Protocol paper for the 'Harnessing resources from the internet to maximise outcomes from GP consultations (HaRI)' study: a mixed qualitative methods study

Engagement with emotional concerns in general practice: a thematic analysis of GP consultations

BACKGROUND

Emotional concerns (defined as any expression of low mood, anxiety, or psychosocial stress) are an important part of the biopsychosocial care model used in modern medical practice. Previous work has demonstrated variable engagement with emotional concerns and that improved communication has been associated with reductions in emotional distress.

AIM

To examine how emotional concerns are engaged with during routine GP consultations.

DESIGN & SETTING

Secondary study using the Harnessing Resources from the Internet (HaRI) database. The available dataset contains 231 recordings from 10 GPs across eight urban and suburban practices recorded in 2017 and 2018.

METHOD

The dataset was reviewed to identify any consultations containing emotional concerns (as defined as any expression of low mood, anxiety, or psychosocial stress) before being imported into NVivo (version 12) to facilitate thematic analysis and coding. Reflexive inductive thematic analysis resulted in two major themes.

RESULTS

The two main themes were as follows: engagement with emotional concerns as dynamic throughout consultations; and GPs engage with emotional concerns both diagnostically and therapeutically. In theme 1, this dynamism relates to competing areas of focus, immediate versus delayed engagement and reiteration of concerns throughout consultations. Emotional concerns can be engaged with in a similar way to physical concerns (theme 2) using a diagnostic and treatment-based approach; however, in addition to this, therapeutic listening and conversation is utilised.

CONCLUSION

Awareness of the dynamic nature of emotional concerns within consultations and encouraging engagement with concerns in a flexible and patient-oriented manner may help improve doctor-patient communication. In addition, investigating how GPs and patients build shared understanding around emotional concerns may identify methods to reduce patients' emotional distress.

Analysis of in-person general practice respiratory consultations: assessing translatability to telehealth

BACKGROUND

The COVID-19 pandemic saw many GPs adopt telehealth as a consultation modality to minimise disease transmission. Patients presenting with respiratory ailments were particularly affected by this transition, given the overlap of general respiratory symptoms with those of COVID-19. It is unclear if the rapid transition to telehealth has compromised the ability to conduct certain tasks that were possible during in-person consultations.

AIM

To investigate the extent to which tasks observed during in-person GP consultations are replicable in telehealth, focusing on patients with respiratory concerns.

DESIGN & SETTING

Twenty-six respiratory consultations were extracted from a database of 281 consultations collated from various general practices in the UK.

METHOD

Interactions between GPs and respiratory patients were assessed through in-depth transcript review and de-identified video analysis. Then, tasks performed and physical artefacts used during the consultations were identified and ranked in terms of their translatability to telehealth, using a newly developed scoring system.

RESULTS

Overall, the translatability to telehealth score for these respiratory consultations was 6.7/10, suggesting that many tasks can be replicated over telehealth, but that they might require additional physical artefacts to support this. However, some tasks are not currently amenable to telehealth (for example, auscultation).

CONCLUSION

While many aspects of respiratory consultations are replicable over telehealth, some tasks cannot be replicated at this stage.

Are chronic condition management visits translatable to telehealth? Analysis of in-person consultations in primary care

BACKGROUND

Telehealth was rapidly adopted in primary care during COVID-19. However, there is a lack of research assessing how translatable in-person consultations are to telehealth.

OBJECTIVE

To examine insights from in-person GP-Patient consultations for patients with chronic conditions, including 1/frequency, duration, conditions of physical examinations, and when they occur during consultations, 2/types of physical artefacts used, 3/clinical tasks performed, and 4/translatability of clinical tasks to telehealth.

METHODS

Eligible consultations were extracted from a dataset archive named HaRI, which contains 281 in-person GP consultations in de-identified transcript and video format. 38 consultations were included for analysis meeting eligibility criteria in this study. A multi-method approach (using content analysis, visualisation, video and time analysis) was applied to eligible consultations, extracting clinical tasks that involve physical interactions. Finally, an evidence-based scoring system was used on each clinical task, determining the likelihood of whether each task could be translated into telehealth.

