Why patients consult and what happens when they do

Healthcare professionals' social distance towards immigrant patients: A descriptive cross-sectional study

OBJECTIVE

This study aimed to determine the attitudes, beliefs, experiences, and the level of social distance among healthcare professionals who provide healthcare to refugee patients.

DESIGN

Descriptive cross-sectional study.

PLACE AND DURATION OF STUDY

The researchers obtained the ethical approval of the study from the Non-Interventional Ethical Committee of Sakarya University Faculty of Medicine on 23/11/2018. The study was carried out between December 2018 and February 2019 at Sakarya University Research and Training Hospital.

METHODOLOGY

A total of 1484 healthcare professionals work at clinics which are likely to offer care to refugee patients. Descriptive analyses were performed for the study. The data were collected by a questionnaire created by the researchers in light of related literature to investigate the sociodemographic characteristics of the participants and their work-related descriptive characteristics (such as, experience, beliefs, etc.) which may affect their attitudes while providing healthcare to refugee patients. The form was prepared by the researchers based on the literature knowledge. For determining the level of social distance towards refugee patients, Arkar's²⁸ social distance scale was used.

RESULTS

Health professionals show a serious level of social distance towards refugee patients due to various difficulties but mainly because of the language barrier.

CONCLUSION

Healthcare professionals have great social distance to refugee patients. Moreover, they can continue their professional attitudes towards patients in emotional terms.

What are the underlying reasons behind socioeconomic differences in doctor-patient communication in head and neck oncology review clinics?

OBJECTIVE

To explore socioeconomic status (SES) differences in patterns of doctor-patient communication within head and neck cancer clinics and why such differences exist.

METHODS

Thirty-six head and neck cancer review appointments with five Physicians were observed and audio-taped, along with follow-up interviews involving 32 patients. Data were analysed using Thematic Analysis, and compared by patient SES (education, occupation and Indices of Multiple Deprivation).

RESULTS

Three main themes were identified: (a) Physicians used more humour and small talk in their consultations with high SES patients; (b) Low SES patients were more passive in their participation, engaged in less agenda setting and information-seeking, and framed their clinical experience differently; (c) Low SES patients had different preferences for involvement, defining involvement differently to high SES patients and were seen to take a more stoical approach.

CONCLUSION

Low SES patients take a more passive role in medical consultations, engage in less relational talk and are less likely to raise concerns, but were satisfied with this. Physicians may adapt their communication behaviour in response to low SES patients' expectations and preferences.

PRACTICE IMPLICATIONS

A question prompt list may help low SES patients to raise concerns during their consultations. This may reduce inequalities in communication and health.

High levels of socioeconomic deprivation do not inhibit patients' communication of concerns in head and neck cancer review clinics

To examine associations between socioeconomic status and the extent to which patients with cancer of the head and neck expressed concerns to surgeons during routine follow-up clinics, we analysed audio recordings of 110 consultations with one consultant. We used the Verona Coding Definitions of Emotional Sequences (VRCoDES) to measure communication between the doctor and the patient, and grouped the English indices of multiple deprivation (IMD) 2015 scores into deciles to compare the VRCoDES with socioeconomic status. There were no significant correlations between IMD decile and the number and type of cues and concerns, or the type of response by the consultant, but there was a positive correlation between IMD decile and duration of appointment (r=0.288, p<0.01). When the duration of appointment was controlled for, there was a negative correlation between IMD decile and number of cues and concerns (r=-0.221, p<0.05). These findings question the assumption that socioeconomic status is associated with a patient's willingness to express concerns. Shorter consultations suggest that less time is spent responding to their concerns or building a rapport. Clinicians might find it advantageous to adopt strategies that will improve their understanding of these patients and help them to communicate more effectively.

Inpatient satisfaction with medical information received from caregivers: an observational study on the effect of social deprivation

BACKGROUND

The main objective of this study was to explore the relationships between inpatients' social differentiation and satisfaction with the medical information delivered by caregivers.

METHODS

In four departments of a teaching hospital, patients were enrolled as well as their attending physician and one of the nurses assigned to them. Structured survey questionnaires were administered face-to-face to patients and caregivers. Patients were asked to rate their satisfaction with the medical information received, the quality and duration of the interactions with the caregivers, and their experience regarding their involvement in medical decision-making. Caregivers were asked to rate their perception of the patients' social position and involvement in medical decision-making. Social deprivation was assessed using the EPICES score in particular. The statistical analysis was mainly descriptive and completed by a structural equation model.

