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.     

Differences in verbal behaviours of patients with and without emotional distress during primary care consultations

BACKGROUND: In primary care consultations patients with emotional distress tend to give verbal cues or symptom reports with psychological or psychiatric contents. This study examined the cue behaviour defined not only by psychological, but also by medical, social and life episodes related contents in patients with and without emotional distress, recognized and not by their GP. The GP's verbal behaviour in relation to patients' cue emission was also investigated. METHOD: For the six participating GPs two groups of matched pairs of patients (N = 238) were created. The two groups comprised either patients considered by GPs as being without emotional distress or patients considered as emotionally distressed. Within each pair, one patient was a case (GHQ-12 score > 2) and the other was the matched control (GHQ-12 score < 3). The medical interviews with these patients were transcribed and classified according to the Verona Medical Interview Classification System (VR-MICS). RESULTS: GHQ positive patients of both groups gave more cues in terms of total proportion than their matched controls (GHQ negative patients). The proportion of cues given by patients was related also to GP's verbal behaviour, increasing with closed psychosocial questions and decreasing with the use of active interview techniques. Attribution of emotional distress was more frequent when patients were high attenders and had a past psychiatric history. The content of cues changed in relation to GP's attribution: recognized patients gave more cues and more often with psychological content, patients not recognized as distressed gave mainly cues related to their lifestyle and life episodes. CONCLUSIONS: To improve the recognition of those emotionally distressed patients most likely to be missed GPs should increase their attention to cues related to life style and life episodes.     

What constructs do GPs use when diagnosing psychological problems?

BACKGROUND: The mismatch between general practice and psychiatric diagnosis of psychological problems has been frequently reported. AIMS: To identify which items from the 28-item general health questionnaire (GHQ-28) best predicted general practitioners' (GPs') own assessments of morbidity and the proportion of time spent in consultations on psychological problems. DESIGN OF STUDY: Cross-sectional survey. SETTING: General practice in southeast London. METHOD: Eight hundred and five consultations were carried out by 47 GPs, during which patients completed the 28-item GHQ, and doctors independently assessed the degree of psychological disturbance and the proportion of the consultation spent on psychological problems. Data from the consultations were entered into a stepwise multiple regression to determine the best GHQ-item predictors of GP judgements. RESULTS: GPs' assessments of the degree of psychological disturbance were best predicted using only seven GHQ items, and their perceptions of the proportion of time spent on psychological problems were predicted by only four items. Items were drawn predominantly from the 'anxiety and insomnia' and 'severe depression' sub-scales, ignoring the 'somatic' and 'social dysfunction' dimensions. CONCLUSION: In diagnosing psychological disturbance GPs ignore major symptom areas that psychiatrists judge important.     

How general practice patients with emotional problems presenting with somatic or psychological symptoms explain their improvement.

BACKGROUND: The emotional problems of patients presenting only somatic symptoms are frequently not detected by general practitioners (GPs), yet clinical outcomes have often been found to be no different from emotional problems directly presented. AIM: To compare clinical outcomes and attributions for improvement of patients with emotional problems presenting only somatic symptoms to GPs, with patients directly presenting emotional problems. DESIGN OF STUDY: Survey of patients with General Health Questionnaire (GHQ) scores in the symptomatic range, with follow-up after three months of a repeat GHQ and a questionnaire of patients' attributions for improvement. SETTING: A sample of 152 adult patients from nine general practices in North and East London. METHOD: Consecutive patients were invited to complete an adapted GHQ prior to their consultation. The consultations were audiotaped and coded to indicate the extent to which psychological discussion took place, as against discussion of other issues. The GPs recorded whether they considered each patient to be emotionally disturbed or psychiatrically ill at the time of the consultation, to assess GP detection of emotional disturbance. To form the initial sample, interviews were conducted one to five days after the consultation with patients who intended to present with either psychological or somatic problems, with a follow-up questionnaire after three months. RESULTS: A total of 106 patients provided follow-up information, of whom 57 presented psychological problems directly at initial consultation and 49 presented only somatic symptoms. There were no differences in clinical outcome at three months between the two groups. Somatic presenters who improved were more likely than psychological presenters to attribute improvement to change in their physical health (68% versus 31%) while psychological presenters were more likely to attribute improvement to the GP's listening and counselling in the consultation (44% versus 18%). Other attributions for improvement, such as passage of time, change in life circumstances, support of family and friends, medication, and 'working through problems myself', were equally common in both groups. CONCLUSIONS: Patients with emotional problems presenting only somatic symptoms have equivalent clinical outcomes to patients presenting psychological problems directly, but are more likely to attribute emotional improvements to change in their physical health. For some such emotionally disturbed patients it may be sufficient for GPs to treat the physical health problems and to reassure the patient, without attempting to treat the underlying emotional disturbance.     

