Patients comment on video-recorded consultations--the "good" GP and the "bad".

The aim of this study was to describe and understand patients' positive and negative experiences of General Practitioners (GPs). Forty-six consultations were videotaped in four primary health care centres in Sweden. Afterwards the patients commented on the recorded consultations. The comments were categorized and analyzed using an exploratory qualitative approach. An image of the "good" GP emerged that had two major characteristics: that of being a caring human; an individual who listens, understands, and is concerned. At the same time, the good GP acts like an ordinary person and treats the patient as an equal. The personal relationship with the GP also influenced the choice and course of medical interventions. For the patient, the manner in which an intervention is seen is linked to whether the GPs treats the patient with respect or not. A typical experience of a "bad" GP was that the GP appeared unreachable as a person. An example is when the patient feels that the GP was not taking his or her symptoms seriously. Another characteristic of the bad GP is failure to communicate to the patient his or her standpoint on issues raised during consultations.     

Assessment in general practice: the predictive value of written-knowledge tests and a multiple-station examination for actual medical performance in daily practice

This study compares the predictive values of written-knowledge tests and a standardized multiple-station examination for the actual medical performance of general practitioners (GPs) in order to select effective assessment methods to be used in quality-improvement activities. A comprehensive assessment was performed in four phases. First, 100 GPs from the southern part of the Netherlands were assessed by a general medical knowledge test and by a knowledge test on technical skills. Second, in order to check for time-order effects, participants were randomly divided into two groups of 50 each, comparable on scores of both knowledge tests and on professional characteristics. Finally, both groups went through a multiple station examination using standardized patients and a practice video assessment of real surgery, but in opposite orders. Consultations were videotaped and assessed by well-trained peer observers. The drop-out rate was 10%. In both groups the predictive value of medical knowledge tests, ranging from 0.43 to 0.56 (Pearson correlation disattenuated), proved to be comparable with the predictive value of the multiple-station examination for actual performance (0.33-0.59). The overall explained variance of scores of the practice video assessment, measured by multiple regression analysis with performance scores as dependent variables and scores on the knowledge tests and the multiple-station examination as independent variables was moderate (19%). A time-order effect showed in only one direction: from practice video assessment to the multiple-station examination. The GP's professional characteristics did not contribute to the explanation of variation in performance. Medical knowledge tests can predict actual clinical performance to the same extent as a multiple-station examination. Compared with a station examination, a knowledge test may be a good alternative method for assessment the procedures of a large number of practising GPs.     

Psychiatric training for family doctors: what do GP registrars want and can a brief course provide this?

CONTEXT: About 40% of British General Practitioners (GPs) train formally in a psychiatric post as part of their general practice training, but such training may not fully meet the needs of future GPs. A specific course in psychiatry for family doctors has run in Manchester for more than a decade. METHOD: Semi-structured interviews conducted with GP registrars before attending the Manchester course in psychiatry with questionnaire follow-up afterwards to ascertain (a) the training 'wants' of GP registrars and (b) whether the course was providing them. RESULTS: GP registrars most frequently wanted training in communication skills, how to access the resources that are available to GPs, the detection of psychiatric illness, drug treatment and the management of aggression. The course was successful in satisfying the first three but failed in the last two. There was trend for those who attended Manchester Medical School, which scored significantly higher on number of topics covered at undergraduate level, to perceive a greater need for training than those who attended other medical schools. However, there was no evidence to link self-perception of greater need with having already worked in general practice during postgraduate training. CONCLUSIONS: More attention needs to be paid to how to address the specific mental health skills training requirements of GP registrars both within the attachment in psychiatry and during the practice year. Preliminary research is required to devise teaching packages before they are entirely satisfactory for GP education.     

General practitioners'' decision making for mental health problems: Outcomes and ecological validity

A major problem in the field of medical decision making is the ecological (external) validity of the results. In a Judgement Analysis study on mental health, vignettes were used to capture the decision strategies of 28 General Practitioners (GPs). Two different decision strategies for mental health problems could be distinguished. Although the results were statistically satisfactory and met the assumptions of Judgement Analysis, it was considered necessary to determine the ecological validity of the vignettes.