RESULTS

A sample of 255 patients, 221 pairs of patient-physician and 235 pairs of patient-nurse were considered. One third of the patients (32.7%) were identified as socially deprived. They were significantly less satisfied with the information they received on their health status or their treatment; 56.7% of patients thought that they received sufficient explanations without having to ask. This proportion was significantly lower in socially deprived patients (42.3%) compared to not deprived patients (63.6%, p < 0.01). Patients' reported involvement in medical decision-making was significantly lower for socially deprived patients (75.0% vs 89.0%, p < 0.001). The structural equation model showed that the main determinant of patients' satisfaction regarding medical information was their perceived involvement in informed medical decision-making (CFI = 0.998, RMSEA = 0.022).

CONCLUSIONS

These findings suggest that physicians and nurses need training on communication targeted towards vulnerable patients, in order to improve the accessibility of medical information, and thus to reduce health inequalities.

Patient-physician concordance and discordance in gynecology: do physicians identify patients' reasons for visit and do patients understand physicians' actions?

OBJECTIVE

To assess physician-patient concordance on reasons for consultation and actions taken during consultation in five different gynecological practices, and to investigate patient and physician factors influencing discordance in reporting.

METHODS

1667 post-encounter questionnaires completed by patients and physicians were compared in terms of reasons for consultation and actions taken during consultation. Patient-physician concordance was assessed using kappa statistics. Multivariable regression analyses served to identify determinants of discordance.

RESULTS

A moderate to high level of patient-physician concordance on reasons for consultation and actions taken during the consultation was found. Discordance regarding reasons for consultation was associated with patient and practice characteristics, discordance regarding actions taken during the consultation only with practice characteristics. Counseling emerged as a particular source of patient-physician discordance.

CONCLUSION

In gynecological practices, discordance depends on the reason or action assessed, but is particularly pronounced when it comes to counseling. The influence of physician characteristics on patient-physician concordance needs more attention in research.

PRACTICE IMPLICATIONS

Gynecologists need to establish a mutual understanding with their patients about the reason of the consultation and the actions taken in the consultation, in particular with regard to counseling.

Is perceived social distance between the patient and the general practitioner related to their disagreement on patient's health status?

OBJECTIVE

To ascertain whether disagreement between patients and general practitioners (GP) on the patient's health status varies according to their respective perceived social distance (PSD).

METHODS

The analysis used the Intermede project's quantitative data collected from 585 patients and 27 doctors via mirrored questionnaires. GPs and patients ranked their own perceived social position (PSP) in society, and their patients' and their GP respectively. PSD was calculated as the PSP's subtraction from the patients' and GPs' assessments.

RESULTS

Disagreement between GPs and patients regarding the patient's health status was associated with PSD by the GP whereas it was not associated with PSD by the patient. In the multilevel analysis, disagreement whereby GPs overestimate patient's health status increased within PSD by the GP: OR:2.9 (95%CI = 1.0-8.6, p = 0.055) for low PSD, OR:3.4 (95%CI = 1.1-10.2, p < 0.05) for moderate PSD and OR:3.8 (95%CI = 1.1-13.1, p < 0.05) for high PSD (reference: no distance).

CONCLUSIONS

Patients perceived with a lower social position by their GP and who consider themselves to have poor health are less likely to be identified in the primary care system.

PRACTICE IMPLICATIONS

Physicians need to be conscious that their own perception influences the quality of the interaction with their patients, potentially resulting in unequal health care trajectories.

The social gradient in doctor-patient communication

OBJECTIVE

In recent years, the importance of social differences in the physician-patient relationship has frequently been the subject of research. A 2002 review synthesised the evidence on this topic. Considering the increasing importance of social inequalities in health care, an actualization of this review seemed appropriate.

METHODS

A systematic search of literature published between 1965 and 2011 on the social gradient in doctor-patient communication. In this review social class was determined by patient's income, education or occupation.

RESULTS

Twenty original research papers and meta-analyses were included. Social differences in doctor-patient communication were described according to the following classification: verbal behaviour including instrumental and affective behaviour, non-verbal behaviour and patient-centred behaviour.

