Patient expectations: What do primary care patients want from the GP and how far does meeting expectations affect patient satisfaction?

There is growing recognition of the importance of patients'expectations in general practice. This study aimed to investigatethe types of expectations adult primary care patients have priorto consulting the GP, and how far meeting expectations is associatedwith increased satisfaction. Patients (n = 504) attending generalpractitioners (n = 25) at 10 London general practices were includedin the study. The Patients Intentions Questionnaire (PIQ) wasadministered prior to the consultation to investigate patients'expectations and the Expectations Met Questionnaire (EMQ) wasadministered after the consultation to find Out what the patientreportedly obtained. Satisfaction with the consultation wasalso measured using the Medical Interview Satisfaction Scale(MISS). The results of a principal components analysis of PIQitem scores indicated that the most wanted items were for ‘explanationof the problem’. There was less desire for ‘support’or ‘tests and diagnosis’. Many of the ‘support’items could potentially be provided to all patients, yet a proportionof patients reported not receiving these items from the GP.The results of one-way ANOVAs revealed that patients with greaternumbers of their expectations met reported significantly highersatisfaction with the consultation than those with lower numbersmet. The PIQ and EMQ could be potentially useful self-audittools for use by general practitioners and trainee GPs.     

Acceptability of shared care for asymptomatic HIV-positive patients

In Britain, Human Immunodeficiency Virus (HIV) disease has beenseen as an illness requiring specialist hospital care at alltimes. However, as its chronic nature has become apparent, thepossibility that it could be managed more cost effectively inprimary care has been raised. This has led to increasing interestin ‘shared care’, that is, care which is sharedbetween a general practitioner and a specialist according toclear protocols, for this group of patients. However, for ‘sharedcare’ to be a success, it must be acceptable to all concerned:patients, GPs and specialists. This paper presents our experienceof recruiting asymptomatic HIV-positive patients into a sharedcare programme: after 10 months' recruitment only 19 of 128eligible patients had accepted the offer of shared care. Thereasons for this, and alternative strategies for increasingGP involvement, are discussed.     

How Much Ulcer is Ulcer-like? Diagnostic Determinants of Peptic Ulcer in Open Access Gastroscopy

A cross-sectional diagnostic prevalence study was carried outwithin a multi-centre experiment with open access gastroscopyin Utrecht, The Netherlands. The objective of the study wasto contribute to improvement of patient selection for open accessgastroscopy and to evaluate diagnostic determinants for pepticulcer. Data were analysed in all 861 patients who were consecutivelynewly referred during the experiment to undergo gastroscopy.Patient characteristics and outcomes of gastroscopies were recorded.Univariate and multivariate (logistic) analyses were carriedout and the results were evaluated with ROC (receiver operatingcharacteristic) analysis. The most important clinical characteristicsto be used for prediction of peptic ulcer are pain on an emptystomach, absence of pain after a meal and absence of obstructivecomplaints. The scoring list derived from the full model, comprisingthese characteristics together with age, sex, information onformer dyspeptic diseases, medication and smoking (‘basiccharacteristics’), predicted peptic ulcer with an AUCof 0.78. The ‘ulcer-like’ model, with characteristicsknown from the literature, had an AUC of 0.76. The amount ofgastroscopy requests on patients suspected of a peptic ulcercould have been reduced from 60 to 44%. Forcing ‘basiccharacteristics’ into scoring lists on peptic ulcer improvedthe pre-diagnostic test capacities. The presented scoring listmay improve gastroscopy requesting by GPs aiming at findingpeptic ulcers. Practical manageability of the list should beprospectively evaluated in future experiments.     

'Baby Check' in the Inner City--Use and Value to Parents

‘Baby Check’, an information booklet designed toaid assessment of acutely ill babies, was given to a group ofsocioeconomically disadvantaged families from one inner citygeneral practice. Parents' perceptions and use of the bookletwere explored in a qualitative study based on audiotaped interviewswith 42 parents of 34 babies under 6 months old. Most families(26) used Baby Check spontaneously. Parents found that BabyCheck was helpful, reduced anxiety and increased confidencecoping with illness, seeking medical advice and communicatingwith doctors. Parents experienced some difficulties, e.g. theyhad concerns about a check for rectal temperature and they soughtmore information and advice about common illnesses. Parentsvalued and were empowered by access to ‘medical’information. Further evaluation and consultation with parentsis required to ensure that information is relevant to theirneeds.     