Video tapes (n = 90) of GP consultations were scored in terms of the units of information (cues) which had been used in the vignette study. Additional data gave access to the judgements of the GPs, which were comparable to the judgements obtained in the vignette study. Results showed that the weights given to the different cues in the vignette study were situated within the confidence interval of the weights from the video study. Thus indicating that the results obtained from the vignette study have ecological validity.     

Students conducting consultations in general practice and the acceptability to patients

OBJECTIVES: The General Medical Council has recommended that medical students should gain more experience in general practice. The study set out to determine patients' reactions to consultations conducted by a medical student alone prior to seeing their GP. DESIGN: A random sample of patients attending general practice surgeries in the Oxford area completed a questionnaire following consultation with a medical student. SETTING: Six general practice teaching surgeries. SUBJECTS: Fifth-year medical students. RESULTS: Of 130 responders 98% experienced no disadvantage in seeing the student; 35% considered that there were advantages in seeing the student; 98% said that they would be prepared to consult with a student again; 85% expressed no concerns about the gender of the student. CONCLUSIONS: The results of this study are very reassuring concerning the acceptability to patients of consulting with medical students and are more favourable than those reported for studies of students being present in consultations by GPs.     

The effects of the introduction of a system of mandatory formative assessment for general practice trainees

A series of questionnaires was used to determine the amount of formative assessment going on within the West of Scotland Region of the UK and its perceived value by trainees (General Practice [GP] Registrars) both at the beginning and end of training. The first survey was carried out in 1989 and the second in 1994. Trainers and course organizers were surveyed in 1994 to determine their attitudes to the use of videotaped consultations for formative assessment. In 1991, the region had initiated a mandatory formative assessment programme which included regular use of videotaped consultations, confidence rating scales and Manchester ratings (RCGP Occasional Paper Number 40). The use of a range of assessment methods for formative assessment of GP Registrars increased considerably between 1989 and 1994. The percentage of trainees using videotaped consultation analysis increased from 76 to 94%, for Manchester ratings from 52 to 68% and for confidence rating scales from 63 to 74%. Video and confidence scales were rated highly by trainees who were assessed by them and by most trainees at the start of the year, but less highly by those who had not been assessed by them by the end of the trainee year. Manchester ratings were not thought to be as useful, and for these there was no difference between users and non-users. Despite the mandatory system, a significant number of trainees (76%) were still not receiving the minimum assessment stipulated. Trainers rated lack of time as the main limiting factor to the greater use of video. We conclude that trainees who are exposed to assessment methods, particularly video, find it useful, but that some trainees are still receiving less than is optimal. We propose increased trainer education and intensified monitoring of the assessment carried out in training Practices.     

What do general practitioners do differently when consulting with a medical student?

Objectives The practice of having medical students see patients in a general practice setting, in their own consulting rooms, prior to the GP preceptor joining the consultation does not increase general practitioner (GP) consultation time. How do GPs meet the needs of both patient and student without extending consultation time? This study sought to quantify and compare GP consultation activities with and without students. Methods This was a prospective cohort study of 523 videotaped consultations. Consultations were analysed in 15‐second intervals using a modified Davis observation code to define GP activity. Estimated marginal means were calculated using mixed model analysis accounting for confounding factors. Results In comparison with consulting alone, GPs precepting a student spent 37 seconds less time examining patients (P = 0.001), 41 seconds less on patient management, and 1 minute, 31 seconds less on clerical and other activities (P < 0.001). This created time for GPs to take a history from both the student and patient (39 seconds longer; P = 0.002) and to teach students (1 minute, 10 seconds; P < 0.001). Discussion General practitioner activity in the consultation changes significantly when precepting a student; GPs spend longer exploring the history in order to unpack the student’s clinical reasoning, verify the patient’s story and resynthesise the information. They spend less time on examination, management and clerical activities and presumably delegate or defer these activities. Conclusions This organising of clinical activities in order to meet the needs of both patient and student is likely to require different processing skills to solo consulting.     