CONCLUSION

This review indicates that the literature on the social gradient in doctor-patient communication that was published in the last decade, addresses new issues and themes. Firstly, most of the found studies emphasize the importance of the reciprocity of communication.Secondly, there seems to be a growing interest in patient's perception of doctor-patient communication.

PRACTICE IMPLICATIONS

By increasing the doctors' awareness of the communicative differences and by empowering patients to express concerns and preferences, a more effective communication could be established.

Use of the BATHE method in the preanesthetic clinic visit

BACKGROUND

In the primary care setting, use of the BATHE (Background, Affect, Trouble, Handling, and Empathy) method of interviewing has been shown to increase patient satisfaction. This technique is a brief psychotherapeutic method used to address patients' physical and psychosocial problems. The BATHE technique has not been evaluated in the perioperative setting as a way of improving patient satisfaction. In this study, we sought to determine whether satisfaction could be enhanced by use of the BATHE technique during the preoperative evaluation by anesthesiologists.

METHODS

Fifty cardiac and 50 general surgery patients were interviewed in the preanesthesia clinic (PAC) of an academic hospital. They were randomly enrolled in the BATHE group or the control group and asked to complete an anonymous satisfaction survey after their visit. This survey was modified from current studies and not validated elsewhere. The relative influence of the BATHE condition was examined as it pertained to interview duration, patient satisfaction, and patient report of the BATHE items being asked.

RESULTS

Ninety-two percent of patients approached by the study group voluntarily enrolled. Patients interviewed using the BATHE method reported being asked about all BATHE questions significantly more often than control patients: t(98)=19.10, P=0.001 (95% confidence interval [CI]=2.59, 3.20). Patients in the BATHE group were more satisfied with their visit to the PAC than those in the control group: t(98)=5.37, P=0.001 (95% CI=0.19, 0.41). The use of the BATHE method did not significantly increase the amount of time physicians spent evaluating patients: t(98)=0.110, P=0.912 (95% CI=-1.519, 1.359).

CONCLUSIONS

Use of the BATHE method in an academic medical center's cardiac and general PAC showed promising results in this preliminary study. A validated and fully developed survey instrument is needed before we can convincingly conclude that the BATHE method is an effective way of improving patient satisfaction.

Do doctors and patients agree on cardiovascular-risk management recommendations post-consultation? The INTERMEDE study

BACKGROUND

Understanding interactions between patients and GPs may be important for optimising communication during consultations and improving health promotion, notably in the management of cardiovascular risk factors.

AIM

To explore the agreement between physicians and patients on the management of cardiovascular risk factors, and whether potential disagreement is linked to the patient's educational level.

DESIGN OF STUDY

INTERMEDE is a cross-sectional study with data collection occurring at GPs' offices over a 2-week period in October 2007 in France.

METHOD

Data were collected from both patients and doctors respectively via pre- and post-consultation questionnaires that were 'mirrored', meaning that GPs and patients were presented with the same questions.

RESULTS

The sample consisted of 585 eligible patients (61% females) and 27 GPs. Agreement between patients and GPs was better for tangible aspects of the consultation, such as measuring blood pressure (κ = 0.84, standard deviation [SD] = 0.04), compared to abstract elements, like advising the patient on nutrition (κ = 0.36, SD = 0.04), and on exercise (κ = 0.56, SD = 0.04). Patients' age was closely related to level of education: half of those without any qualification were older than 65 years. The statistical association between education and agreement between physicians and patients disappeared after adjustment for age, but a trend remained.

CONCLUSION

This study reveals misunderstandings between patients and GPs on the content of the consultation, especially for health-promotion outcomes. Taking patients' social characteristics into account, notably age and educational level, could improve mutual understanding between patients and GPs, and therefore, the quality of care.