Patient Requests in Family Practice: A Focal Point for Clinical Negotiations

A growing body of literature has stressed the importance ofeliciting the patient's views on the management of health andillness. In particular, it is recognized that patients frequentlyenter into clinical encounters with specific requests for services,that is ideas about how they hope to be helped. The presentinvestigation examined the following two questions: (1) whatkinds of requests do adult patients coming to a family practicecentre have prior to seeing the doctor; and (2) will factoranalysis of a 25-item patient request questionnaire provideevidence of the basic or most common dimensions of patient requestsin this population? Two newly-developed instruments were administeredto a sample of 144 adult patients before their visit to thedoctor. Factor analysis yielded five major request factors—‘medicalinformation’, ‘psycho-social assistance’,‘therapeutic listening’, ‘general health advice’,and ‘biomedical treatment’ —partially replicatingthe findings of an earlier pilot study. The clinical implicationsof eliciting patient requests in the light of current behaviouraland social science research into the doctor-patient relationshipare discussed. Future research directions are also outlined.     

Capturing the meaning of 'community' in community intervention evaluation: some contributions from community psychology

Evaluations of community health promotion can underestimatethe gains that an intervention might make in a community ifthe outcomes reported are limited to aggregates of changes inhealth behaviour or attitude made at an individual level Thenotion of ‘community’ revealed by this type of evaluationis relatively unsophisticated compared to the ‘community’rhetoric which often accompanies program definition. Even thoseevaluations which report policy changes or evaluations of howcommunities became involved, often fail to capture the improvementsa community intervention can make on the problem-solving capacitiesof a community and its competence in tackling the issues whichface it. The essence of what some interventions (intentionallyor unintentionally) achieve is, therefore, missed. Empowerment is usually described as a process. But it can beconsidered as an outcome variable in community interventionsif capacity-building is a major activity of an intervention.To capture this in the evaluation design, evaluators shouldbe using active strategies to (i) articulate what empowermentactually means and (ii) challenge what intervention successreally means in interactive dialogues with program workers andthe community. Active and interactive strategies must be usedto clarify program values and intentions because evaluatorswill be misled or confused by words like ‘community involvement’,‘community development’ or ‘community participation’in program documents. These words mean different things to differentgroups. Similarly, ‘empowerment’ must be translatedinto aspects which are recognisable within the life of the programor period of interest. Community psychology is introduced in this paper as a fieldwhich may have much to offer in this analysis. Community psychologyis a field within psychology which should be distinguished fromthe more traditional approaches in community-based health promotionwhich are the legacy of behavioural health psychology.     

Drug prescribing in hospital as experienced by general practitioners: East versus West Germany

BACKGROUND AND OBJECTIVES: Drugs prescribed by the general practitioner (GP) are oftenchanged during hospitalization. This study set out to test thehypothesis that the extent of drug change and the informationprovided by the hospital determines the GPs' assessment of hospitalco-operation. The perception of drug change and hospital co-operationmay also be influenced by the degree of institutional separationof primary and secondary care. Therefore we compared GPs' respectiveattitudes in ‘East’ and ‘West’ Germany. METHOD: In 1993, a representative sample of ‘eastern’ and‘western’ German doctors received a structured questionnaire;554 doctors (63%) participated. RESULTS: Fifty-seven per cent of the western and 39% of the eastern GPsbelieved that their medication was changed in hospital in morethan 60% of their patients. Only a minority of eastern (10%)and western (15%) doctors described the information providedby the hospitals as more or less satisfactory. More westernthan eastern doctors (56% versus 32%) expressed dissatisfactionwith hospital co-operation. Respondents in eastern Germany whofelt sufficiently informed about hospital drug change were morelikely to express satisfaction with the hospital doctors' co-operation.In the former area of West Germany the judgement of co-operationwas significantly better if the extent of drug change and thefrequency of generic drug replacement by original brand-namedrugs were lower. CONCLUSIONS: The study showed that hospital-initiated drug change is a matterof concern, especially for GPs who are working in an area witha tradition of strictly separated primary and secondary care. Keywords. Drug prescribing, family practice, interprofessional relations, health system.     

