General practitioners' use of computers during the consultation.

This study documents the extent of reported computer use by general practitioners (GPs) in consultations with patients, and identifies barriers to their use. There was a 65% response rate from a random sample of 600 GPs in the South and West National Health Service (NHS) region who were sent a questionnaire. Ninety-one per cent (357) had a desktop computer terminal in their consulting rooms. Of these, 98% used the computer to look up information or prescribe medication, 75% entered details about selected problems presented by patients, and 36% entered information about the patient's presenting problem at every consultation. Only 18% used computers to access reference information. Use of the computer for anything other than looking up patient information or prescribing was positively associated with fundholding status and use of a personal computer at home, and was independent of number of years in practice. Sixty-five per cent of responders had positive attitudes to the inclusion of management guidelines on the computer software, and 45% of responders held positive views towards the idea of integrating management guidelines with the patient's personal computerized medical record. Consideration should be given to targeting training at those GPs who appear to be reluctant to use computers during the consultation.     

Does awareness of being video recorded affect doctors' consultation behaviour?

Four general practitioners, two of whom had no previous experience of video recording in the consultation, took part in a study to assess the effect of awareness of video recording on their consultation behaviour. A video camera was sited unobtrusively in each consulting room for a month during which five randomly selected surgeries were recorded with the doctors being informed at the time, and five without their being informed. The video recorded consultations were analysed using TIMER, a tool designed to measure objectively behaviour in terms of physical, verbal and secondary activities in consultations. The proportions of time spent on the 27 consultation parameters were compared when doctors were aware and unaware of the recording, using analysis of variance. This demonstrated only one significant difference, in the low frequency parameter of the doctor's exploration of the patients' concepts (P less than 0.05). In a secondary analysis of the first four consultations in each surgery, where any effect of the presence of the video camera would be expected to be most marked, there was again only one significant difference in the 27 parameters (in patient preparation; P = 0.01). No significant difference owing to awareness of video recording was found in consultation length, the number of problems dealt with, or previous inexperience of video recording. When surgeries at the start of the month were compared with those at the end, four significant differences (P less than 0.05) out of 108 areas were demonstrated both when the doctor was aware and unaware of video recording, and there was no consistency in the direction of the differences.(ABSTRACT TRUNCATED AT 250 WORDS)     

Video Consultation Use by Australian General Practitioners: Video Vignette Study

Background

There is unequal access to health care in Australia, particularly for the one-third of the population living in remote and rural areas. Video consultations delivered via the Internet present an opportunity to provide medical services to those who are underserviced, but this is not currently routine practice in Australia. There are advantages and shortcomings to using video consultations for diagnosis, and general practitioners (GPs) have varying opinions regarding their efficacy.

Objective

The aim of this Internet-based study was to explore the attitudes of Australian GPs toward video consultation by using a range of patient scenarios presenting different clinical problems.

Methods

Overall, 102 GPs were invited to view 6 video vignettes featuring patients presenting with acute and chronic illnesses. For each vignette, they were asked to offer a differential diagnosis and to complete a survey based on the theory of planned behavior documenting their views on the value of a video consultation.

Results

A total of 47 GPs participated in the study. The participants were younger than Australian GPs based on national data, and more likely to be working in a larger practice. Most participants (72%-100%) agreed on the differential diagnosis in all video scenarios. Approximately one-third of the study participants were positive about video consultations, one-third were ambivalent, and one-third were against them. In all, 91% opposed conducting a video consultation for the patient with symptoms of an acute myocardial infarction. Inability to examine the patient was most frequently cited as the reason for not conducting a video consultation. Australian GPs who were favorably inclined toward video consultations were more likely to work in larger practices, and were more established GPs, especially in rural areas. The survey results also suggest that the deployment of video technology will need to focus on follow-up consultations.

Conclusions

Patients with minor self-limiting illnesses and those with medical emergencies are unlikely to be offered access to a GP by video. The process of establishing video consultations as routine practice will need to be endorsed by senior members of the profession and funding organizations. Video consultation techniques will also need to be taught in medical schools.     

More time for complex consultations in a high-deprivation practice is associated with increased patient enablement.