RESULTS

Nine chronic conditions were observed across 38 GP-Patient consultations, predominately diabetes (39 %, 15/38). Out of these 38 consultations, 76 % (29/38) featured physical examinations, where 68 % (26/38) were initiated by GPs (e.g., auscultation), and 26 % (10/38) were initiated by patients (e.g., self-palpation). The average percentage of time spent on physical examination(s) during consultations is low (13.6 %, SD = 9.4 %). A total of 24 clinical tasks were observed across these 38 consultations. Out of these 24 tasks, 92 % (22/24) were supported by physical artefacts. The average score of a task being translatable to Telehealth is 7/10 (where Score 1 = Not amenable to being replicated over telehealth at this stage, scoring 10 = Easily translatable over telehealth with almost no additional equipment being required).

CONCLUSION

All tasks observed across chronic condition management visits were deemed translatable/potentially translatable to telehealth. However, physical interactions between GPs and patients are still essential. Future research in telehealth should focus on examining ways to support physical examination, reduce uncertainty, promote safety netting, and facilitate patients' safety at home with effective technology and support.

How general practitioners and patients discuss type 2 diabetes mellitus and cardiovascular diseases concerns during consultations: Implications for digital health

Objective

To analyse general practitioner-patient consultations about type 2 diabetes mellitus or cardiovascular diseases and describe (i) the nature of self-management discussions; (ii) actions required from patients during and after consultation regarding self-management; and (iii) implications for digital health to support patients during (and after) consultation.

Method

This study screened 281 general practitioner consultations conducted in 2017 within the UK general practice setting from an existing dataset containing videos and transcripts of consultations between GPs and patients. Secondary analysis was conducted using a multi-method approach, including descriptive, content, and visualisation analysis, to inform the nature of self-management discussions, what actions are required from patients, and whether digital technology was mentioned during the consultation to support self-management.

Results

Analysis of eligible 19 consultations revealed a discord between what self-management actions are required of patients during and after consultations. Lifestyle discussions are often discussed in depth, but these discussions rely heavily on subjective inquiry and recall. Some patients in these cohorts are overwhelmed by self-management, to the detriment of their personal health. Digital support for self-management was not a major topic of discussion, however, we identified a number of emergent gaps where digital technology can support self-management concerns.

Conclusion

There is potential for digital technology to reconcile what actions are required of patients during and after consultations. Furthermore, a number of emergent themes around self-management have implications for digitalisation.

Brief opportunistic interventions by general practitioners to promote smoking cessation: A conversation analytic study

Very brief opportunistic interventions for smoking cessation are effective, cost-saving for health systems, and universally recommended in guidelines. However, evidence suggests that clinicians are reluctant to intervene, citing interactional difficulties. Only one UK study has specifically examined smoking discussions, within naturally occurring primary care consultations. However smoking cessation treatment was not available at the time. We examined existing datasets amounting to 519 video-recordings of GP consultations in England for instances of talk about smoking. We used conversation analytic methods to assess patients' responses to doctors asking about smoking, giving advice on smoking, and offering cessation treatment. In 31 recordings it was apparent that the patient smoked, and, in 25/31 consultations, doctors initiated the topic of smoking. They did so by asking about smoking status, commonly during the history-taking phase of the consultation. In many instances, these questions led to active resistance from patients against being placed in a discreditable category, for example by minimising their smoking. This was more pronounced when GPs pursued efforts to quantify the amount smoked. Thereafter, where doctors returned to the topic of smoking, they did so typically by linking smoking to the patient's medical condition, which likewise led to resistance. Guidance recommends that GPs advise on how best to quit smoking where patients are interested in doing so, but this was only evident in a minority of consultations. Where GPs offered support for cessation, they did so using interactional practices that minimised the need for the patient to respond and thereby accept. Interactional difficulties were found to be common in consultations between GPs and people who smoke when GPs actions aligned with some VBA guidelines. Future research should examine when and how advice on how best to quit, and offers of support, should be delivered within primary care consultations.

