ten GPs from the questionnaire who accepted the invitation and volunteered to participate in focus groups.

MAIN OUTCOME MEASURES

A discourse analytical approach using interaction regarding consensus and disagreement between informants in creating major and minor themes.

RESULTS

Consultation skills were forwarded as a major tool in receiving optimal information from patients. However, traditional concepts of family and sexuality restricted information and hampered an accepting attitude. Bringing up issues of sexual identity/orientation was left to the lesbian patient and strongly related to her reason for attending.

CONCLUSION

Consultation skills are a useful but not sufficient means of making lesbian women visible in the doctor-patient relationship. Doctors also need to transcend traditional concepts of family and sexuality and reflect on what is a relevant issue from the patient's perspective.

Perceptions of psychological content in the GP consultation--the role of practice, personal and prescribing attributes

OBJECTIVE

The aim of the present study was to determine the relationship between the characteristics of general practices and the perceptions of the psychological content of consultations by GPs in those practices.

METHODS

A cross-sectional survey was conducted of all GPs (22 GPs based in nine practices) serving a discrete inner city community of 41 000 residents. GPs were asked to complete a log-diary over a period of five working days, rating their perception of the psychological content of each consultation on a 4-point Likert scale, ranging from 0 (no psychological content) to 3 (entirely psychological in content). The influence of GP and practice characteristics on psychological content scores was examined.

RESULTS

Data were available for every surgery-based consultation (n = 2206) conducted by all 22 participating GPs over the study period. The mean psychological content score was 0.58 (SD 0.33). Sixty-four percent of consultations were recorded as being without any psychological content; 6% were entirely psychological in content. Higher psychological content scores were significantly associated with younger GPs, training practices (n = 3), group practices (n = 4), the presence of on-site mental health workers (n = 5), higher antidepressant prescribing volumes and the achievement of vaccine and smear targets. Training status had the greatest predictive power, explaining 51% of the variation in psychological content. Neither practice consultation rates, GP list size, annual psychiatric referral rates nor volumes of benzodiazepine prescribing were related to psychological content scores.

CONCLUSION

Increased awareness by GPs of the psychological dimension within a consultation may be a feature of the educational environment of training practices.

Carbon source utilization profiles as a method to identify sources of faecal pollution in water

AIMS

Carbon source utilization profiles as a phenotypic fingerprinting methodology for determining sources of faecal pollution in water were evaluated.

METHODS AND RESULTS

Three hundred and sixty-five Enterococcus isolates were collected from known faecal sources in four different geographical regions and were identified to species with the commercial Biolog system. Discriminant analysis (DA) was used to identify the substrate-containing wells that best classified the 365 isolates by source. By using 30 of the 95 wells for the analysis, the average rate of correct classification (ARCC) by source was 92.7% for a human vs non-human two-way classification when isolates from all regions were combined into one library. Corresponding ARCCs for other classification schemes were 81.9% for a four-way classification of human vs livestock vs wildlife vs domestic pets, and 85.7% for a three-way classification without human isolates. When three individual libraries were made based on classification of sources within Enterococcus species, the ARCC was 95.3% for the Ent. faecalis library, 95.8% for the Ent. gallinarum library and 94.7% for the Ent. mundtii library. Thirty Enterococcus isolates (unknown sources) were obtained from each of three stream sites where a specific source of pollution was apparent; 90.0% of the isolates from a human-suspected source were classified as human, 86.6% were classified as livestock from a livestock-suspected site, and 93.3% were classified as wildlife from a wildlife-suspected site.

CONCLUSIONS

Phenotypic fingerprinting with carbon source utilization profiles provided levels of correct classification by sources from an Enterococcus library that were in the upper range of those reported in the literature. ARCCs for three Enterococcus species-specific libraries were very high and may be the best approach for further developing this concept and methodology. SIGNIFICANCE ANC IMPACT OF THE STUDY: The results, based on a modest Enterococcus library and a preliminary field validation test, demonstrated the potential for carbon source utilization profiles to be employed as a phenotypic method for determining sources of faecal pollution in water.

"Fire away": the opening sequence in general practice consultations

BACKGROUND

Proponents of recent models of the doctor-patient relationship, such as concordance and shared decision making, have emphasized mutuality rather than paternalism or consumerism. However, little attention has been paid so far to the ways in which this might actually be achieved.

OBJECTIVES

The aims of this study were to establish whether there are any rules governing the opening sequence in general practice consultations, and to analyse the ways in which the observing or breaking of such rules contributes to the development of mutuality between patients and GPs.

METHODS

The paper is based on a qualitative study of 62 patients consulting 20 GPs in 20 practices in the Midlands and Southeast of England. Consultations were audio recorded and transcribed; patients were interviewed before and after each consultation, and doctors were interviewed afterwards. Data were analysed using the sociological method of Conversation Analysis. The outcomes were participants' own understandings as demonstrated in their speech.

RESULTS

A selection rule was identified whereby doctors choose between the questions "How are you?" and "What can I do for you?" to elicit patients' concerns. Deviations from this selection rule may be either repairable or strategic. Repairable deviance is based on misunderstanding between participants, and is resolved interactionally, usually by patients. Strategic deviance is the attempt by doctors to emphasize or de-emphasize certain aspects of their relationships with particular patients. Deviations from the rule which are not repaired lead to misalignment between participants.

CONCLUSION

In relation to concordance, or shared decision making more generally, this analysis demonstrates that alignment or misalignment between participants will occur before any discussion about treatment options occurs. In cases of misalignment, concordance will be much harder to achieve. Mutuality is an achievement of both patients and doctors, and requires the active participation of patients.