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Baumgardner DJ. A Watched Pot Never Boils: Attentive Care Needs No Timer. J Patient Cent Res Rev 2021; 8:5-7. [PMID: 33511248 PMCID: PMC7834172 DOI: 10.17294/2330-0698.1827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Dennis J Baumgardner
- Department of Family Medicine, Aurora UW Medical Group, Advocate Aurora Health, Milwaukee, WI
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Keller S, Dy S, Wilson R, Dukhanin V, Snyder C, Wu A. Selecting Patient-Reported Outcome Measures to Contribute to Primary Care Performance Measurement: a Mixed Methods Approach. J Gen Intern Med 2020; 35:2687-2697. [PMID: 32495096 PMCID: PMC7459066 DOI: 10.1007/s11606-020-05811-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/17/2020] [Indexed: 01/11/2023]
Abstract
New models of primary care include patient-reported outcome measures (PROMs) to promote patient-centered care. PROMs provide information on patient functional status and well-being, can be used to enhance care quality, and are proposed for use in assessing performance. Our objective was to identify a short list of candidate PROMs for use in primary care practice and to serve as a basis for performance measures (PMs). We used qualitative and quantitative methods to identify relevant patient-reported outcome (PRO) domains for use in performance measurement (PRO-PM) and their associated PROMs. We collected data from key informant groups: patients (n = 13; one-on-one and group interviews; concept saturation analysis), clinical thought leaders (n = 9; group discussions; thematic analysis), primary care practices representatives (n = 37; six focus groups; thematic analysis), and primary care payer representatives (n = 10; 12-question survey; frequencies of responses). We merged the key informant group information with findings from environmental literature scans. We conducted a targeted evidence review of measurement properties for candidate PROMs. We used a scoping review and key informant groups to identify PROM evaluation criteria, which were linked to the National Quality Forum measure evaluation criteria. We developed a de novo schema to score candidate PROMs against our criteria. We identified four PRO domains and 10 candidate PROMs: 3 for depressive symptoms, 2 for physical function, 3 for self-efficacy, 2 for ability to participate. Five PROMs met ≥ 70% of the evidence criteria for three PRO domains: PHQ-9 or PROMIS Depression (depression), PF-10 or PROMIS-PF (physical functioning), and PROMIS Self-Efficacy for Managing Treatments and Medications (self-efficacy). The PROMIS Ability to Participate in Social Roles and Activities met 68% of our criteria and might be considered for inclusion. Existing evidence and key informant data identified 5 candidate PROMs to use in primary care. These instruments can be used to develop PRO-PMs.
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Affiliation(s)
- San Keller
- American Institutes for Research in the Behavioral and Social Sciences, Chapel Hill, NC, USA.
| | - Sydney Dy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Renee Wilson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Vadim Dukhanin
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Claire Snyder
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Albert Wu
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Johns Hopkins School of Medicine, Baltimore, MD, USA
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Using eVisit to Reduce Patient Referrals to Clinics and Physician Offices: A Safe Way for Controlling COVID-19 Outbreak. HEALTH SCOPE 2020. [DOI: 10.5812/jhealthscope.103769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Organizational Influences on Time Pressure Stressors and Potential Patient Consequences in Primary Care. Med Care 2019; 56:822-830. [PMID: 30130270 PMCID: PMC6402989 DOI: 10.1097/mlr.0000000000000974] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary care teams face daily time pressures both during patient encounters and outside of appointments. OBJECTIVES We theorize 2 types of time pressure, and test hypotheses about organizational determinants and patient consequences of time pressure. RESEARCH DESIGN Cross-sectional, observational analysis of data from concurrent surveys of care team members and their patients. SUBJECTS Patients (n=1291 respondents, 73.5% response rate) with diabetes and/or coronary artery disease established with practice teams (n=353 respondents, 84% response rate) at 16 primary care sites, randomly selected from 2 Accountable Care Organizations. MEASURES AND ANALYSIS We measured team member perceptions of 2 potentially distinct time pressure constructs: (1) encounter-level, from 7 questions about likelihood that time pressure results in missing patient management opportunities; and (2) practice-level, using practice atmosphere rating from calm to chaotic. The Patient Assessment of Chronic Illness Care (PACIC-11) instrument measured patient-reported experience. Multivariate logistic regression models examined organizational predictors of each time pressure type, and hierarchical models examined time pressure predictors of patient-reported experiences. RESULTS Encounter-level and practice-level time pressure measures were not correlated, nor predicted by the same organizational variables, supporting the hypothesis of two distinct time pressure constructs. More encounter-level time pressure was most strongly associated with less health information technology capability (odds ratio, 0.33; P<0.01). Greater practice-level time pressure (chaos) was associated with lower PACIC-11 scores (odds ratio, 0.74; P<0.01). CONCLUSIONS Different organizational factors are associated with each forms of time pressure. Potential consequences for patients are missed opportunities in patient care and inadequate chronic care support.
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Kumar A, Singh K, Krishnamurthy K, Nielson AL. Exploring the Role of the Public and Private Funded Primary Health Care Facilities for Children in a Pluralistic Health Care Setting of Barbados: One of the English Caribbean Countries. Int J Prev Med 2015; 6:106. [PMID: 26682029 PMCID: PMC4671166 DOI: 10.4103/2008-7802.169073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 07/31/2015] [Indexed: 11/29/2022] Open
Abstract
Background: The major objectives of this study were to evaluate the existing primary health care service provisions in the public and private sector and utilization of the services, and to assess the existing manpower and material resources. Methods: Data were collected through interviews with the primary health care providers. Data were also collected from the records maintained at the polyclinics and the Ministry of Health Statistics. An analysis and discussion of all the available data was conducted to develop a comprehensive primary health care service utilization and resources inventory at the polyclinics. Similar data were collected from the primary care providers in the private sector. Results: In the public sector, there are 8 polyclinics that provide primary health care to the children. All the polyclinics have immunization services and curative acute care. Some of the polyclinics have a range of services, including dental care, eye care, and rehabilitative care services that common to both adults and children. In the private sector, primary health care is delivered through the 76 private office and of the individual physicians and 11 grouped private practices. All of the private offices and group practices have curative acute care for children and some of the offices have immunization services. Over all 87.5% of all the immunizations were done at the polyclinics. Over all 60.1% of acute care visits were to the private sector and 39.9% to the public sector. In the public sector, 59.5% were under 5 years children while 40.5% were 5 years or older. The corresponding figures in the private care settings were 80.9% and 11.9%. Conclusions: The findings demonstrate the complimentary role of the public and the private sector in the primary health care of children in this country. While the private sector has a major role in the curative acute care of children, the public sector plays a pivotal role in the immunization services.
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Affiliation(s)
- Alok Kumar
- Faculty of Medical Sciences, The University of the West Indies and the Queen Elizabeth Hospital, Barbados
| | - Keerti Singh
- Faculty of Medical Sciences, The University of the West Indies and the Queen Elizabeth Hospital, Barbados
| | - Kandamaran Krishnamurthy
- Faculty of Medical Sciences, The University of the West Indies and the Queen Elizabeth Hospital, Barbados
| | - Anders L Nielson
- Faculty of Medical Sciences, The University of the West Indies and the Queen Elizabeth Hospital, Barbados
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Brown P, Elston MA, Gabe J. From patient deference towards negotiated and precarious informality: An Eliasian analysis of English general practitioners' understandings of changing patient relations. Soc Sci Med 2015; 146:164-72. [PMID: 26517293 DOI: 10.1016/j.socscimed.2015.10.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 10/18/2015] [Accepted: 10/19/2015] [Indexed: 11/24/2022]
Abstract
This article contributes to sociological debates about trends in the power and status of medical professionals, focussing on claims that deferent patient relations are giving way to a more challenging consumerism. Analysing data from a mixed methods study involving general practitioners in England, we found some support for the idea that an apparent 'golden age' of patient deference is receding. Although not necessarily expressing nostalgia for such doctor-patient relationships, most GPs described experiencing disruptive or verbally abusive interactions at least occasionally and suggested that these were becoming more common. Younger doctors tended to rate patients as less respectful than their older colleagues but were also more likely to be egalitarian in attitude. Our data suggest that GPs, especially younger ones, tend towards a more informal yet limited engagement with their patients and with the communities in which they work. These new relations might be a basis for mutual respect between professionals and patients in the consulting room, but may also generate uncertainty and misunderstanding. Such shifts are understood through an Eliasian framework as the functional-democratisation of patient-doctor relations via civilising processes, but with this shift existing alongside decivilising tendencies involving growing social distance across broader social figurations.