Patients' use of the internet to negotiate about treatment

The internet provides access to a huge variety of information, including health information. There is, however, a dearth of evidence as to how, and to what ends, patients raise prior use of the internet during medical visits. Analysis is based on the Harnessing Resources from the Internet study. Drawing on data from 281 video-recorded primary care consultations, we use conversation analysis (CA) to systematically inspect the data for instances in which patients reveal that they have accessed publicly available online resources regarding their illness, symptoms, or treatment concerns. Patients invoke the internet to support three types of action: to (i) justify concerns about a serious illness; (ii) provide a warrant for treatment where they have been unable to find a solution; and (iii) advocate in relation to treatment. Although invoking the internet risks potential encroachment into the doctor's domain of authority, patients carefully design their turns when raising the internet so as to orientate to the final decision about treatment as residing firmly within the doctor's domain of authority. The work demonstrates how detailed interactional analysis can be used to illuminate the local work that patients and doctors engage in to manage the rise in availability of information from the internet.

Qualitative study: patients' enduring concerns about discussing internet use in general practice consultations

OBJECTIVES

To examine patients' accounts of their use of the internet before seeing a general practitioner (GP) using thematic analysis of semistructured interviews.

DESIGN

Qualitative semistructured interview study with transcripts analysed thematically.

SETTING

Primary care patients consulting with 10 GPs working at 7 GP practices of varying sizes and at a range of locations around London and the Southeast of England.

PARTICIPANTS

28 adult patients: 16 women and 12 men ranging in age from 18 to 75 from a range of self-defined ethnic backgrounds. Participants were selected based on instances when the patients reported having used the internet before the consultation, when patients referred to the internet in the consultation or when the physician used the internet or made reference to it during the consultation.

RESULTS

Patients report that they can find health information online that they believe is reliable and helpful for both themselves and their GP. However, they report uncertainty about how to share internet-based findings and reluctance to disclose their efforts at researching health issues online for fear of appearing disrespectful or interfering with the flow of the consultation.

CONCLUSIONS

Despite the democratisation of access to information about health due via the internet, patients continue to experience their use of the internet for health information as a sensitive and potentially problematic topic. The onus may well be on GPs to raise the likelihood (without judgement) that patients will have looked things up before consulting and invite them to talk about what they found.

Combining patient talk about internet use during primary care consultations with retrospective accounts. A qualitative analysis of interactional and interview data

Despite widespread acknowledgement of internet use for information about health, patients report not disclosing use of online health information in consultations. This paper compares patients' reported use of the internet with matched video recordings of consultations. The concepts of doctorability and epistemics are employed to consider similarities and differences between patients’ reports in interviews and actions in the consultation. Data are drawn from the Harnessing Resources from the Internet study conducted in the UK. The data set consists of 281 video-recorded general practice consultations, with pre-consultation questionnaires completed by all patients, interviews with all 10 participating doctors and 28 selected patients. We focus on the 28 patient interviews and associated consultation recordings. A conversation analytic (CA) approach is used to systematically inspect both the interview and consultation data. In interviews patients presented use of the internet as associated with appropriate self-management and help-seeking. In consultations patients skilfully translated what they had found on the internet in order to provide grounds for the actions they sought. We conclude that patients translate and utilise what they have found on the internet to assert the doctorability of their presenting problems. Furthermore, patients design their talk in both interviews and consultations to accord with their understanding of the epistemic rights of both doctors and patients. Patients search the internet so they are informed about their medical problem, however they carefully manage disclosure of information to avoid disrupting the smooth running of medical interactions.

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Patients seek information from the internet to support decisions to consult.

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Patients seek information from the internet to support appropriate self-management.

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Patients skilfully translate what they find on the internet to support requests.

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Patients skilfully use the internet to invite action from their doctors.

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Patients do not openly challenge the epistemic authority of the doctor.