A performance assessment module for experienced general practitioners

OBJECTIVE: To trial in Australian general practice a performance assessment module based on review of a sample of videotaped consultations. DESIGN: As part of a broader project 33 doctors provided 20 videotaped consultations collected according patient age, gender and problems encountered. The consultations were rated by a single trained rater. RESULTS: The consultations covered sufficient variety of patient ages, gender balance and problems encountered to achieve validity and the single rater design achieved defensible reliability (generalisability coefficient 0.86). CONCLUSION: The module is suitable for further exploration as an optional method for certification or re-certification assessment.     

Setting a standard for performance assessment of doctor-patient communication in general practice

CONTEXT: Continuing professional development (CPD) of general practitioners. OBJECTIVE: Criterion-referenced standards for assessing performance in the real practice of general practitioners (GPs) should be available to identify learning needs or poor performers for CPD. The applicability of common standard setting procedures in authentic assessment has not been investigated. METHODS: To set a standard for assessment of GP-patient communication with video observation of daily practice, we investigated 2 well known examples of 2 different standard setting approaches. An Angoff procedure was applied to 8 written cases. A borderline regression method was applied to videotaped consultations of 88 GPs. The procedures and outcomes were evaluated by the applicability of the procedure, the reliability of the standards and the credibility as perceived by the stakeholders, namely, the GPs. RESULTS: Both methods are applicable and reliable; the obtained standards are credible according to the GPs. CONCLUSIONS: Both modified methods can be used to set a standard for assessment in daily practice. The context in which the standard will be used - i.e. the specific purpose of the standard, the moment the standard must be available or if specific feedback must be given - is important because methods differ in practical aspects.     

How do we compare with our colleagues? Quality of general practitioner performance in consultations for non-acute abdominal complaints.

OBJECTIVE: To investigate what factors influence the quality of general practitioner performance in consultations for non-acute abdominal complaints and to establish the extent to which performance quality differs between general practitioners (GPs). DESIGN: Explorative study in two parts: (i) detection of variables influencing quality scores of consultations; and (ii) comparison of mean quality scores of the consultations, selected by each GP. SETTING: Sixty-two family practices across The Netherlands. SUBJECTS: Eight-hundred and forty consultations concerning non-acute abdominal complaints, first encounters; 62 GPs. METHOD: Multilevel analysis was carried out to detect factors that influence quality. After correction for the effect of significant factors the mean quality scores of individual GPs were calculated and compared. RESULTS: Eighty-eight per cent of the total variance in quality scores was located at the consultation/patient level, and 12% at the GP level. One consultation characteristic had significant influence on quality: quality scores were higher in consultations of longer than average duration (>15 minutes). Several patient characteristics were of significant influence. Consultation quality scores were higher in consultations for patients with upper abdominal or non-specific abdominal complaints. Quality scores were lower in consultations with female patients and with patients aged >40 years. Together these characteristics explained 20% of the variance at the GP level. None of the GP characteristics investigated in this study appeared to have significant influence on the quality of their performance. After correction of the scores for the effect of significant factors the differences in performance quality between GPs remained significant. CONCLUSIONS: Quality of performance is far more influenced by consultation and patient characteristics than by GP characteristics. After correction for influencing factors, the mean quality scores of GPs still differed considerably and significantly. For many GPs the quality scores varied substantially between different consultations; to a large extent this variation remained unexplained. Consultation quality can be improved by booking more time per patient and by giving more medical/technical attention to female and older patients.     

