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.     

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.     

General practitioners' attitudes to the development of midwifery group practices.

BACKGROUND: The report Changing childbirth (1993) has led to the development of midwifery-led schemes that aim to increase the continuity of maternity care. AIM: To determine the impact of midwifery group practices on the work of general practitioners (GPs) and their perceptions of midwifery group practice care. METHOD: Postal questionnaires were sent to 58 GPs referring women to the care of midwifery group practices (group-practice GPs), and a shorter questionnaire was sent to the remaining 67 GPs (non-group-practice GPs) within the same postcode area as a comparison group. In-depth interviews were conducted with 12 GPs. RESULTS: Questionnaires were returned by 71% of group-practice GPs and 81% of non-group practice GPs. One third of the group practice GPs felt that they were seeing group practice women too few times, and 50% thought midwives discouraged women from visiting their GP for antenatal checks. Over 80% of group practice GPs believed that midwives had the skills to detect deviation from the normal, and 66% would confidently refer women to their care. However, only 14% of group practice GPs believed that their own role was clear, while 64% agreed that communication with group practice midwives was poor, and concerns were expressed about the level of consultation before establishing schemes. Of the non-group practice GPs, 87% said they would consider referring women to the care of a midwifery group practice in the future. CONCLUSIONS: General practitioners were generally positive about the quality of care provided by midwifery group practices but identified issues that require addressing in developing this model of care.     

An exploration of the value of the personal doctor-patient relationship in general practice.

BACKGROUND: Within the context of general practice, continuity of care creates an opportunity for a personal doctor-patient relationship to develop which has been associated with significant benefits for patients and general practitioners (GPs). Continuity of care is, however, threatened by trends in the organisational development of primary health care in the United Kingdom and its intrinsic role within general practice is currently the subject of debate. AIMS: To determine how many patients report having a personal doctor and when this is most valued, to compare the value of a personal doctor-patient relationship with that of convenience, and to relate these findings to a range of patient, GP, and practice variables. DESIGN OF STUDY: Cross sectional postal questionnaire study. SETTING: Nine hundred and ninety-six randomly selected adult patients from a stratified random sample of 18 practices and 284 GP principals in Oxfordshire. METHOD: Qualitative interviews with patients and GPs were conducted and used to derive a parallel patient and GP questionnaire. Each patient (100 from each practice) was invited to complete a questionnaire to evaluate their experience and views concerning personal care. All GP principals currently practising in Oxfordshire were sent a similar questionnaire, which also included demographic variables. RESULTS: Overall, 75% of patients reported having at least one personal GP. The number of patients reporting a personal GP in each practice varied from 53% to 92%. Having a personal doctor-patient relationship was highly valued by patients and GPs, in particular for more serious, psychological and family issues when 77-88% of patients and 80-98% of GPs valued a personal relationship more than a convenient appointment. For minor illness it had much less value. CONCLUSIONS: Patients and GPs particularly value a personal doctor-patient relationship for more serious or for psychological problems. Whether a patient has a personal GP is associated with their perception of its importance and with factors which create an opportunity for a relationship to evolve.     

Views of newly-qualified GPs about their training and preparedness: lessons for extended generalist training

BackgroundGeneral practice is becoming increasingly complex due to an ageing population with multiple morbidities and the shift of services from secondary to primary care, yet GP training remains largely the same. Extended training is now recommended, initially proposed as a fourth GP specialty trainee year, but more recently as a broad-based 4-year specialty training programme.AimTo explore the views of newly-qualified GPs about their training and preparedness for specific aspects of the GP’s role.MethodSemi-structured interviews with 18 GPs between November 2011 and April 2012.ResultsGaining experience in a variety of primary care environments widens insight into patient populations as well as helping GPs develop adaptability and confidence, although this is not routinely part of GP training. However, alongside variety, having continuity with patients in practice remains important. Opportunities to be involved in the management of a practice or to take on substantial leadership roles also vary widely and this may limit preparedness and development of generalist skills.ConclusionExtended training could help prepare GPs for the current challenges of general practice. It could ensure all trainees are exposed to a greater variety of primary care settings including those outside GP practice, as well as experience of business, finance, and leadership roles. Collectively, these changes have the potential to produce GPs with both generalist and enhanced skills, who are better prepared to work collaboratively across the organisational boundaries between primary, secondary, and community care.     

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.     

