A pragmatic cluster randomized controlled trial of an educational intervention for GPs in the assessment and management of depression

BACKGROUND: General practitioners (GPs) can be provided with effective training in the skills to manage depression. However, it remains uncertain whether such training achieves health gain for their patients. METHOD: The study aimed to measure the health gain from training GPs in skills for the assessment and management of depression. The study design was a cluster randomized controlled trial. GP participants were assessed for recognition of psychological disorders, attitudes to depression, prescribing patterns and experience of psychiatry and communication skills training. They were then randomized to receive training at baseline or the end of the study. Patients selected by GPs were assessed at baseline, 3 and 12 months. The primary outcome was depression status, measured by HAM-D. Secondary outcomes were psychiatric symptoms (GHQ-12) quality of life (SF-36), satisfaction with consultations, and health service use and costs. RESULTS: Thirty-eight GPs were recruited and 36 (95%) completed the study. They selected 318 patients, of whom 189 (59%) were successfully recruited. At 3 months there were no significant differences between intervention and control patients on HAM-D, GHQ-12 or SF-36. At 12 months there was a positive training effect in two domains of the SF-36, but no differences in HAM-D, GHQ-12 or health care costs. Patients reported trained GPs as somewhat better at listening and understanding but not in the other aspects of satisfaction. CONCLUSIONS: Although training programmes may improve GPs' skills in managing depression, this does not appear to translate into health gain for depressed patients or the health service.     

Development and feasibility of a modified reattribution model for somatising patients,applied by their own general practitioners

Reattribution has been developed as a cognitive-behavioural treatment model for somatisation in general practice. Our objective is to make reattribution suitable for application on patients with long-standing somatisation, including hypochondria, and to evaluate feasibility. Three modifications were developed: (1) dealing with persistent illness worry, (2) adjustment of the doctor's speed to that of the patient, and (3) the use of symptom diaries. Performance of ten experienced general practitioners (GPs), after a 20h training programme (six sessions of variable length), was measured by self-registrations and audio-taped consultations. GPs were interviewed on factors interfering with performance. Nine GPs completed the course. Reattribution was applied to 51 out of 75 indicated somatising patients, which required on average three consultations of 10-30min duration. We conclude that the modified reattribution model offers a feasible approach to the broad spectrum of somatisation seen in general practice; only the modification 'dealing with illness worry' showed limited feasibility.     

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.     

Attitude of medical students towards general practice and general practitioners.

BACKGROUND: The stimuli for this work came from the need to identify and understand the origin of students' attitudes towards general practice in the context of undergraduate curriculum reform and concerns about recruitment. AIM: To evaluate attitudes of medical students towards general practice as a specialty and general practitioners (GPs) as doctors and explore factors influencing students' attitudes and intended career choice. DESIGN OF STUDY: Cross-sectional survey. SETTING: Final-year students at two London medical schools. METHOD: Questionnaires were distributed to 984 students and the results analysed using SPSS analysis. RESULTS: The mean response rate was 72% (700/984). Medical students had a positive attitude towards general practice as a specialty (mean Likert score = 3.90/5, 95% confidence interval [CI] = 3.86 to 3.94) and towards GPs as doctors (mean Likert score = 3.62/5, 95% CI = 3.59 to 3.66). They rated personal experience of GPs as the most important factor influencing their attitude. Students' attitudes towards general practice and GPs were more positive (P<0.001) in the fifth year. First-year students perceived the media to have a more important role in influencing their attitude than those in the fifth year(P<0.001). General practice was the only career option to significantly increase in popularity between the first and final year(P < 0.001). CONCLUSIONS: Medical students end their undergraduate years with a more positive attitude towards general practice than has been reported elsewhere recently. This may be partially explained by the greater contact with GPs and suggests that efforts by medical schools to ensure a more balanced, community-based curriculum promotes positive attitudes to general practice. The influence of the media on the first years of medical school requiresfurther investigation.     

General practitioners' use of guidelines in the consultation and their attitudes to them.

BACKGROUND: There is concern about the apparent lack of uptake of management and referral guideline information by general practitioners (GPs) in their day-to-day consultations with patients. Little is understood about the barriers to the uptake of guidelines as perceived by GPs. AIMS: To explore how GPs gain access to and use guidelines, including computer-based guidelines, in day-to-day consultations with their patients; and to identify the perceived problems and barriers to the use of guidelines in such situations. METHOD: Postal questionnaires enquiring about the practices and attitudes towards the use of guidelines in general practice were completed by 391 of 600 randomly selected GPs in the South and West NHS region. RESULTS: GPs found guidelines a useful method of accessing expert information. Key factors in their uptake were brevity, an authoritative and unbiased source of evidence, and resonance with the GP's usual practices; they also needed to be flexible enough to incorporate individual viewpoints. Guidelines were perceived as being valuable to enable safe delegation of care to other health professionals and for sharing decision-making with patients. Dissemination of guidelines through the medium of computers was acceptable to the majority of GPs. Virtually all (93%) responders reported adapting guidelines to the needs of individual patients. Older GPs from non-fundholding practices were least likely to show a positive attitude towards guidelines. CONCLUSION: In principle, there is a very positive attitude towards the use of guidelines in general practice. However, those developing guidelines for use by GPs in the consulting room need to be aware of the factors that facilitate their use in practice. Educational strategies aimed at increasing the use of guidelines need to take into account the significant proportion who show negative attitudes towards guidelines, whose characteristics have been identified in this study.     