CQI-2 — a new measure of holistic interpersonal care in primary care consultations

BACKGROUND: The Consultation Quality Index (CQI) is a holistic quality marker for GPs based on patient enablement, continuity of the care and consultation length. AIM: To evaluate the CQI-2, a new version of the CQI incorporating a process measure of GP empathy (the Consultation and Relational Empathy Measure). DESIGN OF STUDY: Cross-sectional questionnaire study. SETTING: General practice in the west of Scotland. METHOD: Empathy, enablement, continuity, and consultation length were measured in 3044 consultations involving 26 GPs in 26 different practices in the west of Scotland. CQI-2 scores were calculated and correlated with additional data on GPs' and patients' attitudes. Comparisons were also made with the UK-wide data from which the original CQI had been calculated. RESULTS: CQI-2 scores were independent of deprivation, access, demographics, and case-mix. GPs with lower CQI-2 scores valued empathy and longer consultations less than these GPs with higher CQI-2 scores. 'Below average CQI-2' GPs (those in the bottom 25%) also felt less valued by patients and colleagues. Patients' showed less confidence in and gained less satisfaction from these doctors. Data ranges from the study were comparable with the UK data ranges used to construct the original CQI. CONCLUSIONS: The CQI-2 is a new measure of holistic interpersonal care. In a small but representative sample of GPs it appears to differentiate between below and above average doctors. CQI-2 scores may reflect important aspects of morale, core values and patient-centred care. There may be potential for its use as part of professional development and as a component of the general medical services contract.     

The impact of training in problem-based interviewing on the detection and management of psychological problems presenting in primary care.

BACKGROUND: The vast majority of mental health problems present to primary care teams. However, rates of under-diagnosis remain worryingly high. This study explores a GP-centred approach to these issues. AIM: To examine the impact of training in problem-based interviewing (BPI) on the detection and management of psychological problems in primary care. METHOD: The detection and management of psychological problems by 10 general practitioners (GPs) who had received PBI training 12 months earlier was compared with that of 10 control GPs matched for age, sex, clinical experience, and practice setting; and had originally applied for, but had not been able to attend, BPI training. Consecutive attendees at one randomly selected surgery undertaken by each GP were invited to participate in the study. Two hundred and eighty patients living in Newcastle upon Tyne met inclusion criteria and gave informed consent. The presence or absence of psychological problems was assessed using patient self-ratings on the 28-item version of the General Health Questionnaire (GHQ) and blind independent observer ratings of the brief Present State Examination (PSE). Patient satisfaction with interviews was rated using the Medical Interview Satisfaction Scale (MISS). After each consultation, the GPs (blind to subjective and observer ratings) recorded their assessment and management of the patients' problems on a Practice Activity Card (PAC). RESULTS: In comparison with control GPs, index GPs demonstrated significantly greater sensitivity in the detection of psychological problems in the GHQ-PAC ratings. The absolute decrease in misdiagnosis of GHQ cases was 9% and of PSE cases was 15%. Patients meeting GHQ criteria for caseness were more likely to be prescribed psychotropic medication by an index GP than compared with a control GP. Length of interview did not differ between the groups and mean scores on the MISS suggested that patients attending PBI-trained GPs, compared with control GPs, were as satisfied or slightly more satisfied with their consultation. CONCLUSION: In comparison with control GPs, PBI-trained GPs were better at recognizing and managing psychological disorders. The potential benefits of BPI training are discussed in light of other attempts to improve mental health skills in primary care.     