Insights into the choice between self-medication and a doctor's prescription: a study of hay fever sufferers

Self-medication plays an increasingly important role in the health care systems of many countries. In the United Kingdom (UK) this is reflected in the current policy of deregulating increasing numbers of prescription-only medicines (POM) to pharmacy medicines (P). The purpose of the work described in this paper was to explore factors affecting clients' choice to self-medicate or to contact their doctor for the treatment of a minor ailment, namely, hay fever. Structured qualitative interviews were conducted with 36 clients recruited through community pharmacies. The main themes investigated were clients' reasons for choosing their particular management option and their attitudes towards the increasing number of OTC medicines and towards self-medication. For clients who obtained the medicine through their doctor, the most common reason for doing so was cost. For clients who obtained their medicine over the counter, the incentive to self-medicate was convenience. Payment for or exemption from prescription charges was a major factor. Many clients mentioned potential risks involved in self-medication and the need for appropriate information. However, clients drew differing conclusions on these issues, reflecting either a negative or a positive attitude towards self-medication.

How well do doctors know their patients? Factors affecting physician understanding of patients' health beliefs

BACKGROUND

An important feature of patient-centered care is physician understanding of their patients' health beliefs and values.

OBJECTIVE

Determine physicians' awareness of patients' health beliefs as well as communication, relationship, and demographic factors associated with better physician understanding of patients' illness perspectives.

DESIGN

Cross-sectional, observational study. RESEARCH PARTICIPANTS: A convenience sample of 207 patients and 29 primary care physicians from 10 outpatient clinics. APPROACH AND MEASURES: After their consultation, patients and physicians independently completed the CONNECT instrument, a measure that assesses beliefs about the degree to which the patient's condition has a biological cause, is the patient's fault, is one the patient can control, has meaning for the patient, can be treated with natural remedies, and patient preferences for a partnership with the physician. Physicians completed the measure again on how they thought the patient responded. Active patient participation (frequency of questions, concerns, acts of assertiveness) was coded from audio-recordings of the consultations. Physicians' answers for how they thought the patient responded to the health belief measure were compared to their patients' actual responses. Degree of physician understanding of patients' health beliefs was computed as the absolute difference between patients' health beliefs and physicians' perception of patients' health beliefs.

KEY RESULTS

Physicians' perceptions of their patients' health beliefs differed significantly (P<0.001) from patients' actual beliefs. Physicians also thought patients' beliefs were more aligned with their own. Physicians had a better understanding of the degree to which patients believed their health conditions had personal meaning (p=0.001), would benefit from natural remedies (p=0.049), were conditions the patient could control (p=0.001), and wanted a partnership with the doctor (p=0.014) when patients more often asked questions, expressed concerns, and stated their opinions. Physicians were poorer judges of patients' beliefs when patients were African-American (desire for partnership) (p=0.013), Hispanic (meaning) (p=0.075), or of a different race (sense of control) (p=0.024).

CONCLUSIONS

Physicians were not good judges of patient's health beliefs, but had a substantially better understanding when patients more actively participated in the consultation. Strategies for increasing physicians' awareness of patients' health beliefs include preconsultation assessment of patients' beliefs, implementing culturally appropriate patient activation programs, and greater use of partnership-building to encourage active patient participation.

Paternalism, participation and partnership - the evolution of patient centeredness in the consultation

OBJECTIVE

There is much discussion at present on the need for a more patient-centered health service. However, it is not always clear what exactly this means for patients or healthcare providers. Furthermore many current trends in healthcare and society may in fact move the consultation further from the patient-centered model. In this article I shall critically review the current state of the consultation.

METHODS

This article is based on a critical review of the literature. I shall firstly outline what is meant by the terms 'patient centeredness' and 'participation'. I shall then examine what wider factors may facilitate or impede effective communication within the consultation.

RESULTS

Patient centeredness and participation is challenged by several factors including the 'co-modification' of healthcare, the information revolution, the tension between choice and continuity, the process of medicalisation, population health strategies and the availability of resources.

CONCLUSION

I will argue that precisely because of these wider trends in society the consultation is now more important than ever as a point of access, communication, understanding and delivery of healthcare.

PRACTICE IMPLICATIONS

The structure and aims of the consultation must be re-visited in the light of the rapid pace of change in service delivery. As such, healthcare professionals may need to advocate for the continuing role of the patient-centered consultation.

["Difficult encounters" in primary care clinic: a patient and doctor perspective]

OBJECTIVES

To find out the prevalence and causes of "difficult encounters" (DE) in Primary Care clinics from the perspective of the patients and doctors, and to whom the responsibility and concordance of the DE (CDE) between doctors and patients is attributed.

DESIGN

Cross-sectional, descriptive.