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Affiliation(s)
- Patrick Brown
- Department of Sociology & Centre for Social Science and Global Health, University of Amsterdam, PO Box 15508, 1001 NA Amsterdam, The Netherlands.
| | - Mary Ann Elston
- Centre for Criminology and Sociology, Royal Holloway (University of London), Egham, Surrey TW20 0EX, UK.
| | - Jonathan Gabe
- Centre for Criminology and Sociology, Royal Holloway (University of London), Egham, Surrey TW20 0EX, UK.
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Griffiths M. Creating the Hybrid Workforce: Challenges and Opportunities. J Med Imaging Radiat Sci 2015; 46:262-270. [PMID: 31052132 DOI: 10.1016/j.jmir.2015.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Marc Griffiths
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK.
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Schattner A. Determining the 'point of change' in the patient's history-the delta rule. INTERNATIONAL JOURNAL OF MEDICAL EDUCATION 2015; 6:63-64. [PMID: 26003914 PMCID: PMC4442010 DOI: 10.5116/ijme.554f.858b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Accepted: 05/10/2015] [Indexed: 06/04/2023]
Affiliation(s)
- Ami Schattner
- Hebrew University Hadassah Medical School, Jerusalem, Israel
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Women Empowerment through Health Information Seeking: A Qualitative Study. INTERNATIONAL JOURNAL OF COMMUNITY BASED NURSING AND MIDWIFERY 2015; 3:105-15. [PMID: 26005690 PMCID: PMC4441348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/04/2015] [Accepted: 02/14/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Today, women empowering is an important issue. Several methods have been introduced to empower women. Health information seeking is one of the most important activities in this regard. A wide range of capabilities have been reported as outcomes of health information seeking in several studies. As health information seeking is developed within personal-social interactions and also the health system context, it seems that the qualitative paradigm is appropriate to use in studies in this regard. This study aimed to explore how women's empowerment through health information seeking is done. METHODS In this qualitative content analysis study, data collection was done with regard to inclusion criteria, through purposive sampling by semi-structured interviews with 17 women and using documentation and field notes until data saturation. Qualitative data analysis was done constantly and simultaneous with data collection. RESULTS Four central themes were emerged to explain women's empowerment through health information seeking that included: a) Health concerns management with three subcategories of Better coping, Stress management, Control of situation, b) Collaborative care with two subcategories of Effective interaction with health professions and Participation in health decision making c) Individual development d) Self-protection with four sub- categories of Life style modification, Preventive behaviors promoting, Self-care promoting, and medication adherence. CONCLUSION The results of this study indicate the importance of women empowerment through foraging their health information seeking rights and comprehensive health information management.
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Tarn DM, Wenger A, Good JS, Hoffing M, Scherger JE, Wenger NS. Do physicians communicate the adverse effects of medications that older patients want to hear? DRUGS & THERAPY PERSPECTIVES 2014; 31:68-76. [PMID: 25750513 DOI: 10.1007/s40267-014-0176-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Physicians routinely discuss adverse effects of medications, but whether discussions match older patients' desire for information is unexplored. This study compares patient preferences for adverse effect discussions with reported physician practice. METHODS Cross-sectional survey of a convenience sample of 100 practicing primary care physicians from 9 medical groups and 178 patients recruited from 11 senior centers in the Los Angeles metropolitan area. Physicians listed the adverse effects they typically discuss when prescribing an ACE inhibitor. Patients were given a hypothetical scenario about a new medication prescription, and were asked to circle the three adverse effects they most wanted to hear about from a list. RESULTS More than 90 % of patients wanted a physician to discuss medication adverse effects: they wanted information about both dangerous (75 % of patients) and common (66 % of patients) adverse effects. However, patients most commonly chose to hear about adverse effects occurring for < 1 % of patients and selected a wide range of adverse effects for discussion. Physicians reported most frequently educating patients about more common and life-threatening adverse effects. Patients who wanted to discuss more adverse effects were more worried about adverse effects than those wishing to hear fewer (4.0 vs. 3.4 on a 5-point Likert scale; p = 0.02). CONCLUSIONS For the studied medication, there was little concordance between the medication adverse effects physicians say they discuss and what patients want to hear. Physicians cannot practically verbally satisfy patients' information desires about the adverse effects of new medications during time-compressed office visits. Innovative solutions are needed.
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Affiliation(s)
- Derjung M Tarn
- Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, CA
| | - Ariela Wenger
- Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, CA
| | - Jeffrey S Good
- Department of Communication and Rhetorical Studies, Syracuse University, Syracuse, NY
| | | | - Joseph E Scherger
- Eisenhower Medical Center, Eisenhower Argyros Health Center, La Quinta, CA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA
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Kaltsa A, Holloway A, Cox K. Factors that influence mammography screening behaviour: A qualitative study of Greek women's experiences. Eur J Oncol Nurs 2013; 17:292-301. [DOI: 10.1016/j.ejon.2012.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 07/19/2012] [Accepted: 08/03/2012] [Indexed: 11/29/2022]
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Lamiani G, Barello S, Browning DM, Vegni E, Meyer EC. Uncovering and validating clinicians' experiential knowledge when facing difficult conversations: a cross-cultural perspective. PATIENT EDUCATION AND COUNSELING 2012; 87:307-312. [PMID: 22196987 DOI: 10.1016/j.pec.2011.11.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Revised: 10/07/2011] [Accepted: 11/26/2011] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To explore clinicians' experiential knowledge when conducting difficult conversations; and to verify if experiential knowledge is culturally based. METHOD Data were collected in Italy and the United States during the Program to Enhance Relational and Communication Skills (PERCS) workshops. At the beginning of each workshop, during a whiteboard exercise, clinicians shared the strategies they had found helpful in difficult conversations. The strategies were analyzed in each country through content analysis. Upon completion of this primary analysis, the themes identified within each country were synthesized into second-order themes by means of aggregated concept analysis. RESULTS We conducted 14 Italian and 12 American PERCS-workshops enrolling a total of 304 clinicians. The suggestions that were similar across both countries were related to: organizational aspects and setting preparation; communication and relational skillfulness; clinician mindfulness; interpersonal qualities and sensibilities; and teamwork and care coordination. Additionally, US participants identified attention to cultural differences as a helpful strategy. CONCLUSION Clinicians can access relational strategies, tied to their experience, that are typically unrecognized in medical education. The whiteboard exercise is an effective teaching tool to uncover and validate already-existing relational knowledge. PRACTICE IMPLICATIONS Communication training programs can foster clinicians' sense of preparation by building upon their already-existing knowledge.
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Affiliation(s)
- Giulia Lamiani
- Department of Medicine, Surgery and Dentistry, University of Milan, Milan, Italy.