The Incidence and Outcome of Rectal Bleeding in General Practice

The objective of the studies reported in this paper was to determinethe incidence as well as the final diagnostic outcome of rectalbleeding presenting in general practice. Because of the widevariety observed in incidence rates among 83 general practitioners(GPs) in the first study (A) an additional study (B) was undertaken.In study B with 10 GPs special efforts were made to maximizethe catchment rate. The mean ‘consultation incidence rate’was 7 per 1000 people per year. A follow-up period of at least1 year was applied to establish the final diagnostic conclusion.Occurrence of colorectal cancer was found in 3% of patientswith rectal bleeding. This may represent an overestimation ofthe prior probability since there was a selection in favourof patients with clinically relevant rectal bleeding. In about90% of patients rectal bleeding was related to minor ailmentsor self-limiting disorders. Further study on predictive valuesof (combinations of) other signs and symptoms is necessary todevelop clinical recommendations.     

Facing future challenges in general practice: a clinical method with computer support

This paper proposes a clinical method for general practice whichis patient-centred and which ensures that the doctor's agendais supported to secure ‘best practice’. It encompassesself-learning for GPs which is patient-focused and describesthe encouragement and support of patient self-care. The methodattempts to be pragmatic and usable within GPs' available time.The method, however, is not solely focused on the GP; it encompassesthe primary health care team and the patient. It uses clinicalinformation systems to assist in the management of the patientcare plan, to supply information to the GP and patient, in orderto aid shared decision making and to quality assure clinicalactivity. It goes further by extending the care process to handle‘virtual’ encounters in which the clinical informationsystems play a central role. Keywords. Family practice, medical informatics, models, philosophy, physician-patient relationships.     

Sticks or carrots: The challenge of implementing a management development strategy in the new NHS

The National Health Service (NHS) is involved in a process offundamental change, with a shift towards devolved responsibilitiesand the establishment of a form of internal market. The challengesof designing and implementing a national management developmentstrategy in such a situation are discussed. A brief examinationof the strategy Itself illustrates the move away from a ‘top-down’approach. In contrast to an earlier strategy, no major nationalprogrammes are proposed. The emphasis is on a ‘nationalframework’ supporting a ‘local relationship betweenindividual and manager’. A number of mechanisms for implementation,measurement and monitoring are analysed: the most promisingin the circumstances is considered to be some kind of accreditationsystem.     

PREVENTION OF ALCOHOL ABUSE-RELATED BIRTH EFFECTS -- I. PUBLIC EDUCATION EFFORTS

Maternal alcohol abuse during pregnancy can result in a patternof anomalies in children called ‘fetal alcohol syndrome’(FAS) and more recently, ‘fetal alcohol abuse syndrome(FAAS)’. FAAS as well as individual alcohol-related anomalies,called ‘alcohol abuse-related birth effects’ (AARBEs),are widely considered to be totally preventable, because theystem from a behaviour that is presumably modifiable. However,current strategies to reduce their occurrence are more palliativethan preventive, because their underlying premise, viz, thatraising public awareness of the potential dangers of commonlyused substances such as alcohol is enough to reduce their use,lacks empirical support. Moreover, in some cases they are alsocounter-productive. After considenng the relevant literature,this review contends that ‘universal’ public educationefforts will only be effective in reducing FAAS and AARBEs ifthey focus on the cause of these disorders, which is alcoholabuse rather than the currently open-ended message that anyamount of alcohol consumption during pregnancy constitutes adanger to an unborn child. This argument lays the ground workfor an alternative and more pragmatic strategy set forth inthe following paper for preventing FAAS and AARBEs.     

Parents and nurses during the immunization of children--where is the power? A conversation analysis