BACKGROUND: Evidence of the beneficial effects of longer consultations in general practice is limited. AIM: To evaluate the effect of increasing consultation length on patient enablement in general practice in an area of extreme socioeconomic deprivation. DESIGN OF STUDY: Longitudinal study using a 'before and after' design. SETTING: Keppoch Medical Centre in Glasgow, which serves the most deprived practice area in Scotland. METHOD: Participants were 300 adult patients at baseline, before the introduction of longer consultations, and 324 at follow-up, more than 1 year after the introduction of longer consultations. The intervention studied was more time in complex consultations. Patient satisfaction, perceptions of the GPs' empathy, GP stress, and patient enablement were collected by face-to-face interview. Additional qualitative data were obtained by individual interviews with the GPs, relating to their perceptions of the impact of the longer consultations. RESULTS: Response rates of 70% were obtained. Overall, 53% of consultations were complex. GP stress was higher in complex consultations. Patient satisfaction and perception of the GPs' empathy were consistently high. Average consultation length in complex consultations was increased by 2.5 minutes by the intervention. GP stress in consultations was decreased after the introduction of longer consultations, and patient enablement was increased. GPs' views endorsed these findings, with more anticipatory and coordinated care being possible in the longer consultations. CONCLUSION: More resource to provide more time in complex consultations in an area of extreme deprivation is associated with an increase in patient enablement.     

Doctor, patient and computer--a framework for the new consultation

Purpose

The use of a computer during general/family practice consultations is on the rise across the world, yet little is known about the effect the use of a computer may have on the all important physician-patient relationship. This paper provides a framework for further analysis of computers influence on physician-patient interactions during general practice consultations.

Methods

This is an observational qualitative study informed by hermeneutics and the phenomenological tradition of Irving Goffman, based in Australian general practice. A single digital video recording of 141 patient encounters over 6 months was made and imported into a tagging software program to facilitate analysis. Through an iterative process several keys and behaviours were described for doctors, patients and the computers in the interaction.

Results

Physicians tended to fall into two categories; unipolar—those who tend to maintain the lower pole of their body facing the computer except were examination of the patient or some other action demands otherwise, and bipolar—those physicians who repeatedly alternate the orientation of their lower pole between the computer and the patient. Patients tended to demonstrate behaviours that focused on the physician to the exclusion of the computer (dyadic) and included the computer in the consultation (triadic). The computer was also seen to influence the physician-patient interaction passively or actively.

Conclusion

In describing and categorising the behaviours of the computer, in addition to the humans in the consultation, a framework is provided for further analytical work on the impact of computers in general practice.     

Computers in the consultation: the patient''s view.

BACKGROUND. The use of computers in general practice consultations is becoming widespread. AIM. A qualitative study was undertaken to determine how patients in one practice responded to the use of computers, and the issues which particularly concerned them when doctors used computers in the consultation. METHOD. Thirty patients whose age-sex characteristics were proportional to the age-sex distribution of one practice were selected to be interviewed within two weeks of a consultation. The interviews were taped, transcribed and analysed. RESULTS: Patients had seen or used computers in many other places and accepted their role in data management. Patients with more experience of computers were more aware of their limitations, particularly with regard to the possibility of loss of confidentiality. Patients did not think the use of a computer led to a loss of the personal touch in the consultation as long as verbal skills and eye contact were maintained. However, they did expect doctors using computers to have acquired computer skills. All but one patient said they wanted to see what was on the screen, although 11 did not know they had the right to read their notes on the screen. CONCLUSION. Patients regarded the use of computers by their doctors as normal and indicative of the doctors being up to date. Most respondents were concerned about possible loss of confidentiality. This concern, and their expressed preference for computer details to be visible and shared, pose challenges to doctors' technical and communication skills.     

Deploying a clinical innovation in the context of actor-patient consultations in general practice: A prelude to a formal clinical trial

Background  

Innovations to be deployed during consultations with patients may influence the clinical performance of the medical practitioner. This study examined the impact on General Practitioners' (GPs) consultation performance of novel computer software, designed for use while consulting the patient.     

Deprivation, psychological distress, and consultation length in general practice.

BACKGROUND: Recent research has shown the benefits of longer consultations in general practice. Approximately 40% of patients presenting to general practitioners (GPs) are psychologically distressed. Studies have shown that psychological morbidity increases with increasing socioeconomic deprivation. The combined effects of psychological morbidity and socioeconomic deprivation on consultation length are unknown. In addition, though it is known that doctors correctly identify half their distressed patients as such, the effect of consultation length on identification is unknown. AIM: To examine factors associated with presentation and recognition of psychological distress in GPs' surgeries and the interaction of these factors with consultation length. DESIGN OF STUDY: A cross-sectional study. SETTING: Nine general practices in the West of Scotland, involving 1075 consultations of 21 full-time GPs. METHOD: The main outcome measures were patient psychological distress (measured by General Health Questionnaire-12), doctors' identification of psychological distress, consultation length, and Carstairs deprivation category scores. RESULTS: The mean consultation length was 8.71 minutes (SD = 4.40) and the prevalence of positive GHQ scores was 44.7%. Increasing GHQ (greater psychological distress) and lower deprivation category scores (greater affluence) were associated with longer consultations. Positive GHQ scoring increased with greater socioeconomic deprivation and also peaked in the 30 to 39 years age group. Recognition of psychological distress was greater in longer consultations (50% increase in consultation length associated with 32% increase in recognition). CONCLUSION: Increasing socioeconomic deprivation is associated with higher prevalence of psychological distress and shorter consultations. This provides further evidence to support Tudor Hart's 'inverse care law' and has implications for the resourcing of primary care in deprived areas.     