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Tarn DM, Mattimore TJ, Bell DS, Kravitz RL, Wenger NS. Provider views about responsibility for medication adherence and content of physician-older patient discussions. J Am Geriatr Soc 2012; 60:1019-26. [PMID: 22646818 DOI: 10.1111/j.1532-5415.2012.03969.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate provider opinions about responsibility for medication adherence and examine physician-patient interactions to illustrate how adherence discussions are initiated. DESIGN Focus group discussions with healthcare providers and audio taped outpatient office visits with a separate group of providers. SETTING Focus group participants were recruited from multispecialty practice groups in New Jersey and Washington, District of Columbia. Outpatient office visits were conducted in primary care offices in Northern California. PARTICIPANTS Twenty-two healthcare providers participated in focus group discussions. One hundred patients aged 65 and older and 28 primary care physicians had their visits audio taped. MEASUREMENTS Inductive content analysis of focus groups and audio taped encounters. RESULTS Focus group analyses indicated that providers feel responsible for assessing medication adherence during office visits and for addressing mutable factors underlying nonadherence, but they also believed that patients were ultimately responsible for taking medications and voiced reluctance about confronting patients about nonadherence. The 100 patients participating in audio taped encounters were taking a total of 410 medications. Of these, 254 (62%) were discussed in a way that might address adherence; physicians made simple inquiries about current patient medication use for 31.5%, but they made in-depth inquiries about adherence for only 4.3%. Of 39 identified instances of nonadherence, patients spontaneously disclosed 51%. CONCLUSION The lack of intrusive questions about medication taking during office visits may reflect poor provider recognition of the questions needed to assess adherence fully. Alternatively, provider beliefs about patient responsibility for adherence may hinder detailed queries. A paradigm of joint provider-patient responsibility may be needed to better guide discussions about medication adherence.
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Affiliation(s)
- Derjung M Tarn
- Department of Family Medicine, David Geffen School of Medicine at UCLA, 10880 Wilshire Blvd., Suite 1800, Los Angeles, CA 90024, USA.
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Abstract
INTRODUCTION Inappropriate nonsteroidal anti-inflammatory drug (NSAID) use can occur by using more than one prescription or over-the-counter NSAID or exceeding the manufacturer's recommended dosage. There are risks associated with inappropriate NSAID use; however, the prevalence and predictors of inappropriate NSAID use are unknown. The study objectives are to estimate the prevalence of inappropriate NSAID use and identify characteristics associated with inappropriate use. METHODS We identified 6877 patients at 2 Veterans Affairs Medical Centers through pharmacy records who filled 3 or more NSAID prescriptions in 6 months. We randomly selected 2535 patients and mailed them a survey about NSAIDs, gastroprotective medications, gastrointestinal (GI) symptoms, and pain. Inappropriate NSAID users either took 2 or more NSAIDs for 3 days or more or exceeded the maximum daily recommended dosage of 1 or more NSAID in the past week. Data were also collected from medical records. RESULTS Approximately 1572 patients (62%) returned the survey, and 1250 reported NSAID use in the past week. Approximately 32% (n = 400) used NSAIDs inappropriately, including taking 2 or more NSAIDs (n = 173), exceeding the highest daily recommended dosage (n = 161) or both (n = 66). Being a minority (odds ratio = 1.62, P < 0.001) and having an income of $20,000 (odds ratio = 1.70, P < 0.001) or lesser both predicted inappropriate NSAID use. Inappropriate NSAID use was associated with more GI symptoms (β = 0.57, P < 0.001) and higher levels of pain (β = 0.85, P < 0.001). CONCLUSIONS Inappropriate NSAID use is prevalent. Providers should consider counseling all patients about NSAID use, especially patients with GI problems or pain problems.
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Effectiveness of intensive physician training in upfront agenda setting. J Gen Intern Med 2011; 26:1317-23. [PMID: 21735348 PMCID: PMC3208461 DOI: 10.1007/s11606-011-1773-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Revised: 05/31/2011] [Accepted: 06/06/2011] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients want all their concerns heard, but physicians fear losing control of time and interrupt patients before all concerns are raised. OBJECTIVE We hypothesized that when physicians were trained to use collaborative upfront agenda setting, visits would be no longer, more concerns would be identified, fewer concerns would surface late in the visit, and patients would report greater satisfaction and improved functional status. DESIGN AND PARTICIPANTS Post-only randomized controlled trial using qualitative and quantitative methods. Six months after training (March 2004-March 2005) physician-patient encounters in two large primary care organizations were audio taped and patients (1460) and physicians (48) were surveyed. INTERVENTION Experimental physicians received training in upfront agenda setting through the Establishing Focus Protocol, including two hours of training and two hours of coaching per week for four consecutive weeks. MAIN MEASURES Outcomes included agenda setting behaviors demonstrated during the early, middle, and late encounter phases, visit length, number of raised concerns, patient and physician satisfaction, trust and functional status. KEY RESULTS Experimental physicians were more likely to make additional elicitations (p < 0.01) and their patients were more likely to indicate agenda completion in the early phase of the encounter (p < 0.01). Experimental group patients and physicians raised fewer concerns in the late encounter phase (p < 0.01). There were no significant differences in visit length, total concerns addressed, patient or provider satisfaction, or patient trust and functional status CONCLUSION Collaborative upfront agenda setting did not increase visit length or the number of problems addressed per visit but may reduce the likelihood of "oh by the way" concerns surfacing late in the encounter. However, upfront agenda setting is not sufficient to enhance patient satisfaction, trust or functional status. Training focused on physicians instead of teams and without regular reinforcement may have limited impact in changing visit content and time use.
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Waterworth S, Gott M, Raphael D, Barnes S. Older people with heart failure and general practitioners: temporal reference frameworks and implications for practice. HEALTH & SOCIAL CARE IN THE COMMUNITY 2011; 19:412-419. [PMID: 21324024 DOI: 10.1111/j.1365-2524.2010.00984.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The aim of the study was to identify the time experiences of older patients and general practitioners (GPs). Secondary analysis of qualitative data collected from two longitudinal studies, one in the United Kingdom (UK) and the other in New Zealand (NZ), was carried out. The UK study involved interviews with 44 older people with heart failure and nine focus group discussions with primary health professionals during 2004-2005. The NZ study involved 79 interviews with 25 older people with heart failure and 30 telephone interviews with GPs during 2008-2009. Temporal reference frameworks function as background expectations and influence how patients and GPs experienced time and act as time controls. The key themes identified were: clock time was evident in how it structured the consultations; both patients and GPs valued needing time and for some GPs this involved creating space for emotional time. There were also tensions between needing time and wasting time; being known over time was important to both patients and GPs. For older people with heart failure improving their quality of care is essential and time is integral to this, not only the clock time and length of consultations. Identifying temporal reference frameworks provides an understanding that there are multiple times and exposes the influence of these in the lives of both the older people and GPs.
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Elder KT, Wiltshire JC, Rooks RN, Belue R, Gary LC. Health information technology and physician career satisfaction. PERSPECTIVES IN HEALTH INFORMATION MANAGEMENT 2010; 7:1d. [PMID: 20808606 PMCID: PMC2921302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
PURPOSE Health information technology (HIT) and physician career satisfaction are associated with higher-quality medical care. However, the link between HIT and physician career satisfaction, which could potentially reduce provider burnout and attrition, has not been fully examined. This study uses a nationally representative survey to assess the association between key forms of HIT and career satisfaction among primary care physicians (PCPs) and specialty physicians. METHODS We performed a retrospective, cross-sectional analysis of physician career satisfaction using the Community Tracking Study Physician Survey, 2004-2005. Nine specific types of HIT as well as the overall adoption of HIT in the practice were examined using multivariate logistic regression. RESULTS Physicians who used five to six (odds ratio [OR] = 1.46) or seven to nine (OR = 1.47) types of HIT were more likely than physicians who used zero to two types of HIT to be "very satisfied" with their careers. Information technology usages for communicating with other physicians (OR = 1.31) and e-mailing patients (OR = 1.35) were positively associated with career satisfaction. PCPs who used technology to write prescriptions were less likely to report career satisfaction (OR = 0.67), while specialists who wrote notes using technology were less likely to report career satisfaction (OR = 0.75). CONCLUSIONS Using more information technology was the strongest positive predictor of physicians being very satisfied with their careers. Toward that end, healthcare organizations working in conjunction with providers should consider exploring ways to integrate various forms of HIT into practice.