Detecting suicidal ideation in older patients: identifying risk factors within the general practice setting

BACKGROUND: GPs are the most frequently accessed health professional among suicidal individuals in the community.AIM: To determine the prevalence of psychological distress and suicidal ideation among patients aged 60 years and older presenting to GPs, and the relationship between these variables in detecting patients who may be contemplating suicide.Design of study: Cross-sectional analysis of older patients presenting to Australian GPs between 2002 and 2003. SETTING: One thousand and sixty-one consecutive patients aged 60 years or over attending one of 54 randomly selected Western Australian GPs. METHOD: Prior to their medical consultation, patients completed a self-report questionnaire, which included questions about current suicidal ideation (Depressive Symptom Inventory Suicidality Subscale [DSI-SS]) and depression (Center for Epidemiological Studies Depression Scale [CES-D]). Patients' chief complaints were obtained from consultation summary sheets completed by their GP. RESULTS: Although only 5.1% of patients presented with psychological complaints, 5.8% acknowledged current suicidal ideation and 23.8% had clinically significant levels of depressive symptomatology. Suicidal ideation was associated with CES-D scores greater than 16 (odds ratio [OR] = 3.7, 95% confidence interval [CI] = 1.5 to 8.9), feelings of depression (OR = 7.7, 95% CI = 3.4 to 17.7), and previous suicide attempt (OR = 7.4, 95% CI = 2.7 to 20.2) in a logistic regression model, but not with poor self-perceived health, use of licit drugs (smoking, alcohol, and hypnotics), or type of presenting complaint at the time of assessment. CONCLUSIONS: Although older general practice patients tend to present for issues related to their physical health, approximately a quarter of this cohort also possess high levels of psychological distress, including current thoughts of suicide. Older patients who show any signs of depression or distress should be asked about psychological symptoms, including suicidal ideation.     

Patients' reasons for not presenting emotional problems in general practice consultations.

BACKGROUND: Patients commonly do not mention emotional problems in consultations, and this is a factor in general practitioners' (GPs') difficulty in identifying psychological morbidity. AIM: To investigate patients' self-reported reasons for not disclosing psychological problems in consultations with GPs. METHOD: From nine general practices, a sample of patients with high General Health Questionnaire scores, who planned to present only somatic symptoms to the GP, were interviewed after their consultation with the GP. The interview covered their reasons for not mentioning emotional problems. A patient satisfaction questionnaire was administered. RESULTS: A total of 83 patients were interviewed. Sixty-four patients confirmed that they had not mentioned emotional problems in the consultation; 23 (36%) of these gave primarily realistic reasons for not presenting emotional problems (e.g. able to cope with distress), 29 (45%) gave reasons related to psychological embarrassment or hesitation to trouble the GP, and 12 (19%) were mainly deterred by the doctors' interview behaviours. The latter group had significantly lower satisfaction scores than patients in the other two groups. In addition, patients in all groups commonly reported perceptions of lack of time (48%) and that there is nothing doctors can do to help (39%) as barriers to mentioning emotional problems. CONCLUSION: An understanding of patients' reasons for not disclosing emotional problems can assist in identifying subgroups of patients with different management needs.     

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.     