Background. Best practice for health care practitioners is consideredpatient-centred approaches which empower patients. Immunizationof young children requires maintaining this approach while retainingprofessional management. Objective. The objectives were to assess situations within theimmunization event with discordance between health providerand caregiver and evaluate strategies used to empowering parentswhile obtaining the desired clinical outcome. Methods. This was a qualitative study nested within a largerstudy of immunization rates in 124 randomly selected primarycare practices. Interactions between immunizing practice nurses,caregivers and children were videotaped and transcribed andunderwent conversation analysis. Six purposively sampled primarycare practices in Auckland, New Zealand, served as the setting.The participants were eight practice nurses immunizing 10 childrenand their parents. Normative pattern of interactions and ‘deviantcases’ involving discordance between nurse and parent. Results. A total of 168 minutes of video-recorded conversationfrom 10 immunization sessions provided strong ‘typical’pattern and equally striking ‘deviant cases’. Parentsmostly treated nurses as ‘experts’ and acceptedasymmetry of knowledge over medical matters. Nurses demonstratedskilful strategies in delineating their area of medical expertisefrom areas in which patients are expert—their knowledgeof themselves and their children. Conclusion. While patient centredness and empowering patientsare contemporary goals of primary health care delivery, theseattributes are not precisely defined. Patients may wish to beinformed, but many trust their health professionals to directtheir decision making. Although health professionals may impartas much knowledge as they can, asymmetry of knowledge remains.However, patients hold expertise beyond their clinical situationin the social and economic world in which they live. Keywords. Caregivers, immunization, power, primary health care, qualitative research.     

Written Simulation of Patient-Doctor Encounters. 1. Research Instrument for Registration of the Performance of General Practitioners

A written simulation of patient-doctor encounters is described,involving five patients with vague complaints, an ‘instruction’patient with sinusitis and a ‘test’ patient withacute appendicitis. Nineteen general practitioners were confrontedwith it. The extent to which the simulation distorted realityand the implications of such distortions were considered inan attempt to assess the content validity. The conclusion wasthat the simulation gave a realistic impression of the generalpractitioners' diagnostic and therapeutic approach to patientswith vague complaints. The searching procedures in relationto the complaint and the patient's perception of the complaintwere adequately depicted, and the therapeutic procedures approximatedclosely to reality. There was some distortion in the attentionpaid to psychosocial aspects as these were given more attentionin the simulation than they receive in reality.     

Explanations, explanations, explanations: how do patients with limited English construct narrative accounts in multi-lingual, multi-ethnic settings, and how can GPs interpret them?

Background. The gap is widening between understanding the subtleways patients and GPs manage their talk, and superficial discussionof the ‘language barrier’ among linguistic minoritypatients. All patients have to explain themselves, not justthose for whom English is their first or main language. Patients'explanations reflect how they want the doctor to perceive themas a patient and as a person: they reveal patients' identities.Yet interpretations are not easy when patients' style of talkingEnglish is influenced by their first language and cultural background. Objective. To explore in detail how patients with limited Englishand GPs jointly overcome misunderstandings in explanations. Methods. Using discourse analysis and conversation analysis,we examine how GPs and their patients with limited English negotiateexplanations and collaborate to manage, repair or prevent understandingproblems. Results. 31% of patients said English was not their first language.Misunderstandings arise owing to a range of linguistic and culturalfactors, including stress and intonation patterns, vocabulary,the way a patient sequences their narrative, and patient andGP pursuing different agendas. Conclusion. When talk itself is the problem, patients' explanationscan lead to misunderstandings, which GPs have to repair if theycannot prevent. Careful interpretation by skilful GPs can revealpatients' knowledge, experience and perspective. Keywords. Communicative style, cultural differences, explanations, misunderstandings.     

The Denominator for Audit in General Practice

Fleming D M (Birmingham Research Unit of the RCGP, LordswoodHouse, 54 Lordswood Road, Harborne, Birmingham B17 9DB). Thedenominator for audit in general practice. Family Practice 1985;2: 76–81. Different denominators for morbidity studies were compared fromtwo large studies in Britain. From the second national morbiditysurvey, data from 24 single-handed doctors showed a close correlationbetween the denominators ‘persons consulting’ and‘list size’ (r > 0.9) in both years of the survey,but a weaker correlation between ‘consultations’and ‘list size’ (r=0.6). However, when examiningrank order statistics for visiting and out-patient referralrates, it was immaterial for most doctors which denominatorwas chosen. Only for recorders with a consultation rate at theextremes of the range was the choice of denominator criticalto the interpretation of the data. In the practice activity analysis study, based on 47 doctorsand a mean of 284 consultations in two weeks, the correlationbetween ‘persons consulting’ and ‘total consultations’was 0.99. Thus the number consultations provided a satisfactoryproxy for persons consulting in a two-week study. These results justify the use of ‘consultations’over two weeks as a denominator in general practice audit incircumstances where rank order is appropriate for the interpretationof data.     