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Affiliation(s)
- Keith T Elder
- School of Health Professions, University of Alabama, Birmingham, AL, USA
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Verrier W, Harvey J. An investigation into work related stressors on diagnostic radiographers in a local district hospital. Radiography (Lond) 2010. [DOI: 10.1016/j.radi.2009.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Becker G, Kempf DE, Xander CJ, Momm F, Olschewski M, Blum HE. Four minutes for a patient, twenty seconds for a relative - an observational study at a university hospital. BMC Health Serv Res 2010; 10:94. [PMID: 20380725 PMCID: PMC2907756 DOI: 10.1186/1472-6963-10-94] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Accepted: 04/09/2010] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In the modern hospital environment, increasing possibilities in medical examination techniques and increasing documentation tasks claim the physicians' energy and encroach on their time spent with patients. This study aimed to investigate how much time physicians at hospital wards spend on communication with patients and their families and how much time they spend on other specific work tasks. METHODS A non-participatory, observational study was conducted in thirty-six wards at the University Medical Center Freiburg, a 1700-bed academic hospital in Germany. All wards belonging to the clinics of internal medicine, surgery, radiology, neurology, and to the clinic for gynaecology took part in the study. Thirty-four ward doctors from fifteen different medical departments were observed during a randomly chosen complete work day. The Physicians' time for communication with patients and relatives and time spent on different working tasks during one day of work were assessed. RESULTS 374 working hours were analysed. On average, a physician's workday on a university hospital ward added up to 658.91 minutes (10 hrs 58 min; range 490 - 848 min). Looking at single items of time consumption on the evaluation sheet, discussions with colleagues ranked first with 150 minutes on average. Documentation and administrative requirements took an average time of 148 minutes per day and ranked second. Total time for communication with patients and their relatives was 85 minutes per physician and day. Consequently, the available time for communication was 4 minutes and 17 seconds for each patient on the ward and 20 seconds for his or her relatives. Physicians assessed themselves to communicate twice as long with patients and sevenfold with relatives than they did according to this study. CONCLUSIONS Workload and time pressure for physicians working on hospital wards are high. To offer excellent medical treatment combined with patient centred care and to meet the needs of patients and relatives on hospital wards, physicians should be given more time to focus on core clinical tasks. Time and health care management solutions to minimize time pressure are required. Further research is needed to assess quality of communication in hospital settings.
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Affiliation(s)
- Gerhild Becker
- Department of Internal Medicine II, University Medical Center Freiburg, Freiburg, Germany
- Palliative Care Research Group, University Medical Center Freiburg, Freiburg, Germany
| | - Dorothee E Kempf
- Palliative Care Research Group, University Medical Center Freiburg, Freiburg, Germany
| | - Carola J Xander
- Department of Internal Medicine II, University Medical Center Freiburg, Freiburg, Germany
- Palliative Care Research Group, University Medical Center Freiburg, Freiburg, Germany
| | - Felix Momm
- Palliative Care Research Group, University Medical Center Freiburg, Freiburg, Germany
- Department of Radiotherapy, University Medical Center Freiburg, Freiburg, Germany
| | - Manfred Olschewski
- Department of Medical Biometry and Statistics, University Medical Center Freiburg, Freiburg, Germany
| | - Hubert E Blum
- Department of Internal Medicine II, University Medical Center Freiburg, Freiburg, Germany
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Here's my phone number, don't call me: physician accessibility in the cell phone and e-mail era. Dig Dis Sci 2010; 55:662-7. [PMID: 20101461 DOI: 10.1007/s10620-009-1089-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 12/03/2009] [Indexed: 12/17/2022]
Abstract
Physician accessibility, for example how available a doctor should be by cell phone or e-mail is an important issue that is not well understood. There can be large differences between the expectations of patients and the perspective of their providers. The rationale for providing accessibility has historical roots and relates to the very basis of the physician-patient relationship and the effects on patient outcomes. While patients may want this line of communication, physicians may worry about disruption from unexpected phone calls, being requested to provide advice without access to records and providing services without adequate remuneration among other concerns. Herein, we discuss the rationale for these concerns, and provide suggestions on how we might overcome them. We suggest a framework with guidelines on establishing and maintaining remote accessibility with patients in the context of a productive physician-patient relationship.
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It's about time: physicians' perceptions of time constraints in primary care medical practice in three national healthcare systems. Med Care 2010; 48:95-100. [PMID: 20057331 DOI: 10.1097/mlr.0b013e3181c12e6a] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As physicians are pressured to deliver an increasing number of preventive services, follow guidelines, engage in evidence-based practice, and deliver patient-centered care in managerially driven organizations, they struggle with how much control they have over their time. METHODS A secondary analysis was conducted with data from 3 parallel studies of clinical decision making in Germany, the United Kingdom, and the United States with 128 physicians per country. Physicians reported how much time they were allocated and how much time they needed for high-quality care for new patient appointments, routine consultations, and complete physicals. They also reported how much control they had over their time in the office and spending adequate time with patients. RESULTS German, British, and American physicians were allocated (on average) 16/11/32 minutes for a new patient appointment, 6/10/18 minutes for a routine visit, and 12/20/36 minutes for a complete physical, but felt that they needed more time. Over half of German and American physicians felt that they always or usually had control over the hours they were required to be in their office or spending sufficient time with their patients while less than half of British physicians felt this way. CONCLUSION German physicians had the least time allocated and needed for most types of appointment. American physicians had the most time allocated and needed for each type of appointment. However, British physicians felt they had the least control over time in their office and spending sufficient time with patients.
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Mechanic D. Rethinking medical professionalism: the role of information technology and practice innovations. Milbank Q 2008; 86:327-58. [PMID: 18522615 DOI: 10.1111/j.1468-0009.2008.00523.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
CONTEXT Physician leaders and the public have become increasingly concerned about the erosion of medical professionalism. Changes in the organization, economics, and technology of medical care have made it difficult to maintain competence, meet patients' expectations, escape serious conflicts of interest, and distribute finite resources fairly. Information technology (IT), electronic health records (EHRs), improved models of disease management, and new ways of relating to and sharing responsibility for patients' care can contribute to both professionalism and quality of care. METHODS The potential of IT, EHRs, and other practice facilitators for professionalism is assessed through diverse but relevant literatures, examination of relevant websites, and experience in working with medical leaders on renewing professionalism. FINDINGS IT and EHRs are the basis of needed efforts to reinforce medical competence, improve relationships with patients, implement disease management programs, and, by increasing transparency and accountability, help reduce some conflicts of interest. Barriers include the misalignment of goals with payment incentives and time pressures in meeting patients' expectations and practice demands. Implementing IT and EHRs in small, dispersed medical practices is particularly challenging because of short-term financial costs, disruptions in practice caused by learning and adaptation, and the lack of confidence in needed support services. Large organized systems like the VA, Kaiser Permanente, and general practice in the United Kingdom have successfully overcome such challenges. CONCLUSIONS IT and the other tools examined in this article are important adjuncts to professional capacities and aspirations. They have potential to help reverse the decline of primary care and make physicians' practices more effective and rewarding. The cooperation, collaboration, and shared responsibility of government, insurers, medical organizations, and physicians, as well as financial and technical support, are needed to implement these tools in the United States' dispersed and fragmented medical care system.