Determinants of mental distress in adults with a severe auditory impairment: differences between prelingual and postlingual deafness

OBJECTIVE: To investigate the determinants of mental health among severe hearing-impaired adults in the Netherlands, separately by prelingual and postlingual age of onset. METHODS: Five hundred twenty-three face-to-face interviews were carried out by persons with practical skills in communication with hearing-impaired people. RESULTS: Of prelingually and postlingually deaf men, 27.1% and 27.7%, respectively, reported mental distress (scores on the General Health Questionnaire > or = 2), and among women these figures were 32.4% and 43.2%. These rates are higher than in the general population (men: 22.0%; women: 26.6%). Among the prelingual category, none of the demographic or hearing loss-related characteristics was associated with mental health status as measured by the General Health Questionnaire (GHQ). Of these variables, only additional impairment or serious illness was associated with the brief Symptom Checklist (SCL-8D). Among the postlingual category, female gender and equilibrium disturbance was associated with both the GHQ and SCL-8D, and additional impairment or serious illness with the SCL-8D. For both categories, the risk of mental distress also was higher in those with more communication problems, lower levels of self-esteem, and poorer acceptance of the hearing loss. Opportunities for identification in youth and social support were not associated with mental health. CONCLUSIONS: Mental health status differs between the hearing-impaired and the general population, but not as much as is sometimes suggested. Mental distress is greater in those in certain categories of the hearing-impaired.     

From the surgery to the surgeon: does deprivation influence consultation and operation rates?

BACKGROUND: Concern about equity of access to health care has increased since the health care reforms implemented in the 1990s. Access to specialist health care is controlled by general practitioners; assessing and ensuring equity should therefore begin in general practice. AIM: This study set out to determine whether there are socioeconomic differences in the relationship between expressed need for possible surgical intervention (consulting a general practitioner) and surgical provision. METHOD: Information on the social class distribution of expressed need was obtained from the third national morbidity survey (1981-82) for 140,049 patients consulting a general practitioner. The conditions examined were: inguinal hernia, gallstones, tonsillitis, varicose veins, cataract and osteoarthritis. This expressed need was compared with the appropriate operation for all residents of North East Thames Regional Health Authority from January 1991 to July 1992 classified, according to area of residence, by the Townsend deprivation score. RESULTS: The relationship between expressed need and provision by deprivation was concordant for some conditions, but discordant for others. For cataract and tonsillitis, there was an inverse U pattern between increasing deprivation and both patient consultation and operation ratios. For varicose veins, deprivation was associated with higher patient consultation and operation ratios. For hernia, gallstones and osteoarthritis, consultations increased with deprivation, but operation ratios were either unrelated to deprivation scores (hernia and gallstones) or decreased by deprivation score (hip operations). CONCLUSION: There are marked socioeconomic differences in consultation ratios for these common conditions which may not be matched by operation ratios. For discordant comparisons, people in the most deprived quartiles were generally least likely to receive surgery despite being most likely to consult a general practitioner with symptoms. If validated, these findings have important implications for general practice and service providers.     

Decisional strategies for the attribution of emotional distress in primary care

BACKGROUND: In primary care the General Health Questionnaire (GHQ) is used to provide an independent assessment of probable caseness of psychological disorder against which to test the ability of the general practitioner (GP) to recognize patients with current emotional problems. METHOD: The aim of the present study was to identify those clinical and psychosocial data on patients that increase the likelihood of GPs' attribution of emotional distress (GP model) and those that predict patients' emotional distress as defined by the GHQ-12 (GHQ model). The associations were explored using a classification tree technique (CHAID) and compared using bivariate logistic regression. Six GPs and 444 primary care patients took part. RESULTS: The accuracy indices of the hierarchical GP and GHQ models were 72% and 69% respectively. The availability of information on patients' psychopharmacological and psychiatric/psychological treatment in the last year was the most important predictor of attribution. Occupational, financial and housing problems and life events of loss were the most important predictors of the GHQ-12 case definition. The overall accuracy of the bivariate model was 73%. Compared with the GHQ-12, GPs gave significantly more importance to psychiatric treatment, psychopharmacological drug use and chronic illness. CONCLUSIONS: The findings suggest that to improve the detection of current emotional distress in primary care patients GPs should pay foremost and systematic attention to social problems and recent life events of loss. These problems are important clues for the possible presence of emotional distress, whereas critical patient data, in particular psychiatric history and psychopharmacological treatment, increase the probability of attribution errors.     

The role of the general health questionnaire in general practice consultations.