SETTING

Urban health centre.

PARTICIPANTS AND METHOD

Four doctors, their 4 residents and patients who went to their clinics (March-May 2007). The doctors selected the DE with qualitative criteria, the patients by means of a non-validated ad hoc questionnaire.

VARIABLES

sex and age of the patients, defined DE, causes and responsibility of the DE, changes in doctor due to unease and a perception of a "difficult professional" (DP) by the patient.

RESULTS

There were 415 visits; 352 questionnaires (85% participation); 212 (60.2%) women, mean age (SD) 54.7 (18.2) years. DE prevalence: 8.5% according to doctors (95% CI, 5.8-11.9) (main cause: idiosyncrasy of the patient), the cause of unease always being attributed to the patient; 3.1% according to the patients (95% CI, 1.6-5.5) (main cause: lack of empathy by the doctor), the unease being attributed to the doctor in 81% of cases. CDE insignificant (kappa=0.003). Only 15 patients (4.3%) felt uncomfortable in a visit in the last year; 18 (5.1%) considered a change of doctor due to unease (95% CI, 3.1-8); 53 (15.1%) had changed at some point for this reason (95% CI, 11.3-18.8) and 11 (3.1%) considered their doctor to be DP (95% CI, 1.6-5.5).

CONCLUSIONS

The prevalence of DE in our clinics is similar to that reported in other studies, but lower than expected for the patients, with an insignificant CDE. Doctors and patients usually attribute the responsibility of the DE to the other party. Few patients consider their doctor to be a DP.

Comparison of rural and urban residents' implicit and explicit attitudes related to seeking medical care

CONTEXT

The decision whether or not to consult a physician draws from a variety of attitudes within an individual's health schema. While rural Americans are in greater need of health care, many of them have fewer external resources than urbanites available to them.

PURPOSE

The objective of this study was to elicit implicit and explicit attitudes related to seeking medical treatment for a condition described as fairly serious. Participants were asked to rate how often they comply with treatment regimens and practice good health habits.

METHODS

The sample of rural (N = 586) and urban (N = 433) North Carolina residents was derived based on random-digit dialing. Multiple regression analyses were performed to investigate how attitudes associated with perceived compliance and health behaviors.

FINDINGS

While rural and urban residents offered very similar responses, the associations between attitudes and behaviors were different. One healthy and 2 unhealthy schema patterns emerged. First, fear of hospitals was associated with effective compliance for rural residents and good health habits for urbanites. Second, affordability concerns were ascribed to rural community residents but seemed to reflect personally relevant implicit attitudes since they were associated with poor health adherence and habits for rural residents. Third, mistrust of doctors predicted low adherence for both groups and was also associated with poorer health habits for urbanites. With inconsistencies among implicit and explicit attitudes and behaviors, some residents seemed to be ambivalent about seeking health care.

Socio-economic status of the patient and doctor-patient communication: does it make a difference?

This systematic review, in which 12 original research papers and meta-analyses were included, explored whether patients' socio-economic status influences doctor-patient communication. Results show that patients from lower social classes receive less positive socio-emotional utterances and a more directive and less participatory consulting style, characterised by significantly less information giving, less directions and less socio-emotional and partnership building utterances from their doctor. Doctors' communicative style is influenced by the way patients communicate: patients from higher social classes communicate more actively and show more affective expressiveness, eliciting more information from their doctor. Patients from lower social classes are often disadvantaged because of the doctor's misperception of their desire and need for information and their ability to take part in the care process. A more effective communication could be established by both doctors and patients through doctors' awareness of the contextual communicative differences and empowering patients to express concerns and preferences.

Emotional profile of physicians who interview frequent attenders

Seventy-five physicians at primary health care centers in Spain described their emotions and thoughts during interviews with frequent attenders. Emotion scales were developed by factor and reliability analysis. Positive emotions were associated with younger physician age and with the thought "This patient really needs me." Feelings of lack of control were associated with rural centers and with the thoughts "Oh my God, him/her again!" and "This patient is really a pain." Anxiogenic emotions were associated with greater workload, requests for tests, requests to see the doctor outside regular hours, and the thoughts "Oh my God, him/her again!" and "I think this patient is trying to use me." Guilt feelings were associated with a lower perceived ability to solve the patient's problem, and with a poor physician-patients relationship. Sadness was associated with more frequent referrals to specialists. Awareness and acceptance of their emotions may improve physicians' emotional intelligence and physician-patient relationships.