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Affiliation(s)
- David Mechanic
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ 08901, USA.
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Tarn DM, Paterniti DA, Kravitz RL, Heritage J, Liu H, Kim S, Wenger NS. How much time does it take to prescribe a new medication? PATIENT EDUCATION AND COUNSELING 2008; 72:311-319. [PMID: 18406562 PMCID: PMC2582184 DOI: 10.1016/j.pec.2008.02.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Revised: 12/19/2007] [Accepted: 02/17/2008] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To measure the length of time spent discussing all aspects of new prescriptions and guideline-recommended aspects of counseling, and to evaluate factors associated with duration of discussion. METHODS We analyzed tape recordings in which 181 patients received 234 new medication prescriptions from 16 family physicians, 18 internists, and 11 cardiologists in 2 healthcare systems in Sacramento, California between January and November 1999. RESULTS Of the mean total visit time of 15.9min (S.D.=434s), a mean of 26s (S.D.=28s) was allocated to guideline-recommended components and a mean of 23s (S.D.=25s) was allocated to discussion of all other aspects of new prescription medications. The majority of time spent discussing individual new prescriptions was dedicated to: medication purpose or justification, directions and duration of use, and side effects. On average, more complete discussion of these components was associated with more time. More time was spent talking about guideline-recommended information if patients were in better health, if there was a third party in the room, and if the medication belonged to a psychiatric, compared to an ear, nose, throat medication class. Less time was spent discussing over-the-counter (OTC) medications and those prescribed to patients with a previous visit to the physician. CONCLUSION Higher quality information transmission between physicians and patients about new medications requires more time, and may be difficult to achieve in short office visits. PRACTICE IMPLICATIONS Time-compressed office visits may need to be redesigned to promote improved provider-patient communication about new medications.
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Affiliation(s)
- Derjung M Tarn
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90024, USA.
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Lado E, Vacariza M, Fernández-González C, Gestal-Otero JJ, Figueiras A. Influence exerted on drug prescribing by patients' attitudes and expectations and by doctors' perception of such expectations: a cohort and nested case-control study. J Eval Clin Pract 2008; 14:453-9. [PMID: 18373568 DOI: 10.1111/j.1365-2753.2007.00901.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Although demand for medication is regarded as one of the most important factors in pharmaceutical expenditure, little is known about patients' influence on drug prescribing. This study assesses the influence exerted on drug prescribing by patients' attitudes and expectations, and by doctors' perception of such expectations. METHOD We conducted a population-based cohort study covering 937 subjects attending a health centre in the northwest of Spain. Prescription-drug advertising directly targeted at patients is banned in Spain. We conducted home-based interviews at the start of follow-up to assess patients' attitudes, and monthly telephone interviews during the 1-year follow-up period to assess consumption of medical drugs and medical visits. Using nested case-control study covering 127 of the cohort subjects who attended the health centre, we assessed patients' pre-consultation expectations for prescriptions, doctors' perception of such patients' expectations, and the drugs actually prescribed. RESULTS Of the total sample, 69.3% answered the home-based questionnaire, 77.6% completed 11 or more months of follow-up, and 100% of cohort subjects who attended the health centre responded to the pre-consultation survey conducted in the waiting room. Patients' attitudes, though not associated with prescription (P > 0.1), were, however, associated with demand for medical consultation (P < 0.01), self-medication (P < 0.01) and prescription expectations (P < 0.01). Although doctors' perception of patients' expectations did indeed show an association with drug prescribing (P = 0.001), there was no association between patients' expectations and doctors' perception of such expectations (P > 0.1), as these tended to be overestimated by doctors. CONCLUSION We conclude that, although doctors prescribe in accordance with what they believe their patients expect, in practice patients exert no influence on drug prescribing because their prescription expectations are misconstrued by doctors, who overestimate them.
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Affiliation(s)
- Eugenia Lado
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, CIBER en Epidemiología y Salud Pública (CIBERESP), Spain
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Brown PR. Trusting in the New NHS: instrumental versus communicative action. SOCIOLOGY OF HEALTH & ILLNESS 2008; 30:349-363. [PMID: 18194357 DOI: 10.1111/j.1467-9566.2007.01065.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Recent reforms within the UK National Health Service, particularly the introduction of clinical governance, have been enacted with the apparent aim of rebuilding patient trust. This paper analyses the approach taken by policy makers, arguing that it is based very much on an instrumental conception of trust. The assumptions and limitations of this model are discussed and in so doing, a communicative understanding of trust is proposed as an alternative. It is argued that the instrumental rationality and institutional focus inherent to instrumental trust neglect the importance of the communication between patient and medical professional and its affective dimensions. Communicative trust goes beyond a mere cognitive appreciation of the system and rather is dependent on the qualitative interaction at the access point, where the patient comes to believe that the communicative rationality of their best interests is mirrored by the professional's instrumental rationality. Whilst recent challenges to the confidence of patients in professionals and medical knowledge make some approximation of an ideal speech situation more imperative than previously, the application of an instrumental concept of trust in the NHS makes such interactions less likely, as well as facilitating a divergence between instrumental and communicative rationality in healthcare provision.
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Ten Wolde GB, Dijkstra A, Van Empelen P, Knuistingh Neven A, Zitman FG. Psychological determinants of the intention to educate patients about benzodiazepines. ACTA ACUST UNITED AC 2007; 30:336-42. [PMID: 18095183 PMCID: PMC2480604 DOI: 10.1007/s11096-007-9183-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 11/26/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE General practitioners and pharmacists do not properly educate their patients about the disadvantages of benzodiazepines. In order to increase and improve education, this study will investigate which psychological factors (i.e., beliefs, outcome expectation, social norm and self-efficacy) predict the intention to educate. METHODS A cross-sectional survey study was conducted in which 339 general practitioners and 149 pharmacists in the Netherlands completed a questionnaire. RESULTS The Results show that the above-mentioned factors play an important role in forming intentions to educate. However, differences exist between general practitioners and pharmacists. CONCLUSION General practitioners and pharmacists intend to educate in cases where they think that benzodiazepines have well-defined disadvantages, when the education they undertake leads to success, when they feel pressure to educate from their surroundings and when they are capable of educating. Implications for practice These findings contribute to a better understanding of patient education and are of great value in developing new interventions to improve education.
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Affiliation(s)
- Geeske Brecht Ten Wolde
- Department of Clinical and Health Psychology, Leiden University, Wassenaarseweg 52, P.O. Box 9555, 2300 RB Leiden, The Netherlands.
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Qureshi NN, Hatcher J, Chaturvedi N, Jafar TH. Effect of general practitioner education on adherence to antihypertensive drugs: cluster randomised controlled trial. BMJ 2007; 335:1030. [PMID: 17991935 PMCID: PMC2078673 DOI: 10.1136/bmj.39360.617986.ae] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2007] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine the impact of a simple educational package for general practitioners on adherence to antihypertensive drugs. DESIGN Cluster randomised controlled trial. SETTING Six randomly selected communities in Karachi, Pakistan. PARTICIPANTS 200 patients with hypertension taking antihypertensive drugs; 78 general practitioners. INTERVENTION Care by general practitioners specially trained in management of hypertension compared with usual care. MAIN OUTCOME MEASURE Correct dosing, defined as percentage of prescribed doses taken, measured with electronic medication event monitoring system (MEMS) bottle. RESULTS 200 patients were enrolled, and 178 (89%) successfully completed six weeks of follow-up. Adherence was significantly greater in the special care group than in the usual care group (unadjusted mean percentage days with correct dose 48.1%, 95% confidence interval 35.8% to 60.4%, versus 32.4%, 22.6% to 42.3%; P=0.048). Adherence was also higher among patients who had higher levels of education (P<0.001), were encouraged by family members (P<0.001), believed in the effect of drugs (P<0.001), and had the purpose of the drugs explained to them (P<0.001). CONCLUSIONS Special training of general practitioners in management of hypertension, emphasising good communication between doctors and patients, is more effective than usual care provided in the communities in Karachi. Such simple interventions should be adopted by other developing countries that are now facing an increasing burden of hypertension. TRIAL REGISTRATION Clinical trials NCT00330408 [ClinicalTrials.gov].