Formative assessment of the consultation performance of medical students in the setting of general practice using a modified version of the leicester assessment package

OBJECTIVE: To evaluate the use of a modified version of the Leicester Assessment Package (LAP) in the formative assessment of the consultation performance of medical students with particular reference to validity, inter-assessor reliability, acceptability, feasibility and educational impact. DESIGN: 180 third and fourth year Leicester medical students were directly observed consulting with six general practice patients and independently assessed by a pair of assessors. A total of 70 practice and 16 departmental assessors took part. Performance scores were subjected to generalizability analysis and students' views of the assessment were gathered by questionnaire. RESULTS: Four of the five categories of consultation performance (Interviewing and history taking, Patient management, Problem solving and Behaviour and relationship with patients) were assessed in over 99% of consultations and Physical examination was assessed in 94%. Seventy-six percent of assessors reported that the case mix was 'satisfactory' and 20% that it was 'borderline'; 85% of students believed it to have been satisfactory. Generalizability analysis indicates that two independent assessors assessing the performance of students across six consultations would achieve a reliability of 0.94 in making pass or fail decisions. Ninety-eight percent of students perceived that their particular strengths and weaknesses were correctly identified, 99% that they were given specific advice on how to improve their performance and 98% believed that the feedback they had received would have long-term benefit. CONCLUSIONS: The modified version of the LAP is valid, reliable and feasible in formative assessment of the consultation performance of medical students. Furthermore, almost all students found the process fair and believed it was likely to lead to improvements in their consultation performance. This approach may also be applicable to regulatory assessment as it accurately identifies students at the pass/fail margin.     

Acquisition of communication skills in postgraduate training for general practice

PURPOSE: The evidence suggests that a longitudinal training of communication skills embedded in a rich clinical context is most effective. In this study we evaluated the acquisition of communication skills under such conditions. METHODS: In a longitudinal design the communication skills of a randomly selected sample of 25 trainees of a three-year postgraduate training programme for general practice were assessed at the start and at the end of training. Eight videotaped real life consultations were rated per measurement and per trainee, using the MAAS-Global scoring list. The results were compared with each other and with those of a reference group of 94 experienced GPs. RESULTS: The mean score of the MAAS-Global was slightly increased at the end of training (2.4) compared with the start (2.2). No significant difference was found between the final results of the trainees and the reference group. According to the criteria of the rating scale the performance of both trainees and GPs was unsatisfactory. CONCLUSION: The results of this study indicate that communication skills do not improve in a three-year postgraduate training comprising both a rich clinical context and a longitudinal training of communication skills, and that an unsatisfactory level still exists at the end of training. Moreover, GPs do not acquire communication skills during independent practice as they perform comparably to the trainees. Further research into the measurement of communication skills, the teaching procedures, the role of the GP-trainer as a model and the influence of rotations through hospitals and the like, is required.     

What is going on when the general practitioner doesn't grasp the situation?

Forty-six consultations with 12 GPs in four primary health centres were videotaped. Afterwards the GPs commented on the tapes. Fourteen consultations, in which it was obvious that the GP felt uncertain and did not grasp the situation, were especially studied. One important contributing factor was that the GP often did not fully understand the patient's reason for the consultation. A general outcome was that the GP usually did not allow himself to use his feelings of uncertainty as useful information about the situation.     

The value of case studies

Background: Studies describing GP consultation have identified duration of consultation as an important marker of patient satisfaction. Duration of consultation differs between countries. Objective: The aim of this study was to measure the duration of consultations and the different segments of the consultation in a representative sample of GPs in the Nantes district (France).

Material and methods: 150 GPs in the Nantes district were randomly selected from the telephone directory. A letter of explanation was sent, followed up by a telephone call asking the GPs to receive an observer into their surgery. The observer timed consultations and the different segments of the consultation. Results: 30 out of 150 GPs contacted agreed to participate. 329 consultations were observed. Average duration of consultation was 14 min and 24 s; it was 15 min in non-computerised practices and 12 min and 50 s in computerised practices. Consultations for psychological problems or with many reasons for consulting took longer. Doctors usually talked more than patients, except during long consultations. Patients were not examined in only 2% of consultations. Trainers in general practice had longer consultations. Discussion: Many GPs refused to receive the observer; the ratio of trainers within the group of respondents (40%) was higher than in the general GP population (7–10%). As in other studies, female GPs were overre-presented as active participants. In our sample, the average duration of consultation was longer than in other studies. The finding regarding the duration of consultation in computerised practices may need validation in other studies. EurJ Gen Pract 2000;6:88–92.     