Consultation use of a computer by general practitioners

Reporting on an experimental field study of computer use by general practitioners during consultations, this paper focuses particularly on the experiences of the doctors in their efforts to communicate concurrently with a patient and a computer. Through the analysis of logs of computer use, video recordings of consultations and interviews with doctors, the authors report on the uptake of the computer facilities, the impact of such use on information handling during the consultation, the doctors' views about using the system, and finally the relationship between doctors' `natural' consulting styles and their uptake and views of the system.     

Surgical pathology extradepartmental consultation practices

OBJECTIVES: To document the practice parameters and case characteristics associated with personal (expert) consultations. We also examine the value, level of participant (customer) satisfaction, turnaround time, and rate of personal consultations. DESIGN: We asked participants in the College of American Pathologists' Q-Probes program to document cases sent for consultation during 4 months or up to 20 cases. They documented patient and specimen characteristics, the turnaround times, and the participants' levels of satisfaction with the consultation experience. PARTICIPANTS: One hundred eighty laboratories/surgical pathology practices. One hundred seventy-two (95.6%) were from the United States; the remainder were located in Canada and Australia. MAIN OUTCOME MEASURES: Rate and turnaround time of consultations and participant level of satisfaction. RESULTS: A total of 2746 consultation cases were examined for an aggregate consultation rate of 0.5% (median, 0.7%). Institutions with a higher occupied bed size and a greater number of surgical pathology cases both had lower consultation rates (P < or =.05). The median turnaround time (defined as the interval from the date on which the case was sent to the date on which the diagnosis was received) was 6 days. Twenty-nine percent and 68% of cases had a turnaround time within 3 and 7 days, respectively. Fifty-two percent of cases were sent to nationally known experts, and 32% were sent to local experts. Skin (18.0%), hematolymphoid (11.6%), and breast (9.6%) specimens were most commonly sent for consultation. In 70.5% of cases, the consultant confirmed the referring pathologist's original diagnosis, but in 15.9% of cases, the consultant also added significant information. Satisfaction rates were higher with faster turnaround times and verbal reporting. Satisfaction rates were lower for cases in which the patient or the clinician requested the consultation and in which the consultant's diagnosis was ambiguous. CONCLUSIONS: This study establishes a multi-institutional consultation rate of 0.5%, defines the nature of surgical pathology consultations, and demonstrates that satisfaction with consultations is associated with a faster turnaround time and receipt of additional, clinically meaningful information.     

Barriers to the adoption of computerised decision support systems in general practice consultations: a qualitative study of GPs' perspectives

INTRODUCTION: Computerised decision support systems are increasingly important in primary care for the practice of evidence-based medicine and the development of shared GP-patient decision making. However, despite their emergence, such systems have not been entirely embraced by GPs. There is little qualitative research exploring practical barriers to the adoption of decision support systems in this setting. METHOD: Qualitative interviews with 15 GPs in the West Midlands. RESULTS: Several practical barriers were identified to the use of computerised support systems in primary care consultations. These included limitations of practitioners' IT skills, problems for GPs in understanding the risk output of systems and GP concerns about communicating risk sufficiently well to patients. Concerns over the time implications of using a system in a consultation was also identified as a barrier. CONCLUSION: Designers of decision support systems for use in primary care consultations must account for the practical needs of users when developing computerised support systems. Systems must be acceptable to the format of a consultation, include definitions of what output means, and help facilitate dialogue between the GP and the patient.     

Video analysis of communication in paediatric consultations in primary care.

BACKGROUND: There is a paucity of research evidence concerning communication in paediatric consultations between GPs, adults, and child patients. AIM: This study was carried out to identify features of the interaction between a doctor, a child patient aged 6-12 years, and their carer in the consultation associated with the child's participation. DESIGN OF STUDY: A qualitative analysis of video recordings of 31 primary care paediatric consultations was undertaken, using strategies from the methodology of conversation analysis. SETTING: Primary care, Suffolk, UK. METHOD: NHS GPs from three primary care trusts (PCTs), were invited to participate in this study. Sixteen volunteers from this sample took part. RESULTS: Analysis of the interaction in the consultations revealed that the children had little involvement. Children participated when invited to do so, and took more time than adults to answer a doctor's question. An adult carer was less likely to answer on behalf of a child, when they were in a position to see that the doctor's gaze was directed at the child, and the doctor addressed the child by name. Adult carers, who had not voiced their own concerns first, were seen to interrupt doctor-child talk. In consultations where the participants sat in a triangular arrangement, all parties being an equal distance apart, triadic talk was noted. CONCLUSION: Child involvement in the primary care consultation is associated with adult carers being able to voice their own concerns early in the consultation, and children being invited to speak with the appropriate recipient design.     