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Affiliation(s)
- Nudrat Noor Qureshi
- Clinical Epidemiology Unit, Department of Community Health Sciences, Aga Khan University, P O Box 3500, Stadium Road, Karachi, 74800, Pakistan
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Baena Díez JM, Gorroñogoitia Iturbe A, Martín Lesende I, de Hoyos Alonso MC, Luque Santiago A, Litago Gil C, de Alba Romero C. [Preventive activities in the elderly]. Aten Primaria 2007; 39 Suppl 3:109-22. [PMID: 19288699 PMCID: PMC7664563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2024] Open
Affiliation(s)
- J M Baena Díez
- Grupo de Actividades Preventivas en los Mayores del PAPPS
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30
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Réplica. Aten Primaria 2007. [DOI: 10.1016/s0212-6567(07)70853-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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McMullan M. Patients using the Internet to obtain health information: how this affects the patient-health professional relationship. PATIENT EDUCATION AND COUNSELING 2006; 63:24-8. [PMID: 16406474 DOI: 10.1016/j.pec.2005.10.006] [Citation(s) in RCA: 612] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2005] [Revised: 09/30/2005] [Accepted: 10/19/2005] [Indexed: 05/06/2023]
Abstract
OBJECTIVE Health information is one of the most frequently sought topics on the Internet. A review of the literature was carried out to determine the use of the Internet for health information by the patient and how this could affect the patient-health professional relationship. METHODS This study is a literature review, summarizing multiple empirical studies on a single subject and is not intended to be a meta-analysis. RESULTS The review showed that the majority of health related Internet searches by patients are for specific medical conditions. They are carried out by the patient: (1) before the clinical encounter to seek information to manage their own healthcare independently and/or to decide whether they need professional help; (2) after the clinical encounter for reassurance or because of dissatisfaction with the amount of detailed information provided by the health professional during the encounter. CONCLUSION There has been a shift in the role of the patient from passive recipient to active consumer of health information. Health professionals are responding to the more 'Internet informed' patient in one or more of three ways: (1) the health professional feels threatened by the information the patient brings and responds defensively by asserting their 'expert opinion' (health professional-centred relationship). (2) The health professional and patient collaborate in obtaining and analysing the information (patient-centred relationship). (3) The health professional will guide patients to reliable health information websites (Internet prescription). PRACTICE IMPLICATIONS It is important that health professionals acknowledge patients' search for knowledge, that they discuss the information offered by patients and guide them to reliable and accurate health websites. It is recommended that courses, such as 'patient informatics' are integrated in health professionals' education.
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Affiliation(s)
- Miriam McMullan
- University of Plymouth, Faculty of Health and Social Work, School of Health Professions, Peninsula Allied Health Centre, Derriford Road, Plymouth PL6 9BH, UK.
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Zantinge EM, Verhaak PFM, Kerssens JJ, Bensing JM. The workload of GPs: consultations of patients with psychological and somatic problems compared. Br J Gen Pract 2005; 55:609-14. [PMID: 16105369 PMCID: PMC1463219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND GPs report that patients' psychosocial problems play a part in 20% of all consultations. GPs state that these consultations are more time-consuming and the perceived burden on the GP is higher. AIM To investigate whether GPs' workload in consultations is related to psychological or social problems of patients. DESIGN OF STUDY A cross-sectional national survey in general practice, conducted in the Netherlands from 2000-2002. SETTING One hundred and four general practices in the Netherlands. METHOD Videotaped consultations (n = 1392) of a representative sample of 142 GPs were used. Consultations were categorised in three groups: consultations with a diagnosis in the International Classification of Primary Care chapter P 'psychological' or Z 'social' (n = 138), a somatic diagnosis but with a psychological background according to the GP (n = 309), or a somatic diagnosis and background (n = 945). Workload measures were consultation length, number of diagnoses and GPs' assessment of sufficiency of patient time. RESULTS Consultations in which patients' mental health problems play a part (as a diagnosis or in the background) take more time and involve more diagnoses, and the GP is more heavily burdened with feelings of insufficiency of patient time. In consultations with a somatic diagnosis but psychological background, GPs more often experienced a lack of time compared to consultations with a psychological or social diagnosis. CONCLUSION Consultations in which the GP notices psychosocial problems make heavier demands on the GP's workload than other consultations. Patients' somatic problems that have a psychological background induce the highest perceived burden on the GP.
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Affiliation(s)
- Else M Zantinge
- Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
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Berney L, Kelly M, Doyal L, Feder G, Griffiths C, Jones IR. Ethical principles and the rationing of health care: a qualitative study in general practice. Br J Gen Pract 2005; 55:620-5. [PMID: 16105371 PMCID: PMC1463218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Researching sensitive topics, such as the rationing of treatments and denial of care, raises a number of ethical and methodological problems. AIM To describe the methods and findings from a number of focus group discussions that examined how GPs apply ethical principles when allocating scarce resources. DESIGN OF STUDY A small-scale qualitative study involving purposive sampling, semi-structured interviews and focus groups. SETTING Twenty-four GPs from two contrasting areas of London: one relatively affluent and one relatively deprived. METHOD Initial interviews asked GPs to identify key resource allocation issues. The interviews were transcribed and themes were identified. A number of case studies, each illustrative of an ethical issue related to rationing, were written up in the form of vignettes. In focus group discussions, GPs were given a number of these vignettes to debate. RESULTS With respect to the ethical basis for decision making, the findings from this part of the study emphasised the role of social and psychological factors, the influence of the quality of the relationship between GPs and patients and confusion among GPs about their role in decision making. CONCLUSION The use of vignettes developed from prior interviews with GPs creates a non-threatening environment to discuss sensitive or controversial issues. The acceptance by GPs of general moral principles does not entail clarity of coherence of the application of these principles in practice.
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Affiliation(s)
- Lee Berney
- Research fellow, Community Health Sciences, St. George's Hospital Medical School, University of London.
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Chew M. What GPs want: time and time again. Med J Aust 2005; 183:58-9. [PMID: 16022606 DOI: 10.5694/j.1326-5377.2005.tb06921.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2005] [Accepted: 06/22/2005] [Indexed: 11/17/2022]
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de Pablo González R. La Atención Primaria de Salud como eje del sistema público sanitario. Semergen 2005. [DOI: 10.1016/s1138-3593(05)72915-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Freeman G, Car J, Hill A. The journey towards patient-centredness. Br J Gen Pract 2004; 54:651-2. [PMID: 15353048 PMCID: PMC1326063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
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Deveugele M, Derese A, De Bacquer D, van den Brink-Muinen A, Bensing J, De Maeseneer J. Consultation in general practice: a standard operating procedure? PATIENT EDUCATION AND COUNSELING 2004; 54:227-233. [PMID: 15288919 DOI: 10.1016/s0738-3991(03)00239-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2003] [Revised: 07/10/2003] [Accepted: 07/22/2003] [Indexed: 05/24/2023]
Abstract
The objectives of this study were to describe the features of consultation within general practice with special attention to the differences between short, moderate and long consultations. An analysis of 2801 videotaped consultations of 183 General Practitioners from six countries participating in the Eurocommunication Study was made. The communicative behaviour was gauged by means of the Roter Interaction Analysis System. The consultation can be seen as a "standard operating procedure" consisting of 8% social behaviour, 15% agreement, 4% rapport building, 10% partnership building, 11% giving directions, 28% giving information, 14% asking questions and 7% counselling. A short consultation can be described as an encounter with a little bit of social behaviour to set the contact, medical questioning, giving directions for the further consultation and advises in order to solve the problem(s) mentioned. In a long consultation doctors take more time for a social talk, they give more attention to the relation or contact with the patient, they listen more extensively, especially to psychosocial problems, and they give more information.