Shared decision making and risk communication in practice: A qualitative study of GPs'' experiences

BACKGROUND: Important barriers to the wider implementation of shared decision making remain. The experiences of professionals who are skilled in this approach may identify how to overcome these barriers. AIMS: To identify the experiences and views of professionals skilled in shared decision making and risk communication, exploring the opportunities and challenges for implementation. DESIGN OF STUDY: Qualitative study. SETTING: Gwent Health Authority. METHOD: Exit interviews using focus group methodology with 20 GPs who had been in practice between 1 and 10 years, and participated in an explanatory trial lasting 6 months. The trial interventions comprised training in shared decision-making skills and the use of risk communication materials. The doctors consulted with up to 48 patients each (mean = 40, half of them audiotaped) for the study. RESULTS: The GPs indicated positive attitudes towards involving patients and described positive effects on their consultations. However, the frequency of applying the new skills and tools was limited outside the trial. Doctors were selective about when they felt greater patient involvement was appropriate and feasible, rather than seeking to apply the approaches to the majority of consultations. They felt they often responded to consumer preferences for low levels of involvement in decision making. Time limitations were important in not implementing the approach more widely. CONCLUSION: The promotion of 'patient involvement' appears likely to continue. Professionals appear receptive to this, and willing to acquire the relevant skills. Strategies for wider implementation of patient involvement could address how consultations are scheduled in primary care, and raise consumers' expectations or desires for involvement.     

Does training general practitioners to elicit patients' illness representations and action plans influence their communication as a whole?

OBJECTIVE: To examine whether the discussion of illness representations and action plans during medical encounters affects the way patients and general practitioners (GPs) communicate. METHODS: In a quasi-experimental design, 10 GPs first performed care-as-usual conversations with patients. After a 6 h training they performed consultations either emphasizing patients' illness representations or action plans. Data were collected from 70 videotaped consultations with hypertensive patients, which were analyzed using the Roter Interaction Analysis System. RESULTS: Compared with care-as-usual consultations, communication in the action plan condition resulted in an increased discussion of lifestyle issues whereas communication in the illness representation condition resulted in more discussion of patient concerns. In both experimental conditions the proportion of affective GP utterances was higher while patients contributed more to the conversation. When GPs changed their communication style, patients did accordingly. CONCLUSION: The explicit address of illness representations or action plans during consultations results in more attention to patient concerns and lifestyle issues and an overall improvement in patient-GP communication in terms of affective atmosphere and patient involvement. PRACTICE IMPLICATIONS: These findings show that after a brief training GPs are able to change their communication style in a way that allows for a more thorough consideration of patient self-management.     

Concerns and confidence of general practitioners in providing telephone consultations.

BACKGROUND: In recent years the number of telephone consultations provided out of hours has increased. However, most general practitioners (GPs) have received little training in this area despite the specific skills needed to compensate for lack of visual information. Moreover, there has been no research exploring GPs' concerns and training needs in telephone consulting. AIM: To assess GPs' concerns and levels of confidence in providing telephone consultations in order to inform the development of a new training course. METHOD: Prior to attending the course, GPs were surveyed by interview or self-completion questionnaire to explore their confidence in providing telephone consultations. RESULTS: Thirty-eight GPs participated, and the sample was highly skewed towards females. The average age of participants was 42 years, 5 years less than the mean for GPs in the area. Low levels of confidence were reported by GPs in providing telephone consultations out of hours. A number of characteristics were common to telephone consultations described as difficult. The most important were lack of visual clues and lack of information about the patient, both of these were heightened in the out-of-hours period. Organizational factors leading to reduced confidence levels were also identified. CONCLUSIONS: This study demonstrates low levels of confidence among GPs conducting telephone consultations, and highlights contributing factors. Although it is not clear how far these results can be generalized, they demonstrate the need to consider telephone consulting skills training in the context of new out-of-hours arrangements. The results have been used to develop a two-day course.     