Comparison of video-recorded consultations with those in which patients' consent is withheld.

BACKGROUND: Video-recorded consultations are widely used for research in general practice. Recently, video recordings have begun to be used for the purposes of general practitioner (GP) registrar assessment. It is unknown, however, whether consultations in which patients withhold consent for recording differ from those that are recorded. AIM: To compare clinical problems and demographic characteristics of adult patients who consent to the video recording of consultations with those who withhold consent. METHOD: This was prospective study of 538 adult patients consulting 42 GPs, based in practices throughout Leicestershire. Each patient attended a surgery session with one of the 42 GPs between April 1995 and March 1996. Clinical presentations and demographic characteristics of patients consenting and withholding consent to the video recording of their consultations were compared. GPs' perceptions of whether patients in these two groups were distressed/upset or embarrassed were also compared. RESULTS: A total of 85.9% (462/538) of adults consented to video recording, and 14.1% (76/538) withheld consent. Multiple logistic regression revealed that patients who presented with a mental health problem were more likely to withhold consent to recording (odds ratio 2.5, 95% confidence interval 1.4-4.6). Younger patients were also more likely to withhold consent to video recording. Additionally, where patients' consent was withheld, GPs perceived patients to be more distressed or embarrassed. CONCLUSION: Younger patients and those suffering from mental health problems are more likely than others to withhold consent to being video recorded for research purposes in general practice. The implications of this study for the assessment of registrar GPs using video-recorded consultations are discussed.     

Long to short consultation ratio: a proxy measure of quality of care for general practice.

Eighty five general practitioners in the Lothian region recorded information on all surgery consultations on one day in every 15 for a year. On the basis of their mean consultation times with patients the working styles of the general practitioners were described as 'faster' (n = 24), 'intermediate' (n = 40) or 'slower' (n = 21). The 21,707 consultations which they carried out over this period were defined as 'short' (five minutes or less), 'medium' (six to nine minutes) or 'long' (10 minutes or more). Independent of doctor style, 'long' consultations as against 'short' consultations were associated with the doctor: (1) dealing with more of the psychosocial problems which had been recognized and were relevant to the patient's care; (2) dealing with more of the long term health problems which had been recognized as relevant; and (3) carrying out more health promotion in the consultation. Patients also reported greater satisfaction with longer consultations. The ratio of long:short consultations was found to be 0.28:1 for 'faster' doctors as against 2.3:1 for 'slower' doctors. When doctors in either group had more heavily booked surgeries or were running late, the long:short consultation ratio fell, in some cases by over 50%. This paper suggests that the ratio of long to short consultation length for a general practitioner might become the basis of a simply proxy measure of quality of care; and that its use might help monitor the effect of recent and proposed changes in the way in which general practice care is delivered.     

Examination of the effects of emotional disturbance and its detection on general practice patients'' satisfaction with the consultation.

BACKGROUND. A patient's satisfaction with a consultation may be influenced by many factors relating to both patient and doctor. AIM. This study set out to examine the effects of emotional disturbance and its detection on general practice patients' satisfaction with the consultation. METHOD. A prospective study involving 893 adult patients attending 12 general practitioners in Glasgow was carried out. Questionnaires were completed by general practitioners after consecutive surgery consultations. Patients completed forms assessing mental state and satisfaction with inter-personal aspects of the consultation. RESULTS. Patients reporting frank psychological disturbance tended to express more dissatisfaction with the inter-personal aspects of the consultation. This effect was alleviated in the majority by recognition of the disturbance by the general practitioner. General practitioners differed markedly in their assessment of the psychological component of consultations. Fewer dissatisfied patients were found in the surgeries of doctors who tended to rate the psychological component of consultations more highly. In contrast, the general practitioner's overall accuracy of diagnosis of psychological distress was a poor predictor of the proportion of dissatisfied patients. CONCLUSION. This preliminary study suggests that a tendency among doctors to assign importance to the psychological component of consultations may enhance elements of patient satisfaction. It is not clear whether this [psychological-mindedness' is an attribute which can be learnt. To resolve this uncertainty, studies are needed of the effects on patients of educational interventions designed to increase general practitioners' sensitivity to psychological distress.     

The workload of GPs: consultations of patients with psychological and somatic problems compared

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.