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Affiliation(s)
- Myriam Deveugele
- Department of General Practice and Primary Health Care, Ghent University, UZ 1K3 De Pintelaan 185, B 9000 Gent, Belgium.
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Jurkat HB, Vollmert C, Reimer C. [Conflict experience of physicians in hospitals]. ZEITSCHRIFT FUR PSYCHOSOMATISCHE MEDIZIN UND PSYCHOTHERAPIE 2004; 49:213-31. [PMID: 12964129 DOI: 10.13109/zptm.2003.49.3.213] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Conflict experience has been qualitatively assessed in a representative study of German hospital physicians. METHODS To explore conflict experience, standardized interviews were conducted. These were evaluated using the qualitative content analysis according to Mayring and supplemented by psychometric testing methods SF-36 (Bullinger and Kirchberger 1998) and EBF (Kallus 1995). RESULTS Conflicts regarding personal needs are the most numerous in the four main areas of administrative workload, time pressure, working overtime, and career prospects - particularly in relation to time pressure. Control concerning administrative workload is attributed mostly externally, whereas control attribution concerning career prospects is mostly internal. Quality of life of hospital physicians is impaired in the area of mental health. CONCLUSIONS The results indicate that it is necessary to reduce the physicians' working hours and, especially, time pressure. Additional possibilities for enhancing motivation and for improving coping skills with respect to conflicts are discussed.
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Affiliation(s)
- Harald B Jurkat
- Klinik für Psychosomatik und Psychotherapie der Justus-Liebig-Universität Giessen, Friedrichstr. 33, 35385 Giessen, Germany.
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Edwards N. Doctors and managers: poor relationships may be damaging patients-what can be done? Qual Saf Health Care 2004; 12 Suppl 1:i21-4. [PMID: 14645744 PMCID: PMC1765767 DOI: 10.1136/qhc.12.suppl_1.i21] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The problem of poor relationships between doctors and managers is a common feature of many healthcare systems. This problem needs to be explicitly addressed and there are a number of positive steps that could be taken. Firstly, there would be value in working to improve the quality of relationships and better mutual understanding of the necessarily different positions of doctors and managers. Finding a common approach to managing resources, accountability, autonomy, and the creation of more systematic ways of working seems to be important. The use of costed clinical pathways may be one approach. Rather than seeing guidelines and accountability systems as a threat to autonomy there is an argument that they are an essential adjunct to it. Redefining autonomy in order to preserve it and to ensure that it encompasses accountability and responsibility will be an important step. A key step is the development of clinical leadership.
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Affiliation(s)
- N Edwards
- NHS Confederation, 1 Warwick Row, London, SW1E 5ER, UK.
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Golin CE, Smith SR, Reif S. Adherence counseling practices of generalist and specialist physicians caring for people living with HIV/AIDS in North Carolina. J Gen Intern Med 2004; 19:16-27. [PMID: 14748856 PMCID: PMC1494686 DOI: 10.1111/j.1525-1497.2004.21151.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
CONTEXT National guidelines recommend that practitioners assess and reinforce patient adherence when prescribing antiretroviral (ART) medications, but the extent to which physicians do this routinely is unknown. OBJECTIVE To assess the adherence counseling practices of physicians caring for patients with HIV/AIDS in North Carolina and to determine characteristics associated with providing routine adherence counseling. DESIGN A statewide self-administered survey. SETTING AND PARTICIPANTS All physicians in North Carolina who prescribed a protease inhibitor (PI) during 1999. Among the 589 surveys sent, 369 were returned for a response rate of 63%. The 190 respondents who reported prescribing a PI in the last year comprised the study sample. MAIN OUTCOME MEASURES Physicians reported how often they carried out each of 16 adherence counseling behaviors as well as demographics, practice characteristics, and attitudes. RESULTS On average, physicians reported spending 13 minutes counseling patients when starting a new 3-drug ART regimen. The vast majority performed basic but not more extensive adherence counseling; half reported carrying out 7 or fewer of 16 adherence counseling behaviors "most" or "all of the time." Physicians who reported conducting more adherence counseling were more likely to be infectious disease specialists, care for more HIV-positive patients, have more time allocated for an HIV visit, and to perceive that they had enough time, reimbursement, skill, and office space to counsel. After also controlling for the amount of reimbursement and availability of space for counseling, physicians who were significantly more likely to perform a greater number of adherence counseling practices were those who 1). cared for a greater number of HIV/AIDS patients; 2). had more time allocated for an HIV physical; 3). felt more adequately skilled; and 4). had more positive attitudes toward ART. CONCLUSIONS This first investigation of adherence counseling practices in HIV/AIDS suggests that physicians caring for patients with HIV/AIDS need more training and time allocated to provide antiretroviral adherence counseling services.
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Affiliation(s)
- Carol E Golin
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Pollock K, Grime J. GPs' perspectives on managing time in consultations with patients suffering from depression: a qualitative study. Fam Pract 2003; 20:262-9. [PMID: 12738694 DOI: 10.1093/fampra/cmg306] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although there is widespread concern that general practice consultations are too short for doctors to provide a high quality of care for patients, the relationship between the length and outcome of these consultations remains unclear. Research to date has neglected the subjective experience of consultation time of both patients and GPs. OBJECTIVES Our aim was to investigate GP perspectives on consultation time and the management of depression in general practice. METHOD A qualitative interview-based study was carried out of 19 GPs from eight West Midlands general practices. RESULTS The GPs in this study acknowledged the pressure of work and resource constraints in general practice. However, they did not feel these prevented them from providing good support and treatment for depression. They were confident in the effectiveness of antidepressants and their own skills in providing counselling support, and were able to utilize time flexibly in responding to patients' variable needs. Depression was viewed as a relatively straightforward problem that usually could be managed within the resources available to general practice. CONCLUSION The doctors generally did not experience time to be a limiting factor in providing care for patients with depression. This is in contrast to the more acute sense of time pressure commonly reported by patients which they felt undermined their capacity to benefit from the consultation. GPs need to be more aware of patient anxieties about time, and to devise effective means of raising patients' sense of time entitlement in general practice consultations.
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Affiliation(s)
- Kristian Pollock
- Department of Medicines Management, Keele University, Staffs ST5 5BG, UK.