The ACA training programme to improve communication between general practitioners and their palliative care patients: development and applicability

ABSTRACT: We describe the development of a new training programme on GP-patient communication in palliative care, and the applicability to GPs and GP Trainees. This 'ACA training programme' focuses on Availability of the GP for the patient, Current issues that should be raised by the GP, and Anticipating various scenarios. Evaluation results indicate the ACA training programme to be applicable to GPs and GP Trainees. The ACA checklist was appreciated by GPs as useful both in practice and as a learning tool, whereas GP Trainees mainly appreciated the list for use in practice.     

Assessment of mutual understanding of physician patient encounters: development and validation of a Mutual Understanding Scale (MUS) in a multicultural general practice setting

Mutual understanding between physician and patient is essential for good quality of care; however, both parties have different views on health complaints and treatment. This study aimed to develop and validate a measure of mutual understanding (MU) in a multicultural setting. The study included 986 patients from 38 general practices. GPs completed a questionnaire and patients were interviewed after the consultation. To assess mutual understanding the answers from GP and patient to questions about different consultation aspects were compared. An expert panel, using nominal group technique, developed criteria for mutual understanding on consultation aspects and secondly, established a ranking to combine all aspects into an overall consultation judgement. Regarding construct validity, patients' ethnicity, age and language proficiency were the most important predictors for MU. Regarding criterion validity, all GP-related criteria (the GPs perception of his ability to explain to the patient, the patient's ability to explain to the GP, and the patient's understanding of consultation aspects), were well-related to MU. The same can be said of patient's consultation satisfaction and feeling that the GP was considerate. We conclude that the Mutual Understanding Scale is regarded a reliable and valid measure to be used in large-scale quantitative studies.     

How do teenagers and primary healthcare providers view each other? An overview of key themes.

BACKGROUND: Teenagers have often been asked for their opinions about health services. However, relatively few studies have involved quantitative and qualitative methods of assessing them. Furthermore, there have been no United Kingdom studies of providers' views on the health of teenagers or of providers' opinions about their role in teenage health. AIM: To determine how teenagers view primary care, to discover how primary care providers view teenage patients, and to note any differences in opinions between the two groups. DESIGN OF STUDY: Questionnaire survey, focus group discussions, and semi-structured interviews. SETTING: Two thousand two hundred and sixty-five teenage patients, 16 general practitioners (GPs), 12 practice nurses, and 12 general practice receptionists in South Wales valley communities. METHOD: Selected practices provided age-sex registers of patients aged between 14 and 18 years and questionnaires were sent to these patients. Focus groups were assembled from those teenagers who had completed and returned the questionnaire. Semi-structured interviews between one member of the study team and GP surgery staff, chosen randomly from staff lists in the selected surgeries. RESULTS: The teenagers reported a lack of knowledge of services available from primary care, a feeling of a lack of respect for teenage health concerns, poor communication skills in GPs, and a poor understanding of confidentiality issues. The providers did not always share these concerns and they also had differing views on communication and confidentiality issues. CONCLUSION: The data demonstrated important findings about how teenagers would like primary care services to be improved. There was an apparent gulf between teenagers' own opinions about health care and the opinions held by primary care providers.     

GP's consult and health behaviour change project. Developing a programme to train GPs in communication skills to achieve lifestyle improvements

OBJECTIVE: The European definition of General Practice states that GPs should use their core competence, amongst others, in their communication with patients. Their communication skills are particularly challenged in the field of lifestyle improvements. Most GPs feel they lack efficacy in achieving lifestyle changes. In November 2002 the Prevention Department of the Scientific Society of Flemish GPs (now Domus Medica) decided to start a project "consulting & behaviour change". Under this project, every Flemish GP should by the year 2007, have (amongst others things) a basic knowledge of the principles of lifestyle improvements and should be able to give a short advice to high risk patients. METHOD: A literature search was conducted to make an inventory of models that could be used to train GPs. Experts at specific methods and topics were consulted to get acquainted with their specific approaches. Experts in the field of CME were gathered to discuss barriers and solutions to these barriers. During steering group meetings, several possible solutions were discussed. RESULTS: The Trans Theoretical Model (TTM-as theoretical framework) and brief motivational interviews (MI-as communication skill) were evaluated as offering the best opportunities for adapting the work situation of the GP. We promoted this approach to the GPs as an ABC concept (Anamnesis/Ask; Be the guide/Decision tree ("Beslissingsboom" in Dutch); Continuity) applied on different topics (smoke stop, alcohol, healthy food, physical activity). In our guidelines we pay more attention to brief motivational interviews for health behaviour changes. Recently we started developing an e-learning website as part of a larger learning project, this in cooperaion with different Flemish partners and disciplines. CONCLUSION: The Trans Theoretical Model and the brief motivational interviewing approach seem to be accepted by health care, educational and scientific organisations. The process of integrating this approach in the GP's daily practice has to be continued and needs better evaluation/follow up. PRACTICE IMPLICATIONS: The integration of the brief motivational interviewing approach can facilitate health behaviour change in practice, without requesting more consultation time.     