Effective improvement of doctor–patient communication: a randomised controlled trial

BACKGROUND: Doctor-patient communication is an essential component of general practice. Improvement of GPs' communication patterns is an important target of training programmes. Available studies have so far failed to provide conclusive evidence of the effectiveness of educational interventions to improve doctor-patient communication. AIM: To examine the effectiveness of a learner-centred approach that focuses on actual needs, to improve GPs' communication with patients. DESIGN OF STUDY: Randomised controlled trial. SETTING: One hundred volunteer GPs in the Netherlands. METHOD: The intervention identified individual GPs' deficiencies in communication skills by observing authentic consultations in their own surgery. This performance assessment was followed by structured activities in small group meetings, aimed at remedying the identified shortcomings. Outcomes were measured using videotaped consultations in the GPs' own surgery before and after the intervention. Communication skills were rated using the MAAS-Global, a validated checklist. RESULTS: The scores in the intervention group demonstrated a significant improvement compared with those of the control group (95% confidence interval = 0.04 to 0.75). The effect size was moderate to large (d-value = 0.66). The level of participation significantly contributed to the effectiveness. Largest improvement was found on patient-centred communication skills. CONCLUSION: The approach of structured individual improvement activities based on performance assessment is more effective in improving communication skills than current educational activities.     

How doctors move from generic goals to specific communicative behavior in real practice consultations

Objective

To understand how recommendations for communication can be brought into alignment with clinical communication routines, we explored how doctors select communicative actions during consultations.

Methods

We conducted stimulated recall interviews with 15 GPs (general practitioners), asking them to comment on recordings of two consultations. The data analysis was based on the principles of grounded theory.

Results

A model describing how doctors select communicative actions during consultations was developed. This model illustrates how GPs constantly adapt their selection of communicative actions to their evaluation of the situation. These evaluations culminate in the selection of situation-specific goals. These multiple and often dynamic goals require constant revision and adaptation of communication strategies, leading to constant readjustments of the selection of communicative actions. When selecting consultation goals GPs weigh patients’ needs and preferences as well as the medical situation and its consequences.

Conclusions

GPs’ selection of communicative actions during consultations is situational and goal driven.

Practice implications

To help doctors develop communicative competence tailored to the specific situation of each consultation, holistic communication training courses, which pay attention to the selection of consultation goals and matching communication strategies besides training specific communication skills, seem preferable to current generic communication skills training.     

A cluster randomised trial to evaluate a nutrition training programme.

BACKGROUND: The need for training to equip primary care staff with the knowledge and skills to provide dietary advice to the public has been acknowledged. Little is known about the effectiveness of such training at improving the dietary counselling skills of multidisciplinary practice teams. AIM: To evaluate the effectiveness of a nutrition training programme, delivered to primary care teams by a dietitian. DESIGN OF STUDY: A paired-cluster randomised trial. SETTING: Twelve general practices in Sunderland, in the United Kingdom. METHOD: A nutrition training programme, aimed at improving the quality of dietary consultations, was developed and delivered to six primary care teams by a dietitian. Main outcome measures were patients' recall of seven key consulting behaviours. Data were collected from patients in intervention and control practices, pre- and post-intervention. Change in knowledge and attitude of practitioners was also measured. RESULTS: All 12 practices completed the trial. Data were collected from 251 patients pre-intervention and 228 patients post-intervention. Of the seven consulting behaviours targeted in the training, only the proportion of consultations where written information (diet sheets) was provided to patients was significantly higher (13% higher, 95% confidence interval [CI = 4 to 21, P = 0.004) in the intervention practices post-training. Some evidence of improved practitioner knowledge and attitude was detected. CONCLUSION: This evaluation of a nutrition training intervention detected only a limited impact on the behaviour, knowledge, and attitudes of primary care practitioners in dietary consultations.     

Blood pressure control in treated hypertensive patients: clinical performance of general practitioners.

BACKGROUND: The blood pressure of many treated hypertensive patients remains above recommended target levels. This discrepancy may be related to general practitioners' (GPs') actions. AIM: To assess clinical performance of GPs in blood pressure control in treated hypertensive patients and to explore the influence of patient and GP characteristics on clinical performance. DESIGN OF STUDY: Cross-sectional study conducted on 195 GPs with invitations to participate made via bulletins and by letter. SETTING: One hundred and thirty-two practices in the southern half of The Netherlands from November 1996 to April 1997. METHOD: Performance criteria were selected from Dutch national hypertension guidelines for general practice. GPs completed self-report forms immediately after follow-up visits of hypertensive patients treated with antihypertensive medication. RESULTS: The GPs recorded 3526 follow-up visits. In 63% of these consultations the diastolic blood pressure (DBP) was 90 mmHg or above. The median performance rates of the GPs were less than 51% for most of the recommended actions, even at a DBP of > or = 100 mmHg. Performance of non-pharmacological actions increased gradually with increasing DBP; prescribing an increase in antihypertensive medication and making a follow-up appointment scheduled within six weeks rose steeply at a DBP of > or = 100 mmHg. Patient and GP characteristics contributed little to clinical performance. Action performance rates varied considerably between GPs. CONCLUSION: GPs seem to target their actions at a DBP of below 100 mmHg, whereas guidelines recommend targeting at a DBP of below 90 mmHg.     