BACKGROUND: The patient self-rating questionnaire is commonly used as a research tool to identify patients with 'unrecognized' depression. There is no evidence to support its use as a clinical tool in general practice. AIM: To determine whether use of the 30-item general health questionnaire (GHQ) is a practical means of increasing identification of 'new' episodes of emotional distress among patients consulting their general practitioner (GP). METHOD: A randomized controlled trial was carried out in a Scottish new town practice with eight partners. In the waiting room, 1912 patients aged over 14 years and consulting over a 10-month period attempted to complete the GHQ. The 'clinical judgement' group posted the questionnaire into a box then attended the doctor as normal. The 'screened' group presented the questionnaire to the doctor. After the consultation, the doctor completed an assessment questionnaire. The main outcome measures were GHQ scores and doctors' assessments of mental health. RESULTS: In total, 1589 patients were eligible to participate. However, 207 patients in the screened group were excluded because the doctor did not look at the questionnaire. The clinical judgement group (59.7% patients) and the screened group (40.3%) were compared. Although the doctors' diagnoses of distress were low in the clinical judgement group (8.1%), they were significantly greater in the screened group (13.9%) where the diagnosis of depression was doubled. The percentage of patients scoring greater than or equal to 9 (GHQ+) was 21.5% and 21.0% respectively. The level of agreement between the doctors' diagnoses of distress and the questionnaires scoring GHQ+ rose from 19% in the clinical judgement group to 35% in the screened group. CONCLUSIONS: The general health questionnaire used in a practice setting increases the identification of patients with emotional distress. However, the use made of the questionnaires in the screened group raises questions of doctor and patient acceptability.     

Detecting psychological distress: can general practitioners improve their own performance?

BACKGROUND: Many studies have suggested that general practitioners fail to detect a substantial minority of their patients who are psychologically distressed, and there is concern about the possible sequelae of this. Individual patients may suffer unresolved problems, and there are potential costs to the health service in consequent recurrent consultations, inappropriate referrals or treatment. Educational interventions based on small groups led by facilitators have been shown to alter the consultation behaviours of general practitioners that are known to be related to accurate detection of psychological distress. AIM: This controlled study aimed to show that, by utilizing a brief self-directed educational intervention focusing on detection of psychological distress, general practitioners can improve their performance significantly. For this purpose, a new educational intervention was designed: the second aim of the study was thus to assess the effectiveness of this specific intervention. METHOD: An educational intervention was designed which focused on skills relevant to detecting psychological distress, using the principles of reflection on general practitioner performance and consultation skill work. It was designed to be used by individual general practitioners without outside support, using a combination of written background material, feedback on performance and analysis of video material. The effectiveness of the intervention was tested by comparing a trial and control cohort of general practitioners, using detection rates as an outcome measure. RESULTS: The detection rate of the general practitioners who underwent the intervention improved significantly compared with their performance before intervention and with that of the control group. CONCLUSION: General practitioners can improve their ability to detect psychological distress in their patients utilizing this self-directed educational approach.     

The relationship between census-derived socio-economic variables and general practice consultation rates in three town centre practices.

BACKGROUND: The relationship between socio-economic factors and consultation rates is important in determining resource allocation to general practices. AIM: To determine the relationship between general practice surgery consultation rates and census-derived socio-economic variables for patients receiving the same primary and secondary care. METHOD: A retrospective analysis was taken of computerized records in three general practices in Mansfield, North Nottinghamshire, with 29,142 patients spread over 15 electoral wards (Jarman score range from -23 to +25.5). Linear regression analysis of surgery consultation rates at ward and enumeration district levels was performed against Jarman and Townsend deprivation scores and census socio-economic variables. RESULTS: Both the Townsend score (r2 = 59%) and the Jarman score (r2 = 39%) were associated with surgery consultation rates at ward level. The Townsend score had a stronger association than the Jarman score because all four of its component variables were individually associated with increased consultations compared with four out of eight Jarman components. CONCLUSIONS: Even in practices not eligible for deprivation payments there were appreciable differences in consultation rates between areas with different socio-economic characteristics. The results suggest that the variables used to determine deprivation payments should be reconsidered, and they support suggestions that payments should be introduced at a lower level of deprivation and administered on an enumeration district basis.     