Subjective health expectations at biological therapy initiation: a survey of rheumatoid arthritis patients and rheumatologists

In The Netherlands, the remuneration system for GPs changed in 2006. Before the change, GPs received a capitation fee for publicly insured patients and fee for service (FFS) for privately insured patients. In 2006, a combined system was introduced for all patients, with elements of capitation as well as FFS. This created a unique opportunity to investigate the effects of the change in the remuneration system on contact type and consultation length. Our hypothesis was that for former publicly insured patients the change would lead to an increase in the proportion of home visits, a decrease in the proportion of telephone consultations and an increase in consultation length relative to formerly privately insured patients. Data were used from electronic medical records from 36 to 58 Dutch GP practices and from 532,800 to 743,961 patient contacts between 2002 and 2008 for contact type data. For consultation length, 1,994 videotaped consultations were used from 85 GP practices in 2002 and 499 consultations from 16 GP practices in 2008. Multilevel multinomial regression analysis was used to analyse consultation type. Multilevel logistic and linear regression analyses were used to examine consultation length. Our study shows that contact type and consultation length were hardly affected by the change in remuneration system, though the proportion of home visits slightly decreased for privately insured patients compared with publicly insured patients. Declaration behaviour regarding telephone consultations did change; GP practices more consistently declared telephone consultations after 2006.     

Helping general practitioners to keep up with the literature: evaluation of an RCGP initiative

The recent Report of The Medical Information Review Panel suggested that locally-produced abstracting bulletins are likely to be of great value in promoting continuing education; most notably by helping GPs to 'keep up with the literature'. The Report identified Current Medical Abstracts for Practitioners (CMAP) , a publication produced by the S.E. Scotland Faculty of the Royal College of General Practitioners (RCGP), as an example of the kind of bulletin it had in mind. It further suggested that the role and effectiveness of this publication should be investigated.
A survey of the readership of CMAP was therefore carried out. It was found that CMAP is regularly read by only 28% of those to whom it is sent (free of charge). More particularly, CMAP is read predominantly by those GPs who are already conscientious users of medical literature: they use the bulletin as a complement and supplement to their other professional reading. Those GPs who devote little time to journal reading, in general, tend to ignore CMAP. They do not seek to use it as a substitute for more extensive reading of medical journals.
It therefore appears that CMAP does little to overcome the problem of GPs who do not keep up with the literature, and it is unlikely that similar publications will be initiated in other areas. Indeed, publication of CMAP may be ceased, at least in its present form.     

Children as informal interpreters in GP consultations: pragmatics and ideology

This paper explores the views of General Practitioners (GPs) about the appropriateness of children undertaking a task of interpretation between the GP and an adult patient in primary heath care consultations. We argue that the operational constraints that GPs face because of the limited availability of professional interpreters or bi-lingual Health Advocates create situations where children are accepted in this role by GPs, subject to specific limitations and contingencies. The contingent nature of perceptions of children's acceptability as informal interpreters is shown to be related primarily to the nature of the medical consultation in terms of whether it is likely to be straightforward, complex or sensitive. At the same time GPs express an ideological opposition to the appropriateness of this task for children generally. This ideological opposition is explicitly linked by GPs to broader constructions of a 'proper' childhood, characterised as a time of innocence and freedom from worry.     

Teaching junior doctors to manage patients who somatise: is it possible in an afternoon?