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.     

Longitudinal study: Impact of communication skills training and a traineeship on medical students’ attitudes toward communication skills

ObjectivesTo study longitudinally students’ attitudes towards communication skills (CS) in order to examine whether CS training (CST) has an enduring impact on medical students’ attitudes toward being a lifelong learner of CS.Methods105 students completed the Communication Skills Attitude Scale at 4 times: before CST, after CST and before and after a traineeship.ResultsOur final sample size is 105 students. CST improved the attitudes of our students toward CS, and the traineeship stabilised those attitudes. However, while the improvement in positive attitudes was sustained over time, negative attitudes increased 6 months after CST.ConclusionCST using experiential methods in a safe environment has the potential to improve students’ attitudes towards CS. A short traineeship in general medicine allows students to quickly integrate CST into clinical practice, without deteriorating their attitudes toward CS. However, 6 months of medical lessons without CST reinforces students’ negative attitudes.Practice implicationsTo avoid the deterioration of attitudes over time, CST should be continuous or at least spaced at intervals less than 6 months and supported by the institutional authorities. In addition, placing the CST close to an observation traineeship in general practice seems an interesting way to prevent further deterioration of attitudes.     

Breast is best for GPs--or is it? Breastfeeding attitudes and practice of general practitioners in the Mid-West of Ireland

In light of the 1994 National Breastfeeding Policy and the 1999 Mid-Western Health Board (MWHB) Breastfeeding Strategy, a telephone survey of 164 General Practitioners (GPs) in the Mid-West was performed to ascertain their attitudes and practice in relation to breastfeeding. 95% believe breastfeeding promotion is part of their role and almost 40% consider GPs influential in the decision to breastfeed. Less than 10% have formal breastfeeding training, while 1/3 would be interested in formal training. 80% promote breastfeeding, and 90% are confident to deal with breastfeeding problems. Those with formal training reported higher promotion and confidence rates, and scored higher on management scenarios, GPs in the Mid-West of Ireland have positive attitudes towards breastfeeding. Training in relation to breastfeeding appears lacking, however. Formal training appears to confer advantage, and if, made accessible to interested GPs has the potential to positively influence breastfeeding rates.     

Keeping morality out and the GP in. Consultations in Danish general practice as a context for smoking cessation advice

OBJECTIVE: To describe consultations in Danish general practice as a context for a mass strategy of smoking cessation advice. METHODS: The focus of the study was on consultations for health problems that were not related to smoking. Interviews with eleven patients and their six GPs were grounded in observation of their own consultations. RESULTS: Patients and GPs agreed that the GP should adopt an attitude of moral acceptance towards patients. Ideals of moral acceptance of patients in general practice consultations were challenged by the prevailing negative moral values associated with smoking. A general aim of mutuality in the conversation in consultations could not always be achieved in smoking cessation advice. Achieving mutuality was especially a problem when smoking cessation advice was repeated at short intervals. CONCLUSION: Two elements of Danish general practice consultations were challenged by smoking cessation advice to patients without smoking-related illness: the ideal of moral acceptance of patients in general practice consultations held by GPs and patients and the wish for mutuality in the conversation during consultations. PRACTICE IMPLICATIONS: A conversation about smoking based on motivational interviewing would fit in the context of Danish general practice. Relieving the conversation of blocks due to moral implications, however, is still a challenge.     

Effectiveness of a Web-based genomics training for health educators in Texas

PurposeWith advanced genomic developments, better prevention strategies are available via personalized genomic services. Because there is a shortage of genetic professionals, and primary-care providers are overwhelmed with routine practice, involving health educators—whose expertise includes educating the general public and promoting healthy behavior—to provide basic genomics education may facilitate better services. We developed the first evidence- and theory-based family health history Web-based training for Texas health educators. This report presents its evaluation results.MethodsApproximately one-third of Texas health educators holding (Master) Certified Health Education Specialist designation (~40% were racial/ethnic minorities) participated in the family health history Web-based training. Attitudes, self-efficacy, intention, knowledge, and practice were assessed at baseline, immediately after training, and 3 months posttraining. Qualitative data were collected to provide additional evaluation findings.Resultsarticipants significantly improved their attitudes, knowledge, intention, and self-efficacy regarding family health history education, immediately posttraining and after 3 months. The number of participants practicing family health history was significantly increased. Participants’ overall assessment of the program was positive.ConclusionThis family health history Web-based training successfully increased the number of genomically competent and culturally diverse Texas health educators. Ongoing efforts are needed to sustain and expand this education as well as to disseminate it to all health educators in the United States.Genet Med 2014:16(3):271–278