Do nursing home residents make greater demands on GPs? A prospective comparative study.

BACKGROUND: The number of people residing in nursing homes has increased. General practitioners (GPs) receive an increased capitation fee for elderly patients in recognition of their higher consultation rate. However, there is no distinction between elderly patients residing in nursing homes and those in the community. AIM: To determine whether nursing home residents receive greater general practice input than people residing in the community. METHOD: Prospective comparative study of all 345 residents of eight nursing homes in Glasgow and a 2:1 age, sex, and GP matched comparison group residing in the community. A comparison of contacts with primary care over three months in terms of frequency, nature, length, and outcome was carried out. RESULTS: Nursing home residents received more total contacts with primary care staff (P < 0.0001) and more face-to-face consultations with GPs (P < 0.0001). They were more likely to be seen as an emergency (P < 0.01) but were no more likely to be referred to hospital, and were less likely to be followed-up by their GP (P < 0.0001). Although individual consultations with nursing home residents were shorter than those with the community group (P < 0.0001), the overall time spent consulting with them was longer (P < 0.001). This equated to an additional 28 minutes of time per patient per annum. Some of this time would have been offset by less time spent travelling, since 61% of nursing home consultations were done during the same visit as other consultations, compared with only 3% of community consultations (P < 0.0001). CONCLUSION: Our study suggests that nursing home residents do require a greater input from general practice than people of the same age and sex who are residing in the community. While consideration may be given to greater financial reimbursement of GPs who provide medical care to nursing home residents, consideration should also be given to restructuring the medical cover for nursing home residents. This would result in a greater scope for proactive and preventive interventions and for consulting with several patients during one visit.     

Gender differences and the relationships of perceived background stress and psychological distress with cardiovascular responses to laboratory stressors

The primary aim of this study was to evaluate the relationships of perceived background stress and self-reported psychological distress on cardiovascular reactivity during acute laboratory stressors. The Perceived Stress Scale (PSS) was used as the measure of perceived background stress, and the General Health Questionnaire (GHQ) was used as the measure of psychological distress. A secondary aim was to examine whether background stress and psychological distress affected the susceptibility to induction of a negative mood using music. Heart rate (HR) and blood pressure (BP) were measured in 149 female and male college students at rest and during a stressful mental arithmetic (MA) task and a mood induction procedure. Higher scores on the GHQ were associated with lower systolic BP reactivity during the MA task by all participants. Higher scores on the PSS and GHQ were also associated with lower diastolic BP and HR reactivity, but only in females. Thus, higher self-reports of background stress and psychological distress tended to result in blunted reactivity to an acute laboratory challenge. Higher levels of background stress and psychological distress were not associated with greater susceptibility to a negative mood induction. This study adds to the growing literature indicating that potentially negative health outcomes may be associated with diminished cardiovascular reactivity under certain conditions.     

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.     

Psychological distress: outcome and consultation rates in one general practice

This paper reports a one-year follow-up of random samples of 90 male and 96 female patients attending one general practitioner. There was no statistically significant difference between men and women in the total score on the 28-item general health questionnaire or any of the subscores. However, the diagnostic labels applied to the two sexes were strikingly different as was the prescribing of psychotropic drugs. Outcome of psychological distress was assessed in terms of change in total general health questionnaire score. Two thirds of the patients (65%) showed normal scores at the beginning and end of the follow-up period, 19% changed from abnormal to normal and 8% changed from normal to abnormal. The remaining 9% had persistently high scores though less than half had been given a psychiatric diagnosis. They had very high consultation rates persisting over several years and three-quarters were known to have chronic physical illness. It seems possible that some patients with persistently high consultation rates who present with chronic, mainly somatic, symptoms may be or may become psychologically distressed to a significant degree and that this psychological distress goes unrecognized in the presence of physical disease.