CONTEXT: Many patients in primary care somatise psychological distress. Training general practitioners (GPs) to manage somatisation has been shown to lead to improvements in their management of these patients. However, the training has been intensive and conducted by psychiatrists, making it impractical for widespread use. The aim of this research was to determine the effectiveness of a teaching package in improving the ability of GP registrars to manage patients who somatise, when taught by GP vocational course tutors within the constraints of a general practice vocational training scheme. METHODS: This was a before-and-after training evaluation of GP registrars' skills. A total of 22 GP registrars and 6 GP course organisers were recruited from 3 GP vocational training schemes. The GP trainees had 2 videotaped consultations with trained actors role-playing patients with somatised depression, before and 1 month after training. RESULTS: There was a significant overall improvement in the ability of GP registrars to manage patients who somatise (mean scores on a 4-point Likert scale: pre-training 1.4 [standard deviation, SD, 0.6]; post-training 2.2 [SD 0.9]; P = 0.002). General practice registrars improved their ability to use a negotiating style of consultation (skill present in 8/22 pre-training, 16/22 post-training; P = 0.02) and also demonstrated more empathy during the 'consultation' after training (mean scores on a 5-point Likert scale: pre-training 2.3 [SD 1.0]; post-training 3.0 [SD 0.8]; P = 0.03). CONCLUSIONS: Using a structured training package, it is possible for GP vocational course tutors to successfully teach GP registrars to manage patients who somatise psychological distress. Given limited resources for teaching in terms of cost and time, this training package could have important implications for training medical staff.     

Outcomes of an educational activity with Victorian GPs aimed at improving knowledge and practices in relation to sexually transmissible diseases

OBJECTIVE: To measure the effect of a simple educational strategy for general practitioners (GPs) on their knowledge and self-reported practice in relation to sexually transmissible disease (STD) management. METHOD: In 1995, we surveyed 520 Victorian GPs; 444 (85%) responded. A sub-sample of 242 was sent an educational package in relation to STD management that required them to reflect on their performance in the survey in relation to that of the sample as a whole. Two months after they had received the package, a brief follow-up questionnaire, using a selection of questions from the first survey, was sent to these GPs. RESULTS: Practitioners showed statistically significant improvements in knowledge and self-reported practice for four of the six outcomes that were examined. CONCLUSION: A relatively simple educational package for GPs had a high participation rate and resulted in improvements in knowledge and self-reported practice that could contribute to increased STD case finding in the general practice setting. IMPLICATIONS: The key to enabling GPs to make a greater contribution to improved STD control is to encourage them to be more active in diagnosing and treating asymptomatic disease. For asymptomatic patients, sexual history-taking and selective screening are important skills but there are barriers to their implementation in the general practice setting. A key objective of GP educational programs in relation to STDs is to increase their likelihood of taking a sexual history and the significant increase in this measure for the whole sample was encouraging.     

Decreasing the number of consultations for minor illnesses of Turkish and Dutch inhabitants of a deprived area in The Netherlands: an intervention study

OBJECTIVE: The purpose of this study was to assess the effectiveness of GPs personally handing out to their patients booklets about minor ailments and self-limiting health problems (minor illnesses). METHODS: The study was a pre-test-post-test, control group design and took place in seven general practices. The participants were 162 patients (72 Turkish, 70 Dutch and 20 of other nationality) who frequently visit their GP (>5 times a year), living in deprived areas of The Hague. They were recruited in the waiting rooms of participating general practices. GPs personally handed out booklets to their patients about 12 of the most common minor illnesses and explained how to use them. The main outcome measures were consultations for the 12 minor illnesses listed in the booklet, reported by the patients themselves as well as registered in the general practice medical records, and the number of self-reported illnesses the patients suffered from. RESULTS: The results of both the self-report and the medical records show a significant decrease in number of consultations for minor illnesses in the entire research population, Turkish as well as Dutch. The number of self-reported self-limiting health problems of the Dutch increased. CONCLUSION: Due to the non-randomization procedure, some caution with regard to generalization must be taken. The results indicate that distribution by the GP of booklets with tailored information when a patient is ill leads to a reduction in consultations for minor illnesses.