Doctor-patient communication: a skill needed in saudi arabia

Doctor-patient communication is a skill essential for the satisfaction of the patients' needs and expectations. It involves an art that every practicing physician should have. The situations in health care delivery that demands good doctor-patient communication are many. Diabetes care, the management of hypertension, explaining serious disease diagnoses, prognosis, and investigative procedures are some of the common situations where good doctor-patient communication is very essential. Doctor-patient communication assumes a special status in Saudi Arabia where as a result of mixed ethnicity of the manpower in the health service and the expatriate community, there is a vast diversity of languages, health traditions and beliefs. The skill of doctor-patient communication can be developed and improved by the application of the principles of the patient-centered approach, the utilization of patient-oriented evidence that matters, and its inclusion in the undergraduate curriculum in the first few years of medical school. There should be continuous medical education programs for practicing doctors on the skills of doctor-patient communication through seminars and workshops. This would be a further step towards the improvement of the consumer's well-being.

Predictors of health care seeking for irritable bowel syndrome and nonulcer dyspepsia: a critical review of the literature on symptom and psychosocial factors

OBJECTIVES

Health care use is a costly outcome of the irritable bowel syndrome (IBS) and nonulcer dyspepsia (NUD), but the predictors of this behavior remain poorly defined. We aimed to systematically review the literature to determine which symptoms and psychosocial factors drive health care seeking in these disorders.

METHODS

A broad based MEDLINE and Current Contents search between 1966 and 2000 identified 44 relevant publications. References from these articles were also reviewed.

RESULTS

The literature suggests that symptom severity is an important factor, but only explains a small proportion of the health care seeking behavior associated with these disorders in population-based studies. Psychosocial factors including life event stress, psychological morbidity, personality, abuse and abnormal illness attitudes and beliefs have been found to characterize those that seek help versus those that do not. The role of other psychosocial factors such as social support, coping style and knowledge about illness are as yet undetermined.

CONCLUSIONS

A model for health care seeking for IBS and NUD, with an emphasis on psychosocial factors is presented, but remains to be tested.

Frequent attenders' consulting patterns with general practitioners

BACKGROUND

Despite the growing literature on frequent attendance, little is known about the consulting patterns of frequent attenders with different doctors. To develop appropriate intervention strategies and to improve the clinical care of frequent attenders, a full understanding of these consulting patterns is essential.

AIMS

This paper has three aims: to determine whether frequent attenders consult more with some doctors than others; to determine how many different doctors frequent attenders consult with; and to determine whether frequent attenders exhibit greater continuity of care than non-frequent attenders.

METHOD

Analysis of a validated dataset of 592,028 consultations made by 61,055 patients from four practices over 41 months. Comparisons between the consulting patterns of the frequent attenders, defined as the most frequently consulting 3% of the population by practice, with non-frequent attenders and the overall practice populations.

RESULTS

There was considerable variation in the numbers and proportions of consultations with frequent attenders between individual doctors. Most of the frequent attenders consulted with most or all of the doctors within practices over the timeframe. Frequent attenders exhibited more continuity of care than non-frequent attenders.

CONCLUSION

The reasons why some doctors have more consultations with frequent attenders is unclear. Some doctors may actively encourage frequent attendance. While many frequent attenders have clear allegiances to one doctor, many also consult widely with a large number of doctors. The consequences of such behaviour are unknown. These findings have important implications in the development of appropriate interventions for reducing problematic frequent attendance.

Primary care physician and patient factors that result in patients seeking emergency care in a hospital setting: the patient's perspective

Much has been written about "abuse" and "overutilization" of Emergency Departments (EDs). We undertook to study, from the patient's perspective, physician and patient factors that influence the patient's decision to seek ED care. The study was designed as a convenience cohort, multi-centre survey, conducted in 13 hospitals in the Greater Toronto Area. In our study group of 948, most ambulatory patients (93%) seeking care in an ED have a primary care physician. From the patient's perspective, most (76%) primary care physicians are not educating their patients about which situations warrant ED care and up to 54% are not informing their patients about which services are offered in the office. As many as 55% of patients presented to the ED because it was more convenient. Only a minority (23%) of patients felt their acuity of illness warranted an ED visit. Primary care physicians need to play a stronger role in educating their patients about the utilization of emergency care and the services offered in the office setting.

