Innovative consultation time as a common European currency

Consultation length, process quality and diagnosis quality of primary care in rural China: A cross-sectional standardized patient study

OBJECTIVE

Consultation length, the time spent between patient and health care provider during a visit, is an essential element in measuring quality of health care patients receive from a primary care facility. However, the linkage between consultation length and process quality and diagnosis quality of primary care is still uncertain. This study aims to examine the role consultation length plays in delivering process quality and diagnosis quality, two central components of overall primary care quality, in rural China.

METHODS

We recruited unannounced standardized patients (SPs) to present classic symptoms of angina and tuberculosis in selected healthcare facilities in three provinces of China. The consultation length and primary care quality of SPs were measured and compared with both international and national standards of care. Ordinary Least Squares (OLS) regressions for process quality (continuous dependent variable) and Logistic regressions for diagnosis quality (binary dependent variable) were performed to investigate the relationship between consultation length and primary care quality.

RESULTS

The average consultation lengths among patients with classic symptoms of angina and those with symptoms of tuberculosis were approximately 4.33 min and 6.28 min, respectively. Providers who spent more time with patients were significantly more likely to complete higher percentage of recommended checklist items of both questions and examinations for angina (β = 1.39, 95%CI 1.01-1.78) and tuberculosis (β = 0.89, 95%CI 0.69-1.08). Further, providers who spent more time with patients were more likely to make correct diagnosis for angina (marginal effect = 0.014, 95%CI 0.002-0.026) and for tuberculosis (marginal effect = 0.013, 95%CI 0.005-0.021).

CONCLUSIONS

The average consultation length is extremely short among primary care providers in rural China. The longer consultation leads to both better process and diagnosis quality of primary care.

PRACTICE IMPLICATIONS

We recommend primary care providers to increase the length of their communication with patients. To do so, government should implement healthcare reforms to clarify the requirements of affordable and reliable consultation length in medical care services. Moreover, such an experience can also be extended to other developing countries.

Crying patients in General/Family Practice: incidence, reasons for encounter and health problems

Context: Despite evidence demonstrating the benefits of understanding patients, there is a paucity of information about how physicians address psychological and social concerns of patients. No one study has been published about the incidence of crying in General/Family Practice. Objective: To know the incidence of crying in primary care/general practice, and the patients’ characteristics, their reasons for encounter and their health problems. Design: A descriptive, prospective study, of one year, of three general practitioners/family physicians in Madrid, Spain. Setting: primary care (doctors’ office and patients’ home). Subjects: Face to face encounters with crying patients. Main outcome measure: At least one rolling tear. Results: Patients cried in 157 encounters out of a total of 18,627 giving an incidence rate of 8.4 per thousand. More frequent reasons for encounters were: feeling depressed (12.7%), social handicap (mainly social isolation/living alone) (6.4%), relationship problem with partner (5.1%) and feeling anxious (3.2%). More frequent health problems were: depressive disorder (23.6%), anxiety disorder (8.3%), cerebrovascular disease (5.1%) and loss/death of partner (3.8%). Conclusions: Crying in primary care is not uncommon. Reasons for crying cover the whole range of human problems, mainly social and psychological problems.

Pudor, honor, and autoridad: the evolving patient-physician relationship in Spain

The expression of emotion and the sharing of information are determined by cultural factors, consultation time, and the structure of the health care system. Two emblematic situations in Spain - the expression of aggression in the patient-physician encounter, and the withholding of diagnostic information from the patient - have not been well-described in their sociocultural context. To explore these, the authors observed and participated in clinical practice and teaching in several settings throughout Spain and analyzed field notes using qualitative methods. In this paper, we explore three central constructs - modesty (pudor), dignity (honor), and authority (autoridad) - and their expressions in patient-physician encounters. We define two types of emotions in clinical settings - public, extroverted expressions of anger and exuberance; and private, deeply held feelings of fear and grief that tend to be expressed through the arts and religion. Premature reassurance and withholding of information are interpreted as attempts to reconstruct the honor and pudor of the patient. Physician authority and perceived loyalty to the government-run health care system generate conflict and aggression in the patient-physician relationship. These clinical behaviors are contextualized within cultural definitions of effective communication, an ideal patient-physician relationship, the role of the family, and ethical behavior. Despite agreement on the goals of medicine, the behavioral manifestations of empathy and caring in Spain contrast substantially with northern European and North American cultures.

Expectations of health care: promoted, managed or shared?

Volume, costs and content of medical care depend on professional and public expectations. The UK National Health Service (NHS) removed price barriers to access, so depressed expectations became an important factor in cost control. In USA, professional control of care business inflated expectations and costs. Managed care in the NHS failed to rationalize care because managers seem even less trustworthy than clinicians as arbiters of rational expectations in contexts of underfunding. Rational expectations depend on restored trust, mutual and managerial respect for expertise of both clinicians and patients, and transcendence of the provider-consumer model for value production in medical care.

Cochrane Lecture 1997. What evidence do we need for evidence based medicine?

As presently understood, evidence based medicine aims to advance practice from its traditional unverifiable mix of art and science to rational use of measurable inputs and outputs. In practice, however, its advocates accept uncritically a desocialised definition of science, assume that major clinical decisions are taken at the level of secondary specialist rather than primary generalist care, and ignore the multiple nature of most clinical problems, as well as the complexity of social problems within which clinical problems arise and have to be solved. These reductionist assumptions derive from the use of evidence based medicine as a tool for managed care in a transactional model for consultations. If these assumptions persist, they will strengthen reification of disease and promote the episodic output of process regardless of health outcome. We need to work within a different paradigm based on development of patients as co-producers rather than consumers, promoting continuing output of health gain through shared decisions using all relevant evidence, within a broader, socialised definition of science. Adoption of this model would require a major social and cultural shift for health professionals. This shift has already begun, promoted by changes in public attitudes to professional authority, changes in the relation of professionals to managers, and pressures for improved effectiveness and efficiency which, contrary to received wisdom, seem more likely to endorse cooperative than transactional clinical production. Progress on these lines is resisted by rapidly growing and extremely powerful economic and political interests. Health professionals and strategists have yet to recognise and admit the existence of this choice.