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Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. Doctors who are using e-mail with their patients: a qualitative exploration. J Med Internet Res 2003; 5:e9. [PMID: 12857665 PMCID: PMC1550557 DOI: 10.2196/jmir.5.2.e9] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2003] [Accepted: 03/17/2003] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite the potential for rapid, asynchronous, documentable communication, the use of e-mail for physician-patient communication has not been widely adopted. OBJECTIVE To survey physicians currently using e-mail with their patients daily to understand their experiences. METHODS In-depth phone interviews of 45 physicians currently using e-mail with patients were audio taped and transcribed verbatim. Two investigators independently qualitatively coded comments. Differences were adjudicated by group consensus. RESULTS Almost all of the 642 comments from these physicians who currently use e-mail with patients daily could be grouped into 1 of 4 broad domains: (1) e-mail access and content, (2) effects of e-mail on the doctor-patient relationship, (3) managing clinical issues by e-mail, and (4) integrating e-mail into office processes. The most consistent theme was that e-mail communication enhances chronic-disease management. Many physicians also reported improved continuity of care and increased flexibility in responding to nonurgent issues. Integration of e-mail into daily workflow, such as utilization of office personnel, appears to be a significant area of concern for many of the physicians. For other issues, such as content, efficiency of e-mail, and confidentiality, there were diverging experiences and opinions. Physicians appear to be selective in choosing which patients they will communicate with via e-mail, but the criteria for selection is unclear. CONCLUSION These physician respondents did perceive benefits to e-mail with a select group of patients. Several areas, such as identifying clinical situations where e-mail communication is effective, incorporating e-mail into office flow, and being reimbursed for online medical care/communication, need to be addressed before this mode of communication diffuses into most practices.
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Affiliation(s)
| | | | | | - Daniel Z Sands
- Beth Israel Deaconess Medical Center and Harvard Medical SchoolBoston MAUSA
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Kovac SH, Klapow JC, Kroenke K, Spitzer RL, Williams JBW. Differing symptoms of abused versus nonabused women in obstetric-gynecology settings. Am J Obstet Gynecol 2003; 188:707-13. [PMID: 12634645 DOI: 10.1067/mob.2003.193] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to document the prevalence rates of reported abuse in obstetric/gynecology settings and to characterize physical symptoms, function, and psychologic distress of women who report abuse. STUDY DESIGN This was a descriptive study of 118 patients who reported physical or sexual abuse in the past year and 2800 patients who reported no abuse at seven obstetric/gynecology practices. The Patient Health Questionnaire measured psychiatric diagnoses, somatic complaints, and psychosocial stressors. The Medical Outcomes Study Short Form 20 assessed health status, and self-reported health care use was measured. RESULTS Four percent of women reported recent abuse. Patients who reported abuse had more psychiatric diagnoses, more severe psychologic distress, more somatic symptoms, more psychosocial stressors, more physician visits, and poorer reported health status compared with nonreporters of abuse. CONCLUSION Enhanced recognition of possible abuse through screening may identify women in need of intervention and help to reduce the need for continued medical intervention.
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Affiliation(s)
- Stacey H Kovac
- Center for Outcomes and Effectiveness Research and Education, University of Alabama at Birmingham, USA.
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Pablo González RD. La necesidad de recuperar la calidad asistencial y la dignidad del profesional en la Atención Primaria de salud. Semergen 2003. [DOI: 10.1016/s1138-3593(03)74149-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Wilson A, Childs S. The relationship between consultation length, process and outcomes in general practice: a systematic review. Br J Gen Pract 2002; 52:1012-20. [PMID: 12528590 PMCID: PMC1314474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023] Open
Abstract
The aim of the study was to examine differences in consultation process and health outcomes between primary care physicians who consult at different rates. A systematic review of observational studies was carried out, restricted to English language journal papers reporting original research or systematic reviews. Qualitative analysis with narrative overview of methodology and key results was undertaken, using MEDLINE (1966 to 1999), EMBASE (1981 to 1999), and the NHS National Research Register. Secondary references from this search were also considered for inclusion. Main outcome measures were objectively measured process or healthcare outcomes. Thirteen papers, describing ten studies, were identified. There were consistent differences in several elements of process and outcome between general practitioners (GPs) who consult at different rates. Although average consultation length may be a marker of other doctor attributes, the evidence suggests that patients seeking help from a doctor who spends more time with them are more likely to have a consultation that includes important elements of care.
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Affiliation(s)
- Andrew Wilson
- Department of General Practice and Primary Care, University of Leicester, Leicester General Hospital, Leicester LE5 4PW.
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Rose PW, Jenkins L, Fuller A, Shepperd S. Doctors' and patients' use of the Internet for healthcare: a study from one general practice. Health Info Libr J 2002; 19:233-5. [PMID: 12485155 DOI: 10.1046/j.1471-1842.2002.00402.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Peter W Rose
- Department of Primary Health Care, University of Oxford, UK.
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Harding R, Sherr L, Singh S, Sherr A, Moorhead R. Evaluation of welfare rights advice in primary care: the general practice perspective. HEALTH & SOCIAL CARE IN THE COMMUNITY 2002; 10:417-422. [PMID: 12485128 DOI: 10.1046/j.1365-2524.2002.00393.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Income maximisation may reduce enduring poverty-related health inequalities. Specialist welfare rights advice in primary care has been proposed and, in some areas, implemented, but evaluation data from the general practice perspective is needed. The present study aimed to evaluate the impact on general practice of specialist welfare rights advice, comparing practices with and without in-house provision of welfare advice using a cross-sectional postal questionnaire. This study was conducted in general practice surgeries in an inner-London health authority with high indicators of deprivation. Questionnaires were sent to practice managers. Comparative data (according to whether specialist advice was currently offered) addressed processes of identifying and meeting welfare needs and outcomes in terms of efficiency of provision. Seventy-nine surgeries participated. Those with welfare rights advisers (n = 42) were significantly more likely to report that current provision was adequate, that it was easier for staff to access advice on their patients' behalf (and by patients themselves) and that the process of advice provision ran smoothly. Lack of funding and space were the principal reasons for not having in-house advice. Surgeries wish provision to be expanded within practices. Welfare rights advice in surgeries improves ability to meet welfare needs via specialist advisers. Referral processes are simplified, enabling general practitioners to ensure that relevant advice is provided without the need for welfare knowledge themselves. General practices welcome the expansion of provision, with the proviso that adequate resources are identified. The current lack of basic information in surgeries must be addressed (e.g. information on local providers, printed information detailing range and eligibility criteria of welfare benefits).
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Affiliation(s)
- Richard Harding
- Department of Primary Care and Population Sciences, Royal Free University College Medical School, London, UK and Institute of Advanced Legal Studies, London, UK.
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Pollock K, Grime J. Patients' perceptions of entitlement to time in general practice consultations for depression: qualitative study. BMJ 2002; 325:687. [PMID: 12351362 PMCID: PMC126657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
OBJECTIVE To investigate patients' perceptions of entitlement to time in general practice consultations for depression. DESIGN Qualitative study based on interviews with patients with mild to moderate depression. SETTING Eight general practices in the West Midlands and the regional membership of the Depression Alliance. PARTICIPANTS 32 general practice patients and 30 respondents from the Depression Alliance. RESULTS An intense sense of time pressure and a self imposed rationing of time in consultations were key concerns among the interviewees. Anxiety about time affected patients' freedom to talk about their problems. Patients took upon themselves part of the responsibility for managing time in the consultation to relieve the burden they perceived their doctors to be working under. Respondents' accounts often showed a mismatch between their own sense of time entitlement and the doctors' capacity to respond flexibly and constructively in offering extended consultation time when this was necessary. Patients valued time to talk and would often have liked more, but they did not necessarily associate length of consultation with quality. The impression doctors gave in handling time in consultations sent strong messages about legitimising the patients' illness and their decision to consult. CONCLUSIONS Patients' self imposed restraint in taking up doctors' time has important consequences for the recognition and treatment of depression. Doctors need to have a greater awareness of patients' anxieties about time and should move to allay such anxieties by pre-emptive reassurance and reinforcing patients' sense of entitlement to time. Far from acting as "consumers," patients voluntarily assume responsibility for conserving scarce resources in a health service that they regard as a collective rather than a personal resource.
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Affiliation(s)
- Kristian Pollock
- Department of Medicines Management, Keele University, Keele ST5 5BG.
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