Images of contracting for the mental health service

Research into the development of contracts for mental healthservices with 12 localities in the Northern Regional HealthAuthority was conducted in 1990/91. Purchasers and providersin each locality negotiated a specific contract for the firstyear of the reforms introduced in ‘Working for Patients’.From this exercise three images of the contracting process weredeveloped to describe the variety of attitudes to the new systemamong local managers and professional staff. These images, ‘businessas usual’, ‘competitive bidding’ and ‘collaborativecommissioning’, are described and their relevance to theanalysis of policy implementation discussed.     

Focus Groups: a Method for Developing Consensus Guidelines in General Practice

The measurement of quality in any clinical discipline depends,in part, on a comparison with an accepted standard. Currently,such standards do not exist for the management of many commonclinical situations in Australian general practice. As partof the General Practice Evaluation Programme, a group of Illawarrageneral practitioners (GPs) selected ‘GP management ofthe menopause and asthma’ for in-depth study, and wereable to arrive at a consensus on ‘principles of practice’and ‘minimal acceptable care’ for these conditionsthrough a series of focus (research) group meetings. However,the process by which these standards were derived was felt,of itself, to be a valuable means of: (i) reducing professionalisolation; (ii) promoting quality assurance; (iii) introducingpeer review; (iv) introducing clinical audit; and (v) providingmeaningful and targeted continuing medical education appropriateto Australian general practice. This paper describes the focusgroup methodology used in this process.     

OUT-PATIENT ALCOHOL DETOXIFICATION--OUTCOME AFTER 2 MONTHS

We assessed the outcome after 2 months of 28 alcohol-dependentsubjects following out-patient detoxification using an uncontrolledfollow-up study with data collected at the time of detoxification(T1) and after 2 months (T2). We also determined the cost ofout-patient versus in patient detoxification. The setting wasa psychiatric emergency clinic at a South West London UniversityHospital. Self-reported alcohol consumption in the week beforeT1 and T2, score on the ‘Alcohol Problems Inventory’measuring alcohol-related relational, occupation, legal andmedical problems in the 2 months prior to T1 and T2, mean corpuscularvolume and gamma-glutamyl transferase at T1 and T2 were usedas outcome measures. Eight subjects had a ‘good’outcome (seven were abstinent and one only drank four unitson one day). Nine subjects were ‘improved’ by eitherhalving their alcohol consumption, or halving their ‘AlcoholProblems Inventory’ score at T2. ‘Good’ and‘improved’ outcome were confirmed by mean corpuscularvolume and gamma-glutamyl transference results. Eleven subjectswere ‘not improved’. Engagement following detoxificationwith voluntary alcohol agencies was associated with a betteroutcome. In-patient detoxification is calculated to be six timesmore expensive than out-patient detoxification. Out-patientdetoxification is a cost-effective step in the treatment ofalcohol-dependent patients.     

GPs' explanatory models for irritable bowel syndrome: a mismatch with patient models?

Background. Inconsistencies in doctors’ views about causesand treatment of irritable bowel syndrome (IBS) lead to frustrationfor doctors and in doctor–patient interactions. Diagnosisby GPs does not correspond well to established diagnostic criteria. Objective. To understand GPs’ explanatory models (EMs)and management strategies for IBS. Methods. Qualitative, semi-structured interviews with 30 GPs(15 from the UK and 15 from The Netherlands). Results. Diagnosing IBS in primary care is a complex process,involving symptoms, tests, history and risk calculation. GPswere uncertain about the aetiology of IBS, but often viewedit as a consequence of disordered bowel activity in responseto stress, which was viewed as a function of people's responsesto their environment. GPs tend to diagnose IBS by exclusion,rather than with formal diagnostic criteria. They endeavouredto present the IBS diagnosis to their patients in a way thatthey would accept, fearing that many would not be satisfiedwith a diagnosis that had no apparent physical cause. GPs focusedon managing symptoms and reassuring patients. Many GPs feltthat patients needed to take the responsibility for managingtheir IBS and for minimizing its impact on their daily lives.However, the GPs had limited awareness of the extent to whichIBS affected their patients’ daily lives. Conclusions. GPs’ diagnostic procedures and EMs for IBSare at odds with patient expectations and current guidelines.Shared discussion of what patients believe to be triggers forsymptoms, ways of coping with symptoms and the role of medicationmay be helpful. Keywords. Explanatory model, GP perception, irritable bowel syndrome, primary care, qualitative.