Lifestyle discussion in the provision of health care. An empirical study of patient-physician interaction

The main issue explored is how patients and physicians communicate about lifestyle in the clinical encounter and what role this talk plays in terms of the outcome of the consultation. The data, collected at two primary health care centers, consist of 42 audiorecorded consultations. The analyses are based on these transcribed dialogues. Our study shows that communication about lifestyle issues is used as a source for determining what health care measures are relevant. Physicians provided a variety of types of information and explicit connections were made between lifestyle and the medical problem by physicians as well as patients. Within the process of reaching decisions on advice or treatment, two forms of interaction appeared referred to here as "paternalism" and "mutuality". In general, the results show that the physicians are very cautious about making explicit medical inferences concerning specific issues of the individual's lifestyle.

Social and economic factors as obstacles to blood pressure control

Further improvement in blood pressure control at the population level will result from dealing with hard-to-solve problems, such as access to care, long-term management of a chronic disease, and societal influences on lifestyle. Additional knowledge and experimental data are needed, reinforced by clear public health choices in this direction.

How do patients' views about medication affect their self-management in asthma?

Successful management of asthma increasingly depends on decisions by patients about when and how to use inhalers and tablets prescribed for their asthma control. Patients with negative attitudes to asthma medication may not be willing to follow their management plan's advice to increase medication when their symptoms worsen. Patients do not always believe their doctors' reassurance about side effects. Although patient dislike of steroid medication is sometimes believed to be the main influence on reluctance to take medication, studies suggest that patients dislike taking any medication regularly. Evidence shows that patients are no more likely to use a combined inhaler regularly than separate steroid and relief inhalers. A proportion of patients with difficult to control asthma follow a chaotic self-management style. Attitudes among these patients may reflect personal styles, and be difficult to change. Among the majority of patients studies now show that patient self-management, and outcomes for patients can be improved by structured behavioural interventions. For most patients attitudes to medication will follow control of symptoms. The experience of successful control by medication, in the ways that patients think are important, are most likely to influence patients in positive attitudes to medication.

The modernisation of general practice in the UK: 1980 to 1995 and beyond. Part I

The UK is unusual in providing universal free healthcare in which access to specialists is largely controlled by general practitioners with 24-hour responsibility, throughout the year, for a defined list of patients of all ages. It is generally considered that this gatekeeper function has contributed to the relatively low cost of the National Health Service, but major changes in the organisation and clinical role of general practitioners have occurred, culminating in a new contract that aims to re-orientate general practice towards health promotion, disease prevention and the management of chronic disease. The implications of these changes are discussed.

The patient perspective. What should a new anti-asthma agent provide?

Patients want medication that they feel confident using and that will control symptoms and be well tolerated. Patients may dislike and use ineffectively some asthma delivery devices such as inhalers, and they may have anxieties about adverse effects of inhaled corticosteroid medication. Oral medication may offer the advantage of improved patient compliance and, in 2 studies, patients have stated a preference for oral medication. However, the introduction of any new medication is likely to arouse anxieties and expectations in patients, and it is important that they be given clear information on medication use and that time be spent discussing any concerns about change. In the general practice consultation, patients are not always able to raise all the issues that are important to them in their asthma management. Asthma clinics staffed by nurses have more time and the opportunity to deal with patient concerns and teach good medication practice. Pharmacists may also have a role to play in patient counselling and giving advice on changes in medication.

Health care sought and received by men with urinary symptoms, and their views on prostatectomy

BACKGROUND

Urinary symptoms are common among middle aged and elderly men.

AIM

A study was undertaken to describe the health care sought by men aged 55 years and over with urinary symptoms, the action taken by general practitioners and urologists, and the men's views on prostatectomy.

METHOD

A postal questionnaire was sent to 516 men aged 55 years and over in the North West Thames Regional Health Authority, with previously identified mild, moderate or severe urinary symptoms.

RESULTS

The response rate among eligible subjects was 83%. Of 420 respondents 45% had seen their general practitioner for their symptoms. General practitioners had referred 62% of these men to a urologist, reassured 21% and prescribed medication to 17%. The probability of a man seeking medical advice increased with increasing symptom severity. In contrast, the decision to refer was independent of symptom severity. Of the men referred to a urologist, the majority (71%) were offered and accepted surgery. The remainder were reassured (17%), or received a prescription (4%). Eight per cent were offered surgery but declined. When presented with details and information on the risks and benefits of prostatectomy, 22% of men with symptoms would probably or definitely refuse treatment, while a further 47% of men were unsure.

CONCLUSION

There are many men who do not seek treatment for urinary symptoms and, of those who do, subsequent referral is not associated with symptom severity. There is scope for improving the referral process through the shared development of guidelines between general practitioners, hospitals and commissioning agencies.

Content and predictors of consultation experiences among Finnish primary care patients

The study focuses on how patients' explanations of their illnesses, their own diagnoses and their expectations are related to their experience of general practice consultations. Before seeing the General Practitioner (GP) on call, 127 Finnish acute health centre patients were interviewed about their interpretation of their symptoms, their explanations for the causes of their illnesses and their expectations of the forthcoming consultations. After seeing the GP they were asked to describe what happened in the consultations and to evaluate their experiences. In the qualitative analysis, the following consultation experiences were found: (1) being treated with holistic approach; (2) enjoyment of support and consolation; (3) receipt of important information; (4) subjection to routine and ritualistic conduct; (5) experience of insecurity and helplessness; and (6) experience of indifference and neglect. Loglinear models for predicting the success of medical consultations showed that 'negative medical consultation' is more likely to happen if: (a) the patient's illness explanation integrates both biomedical and psychosocial models; and (b) there is no match between the patient's own and the doctor's diagnosis.

Patient views on quality care in general practice: literature review

The present paper examines research on patient satisfaction and the factors which influence patient attitudes regarding quality in general practice. Although data are used from U.S. and other sources, conclusions are drawn with a specific focus on a U.K. general practice context. This is a research area with a growing literature, much of it based on unsystematic research. The purpose of this paper is to make a contribution to the process or ordering the data in a manner which will be of utility to those involved in the provision of healthcare and the assessment of that provision. The data suggest conclusions in two broad areas: (1) methods by which patient satisfaction may be assessed; specific published instruments are reviewed, and (2) factors which have been indicated, by the research to date, to influence patient satisfaction. Most consistently identified as being of particular value to patients are interpersonal skills on the part of the practitioner. It is suggested that such techniques should receive wider acknowledgement as a basic element of the practitioner's technical repertoire.

Is personal continuity of care compatible with free choice of doctor? Patients' views on seeing the same doctor

While much has been written about the benefits of personal continuity of care there has been little research about the views of patients. In this cross sectional study 111 patients from three group practices (one of which ran a personal list system) were interviewed at home within a week of consulting a general practitioner. Patients were selected randomly from a systematic series of consulting sessions and a semi-structured interview was administered. Patients receiving more personal continuity of care were likely to be older, to have booked their most recent appointment further in advance, to desire personal continuity of care, to have an external health locus of control and to have a lower extroversion score. In the practice with a personal list, patients had a high level of continuity of care, were satisfied and showed little interest in having a choice of doctor. In the combined list practices patients valued their choice of doctor but often could not exercise it enough and they were more critical. They made more suggestions for change than those in the practice with a personal list system, mostly about receptionists and appointments. It is concluded that most patients like to see the same doctor, but they may not be willing to wait two days for this if there is a quicker option. It may be difficult to deliver both personal continuity of care and choice in group practice.

An evaluation of early patient contact for medical students

The introduction of early patient contact for first-year medical students in the form of talking with a patient at an out-patient clinic was evaluated. The aim of the session was to give students an insight into the patient's view of the illness and treatment, and the effect of the condition on his or her lifestyle. Students found the visit useful and enjoyable. Students were asked to complete an evaluation questionnaire after the visit. Students said that they had learned a variety of things from the visit. These included: how it felt to be a patient (27%); the need to communicate clearly (23%); about doctor-patient interaction (23%); and the effect of illness on the patient (16%). Students also said that they would like to remember things from the visit to put into practice later on, particularly concerning the area of communication. The visit appeared to be a successful integration of preclinical and clinical disciplines.