General practitioner empathy, patient enablement, and patient-reported outcomes in primary care in an area of high socio-economic deprivation in Scotland--a pilot prospective study using structural equation modeling

Objective

The aim of this pilot prospective study was to investigate the relationships between general practitioners (GPs) empathy, patient enablement, and patient-assessed outcomes in primary care consultations in an area of high socio-economic deprivation in Scotland.

Methods

This prospective study was carried out in a five-doctor practice in an area of high socio-economic deprivation in Scotland. Patients’ views on the consultation were gathered using the Consultation and Relational Empathy (CARE) Measure and the Patient Enablement Instrument (PEI). Changes in main complaint and well-being 1 month after the contact consultation were gathered from patients by postal questionnaire. The effect of GP empathy on patient enablement and prospective change in outcome was investigated using structural equation modelling.

Results

323 patients completed the initial questionnaire at the contact consultation and of these 136 (42%) completed and returned the follow-up questionnaire at 1 month. Confirmatory factor analysis confirmed the construct validity of the CARE Measure, though omission of two of the six PEI items was required in order to reach an acceptable global data fit. The structural equation model revealed a direct positive relationship between GP empathy and patient enablement at contact consultation and a prospective relationship between patient enablement and changes in main complaint and well-being at 1 month.

Conclusion

In a high deprivation setting, GP empathy is associated with patient enablement at consultation, and enablement predicts patient-rated changes 1 month later. Further larger studies are desirable to confirm or refute these findings.

Practice implications

Ways of increasing GP empathy and patient enablement need to be established in order to maximise patient outcomes. Consultation length and relational continuity of care are known factors; the benefit of training and support for GPs needs to be further investigated.     

Characteristics of children consulting for cough, sore throat, or earache.

BACKGROUND: GPs are often consulted for respiratory tract symptoms in children. AIM: To explore characteristics of children, their parents, and their GPs that are correlated with consulting a GP for cough, sore throat, or earache. DESIGN OF STUDY: Second Dutch National Survey of General Practice (DNSGP-2) with a health interview and an additional questionnaire. SETTING: Children aged 0-17 years registered with 122 GPs in Dutch general practice. METHOD: Characteristics of patients and their GPs were derived from the DNSGP-2 health interview and a questionnaire, respectively. Characteristics of the illness symptoms and GP consultation were acquired by means of an additional questionnaire. Data were analysed using multivariate logistic regression. RESULTS: Of all children who completed the questionnaire, 550 reported cough, sore throat, or earache in the 2 weeks preceding the interview with 147 of them consulting their GP. Young children more frequently consulted the GP for respiratory symptoms, as did children with fever, longer duration of symptoms, those reporting their health to be 'poor to good', and living in an urban area. When parents were worried, and when a child or their parents were cued by someone else, the GP was also consulted more often. GP-related determinants were not associated with GP consultation by children. CONCLUSION: This study emphasises the importance of establishing the reasons behind children with respiratory tract symptoms consulting their GP. When GPs are aware of possible determinants of the decision to consult a GP, more appropriate advice and reassurance can be given regarding these respiratory symptoms, which are generally self-limiting.     

Validity aspects of the patient feedback questionnaire on consultation skills (PFC), a promising learning instrument in medical education

Objective

A focus on the communicator competency is considered to be an important requirement to help physicians to acquire consultation skills. A feedback questionnaire, in which patients assess consultation skills might be a useful learning tool. An existing questionnaire on patient perception of patient-centeredness (PPPC) was adapted to cover the ‘communicator’ items in the competency profile. We assessed the face and content validity, the construct validity and the internal consistency of this new patient feedback on consultation skills (PFC) questionnaire.

Methods

We assessed the face validity of the PFC by interviewing patients and general practice trainees (GPTs) during the developmental process. The content validity was determined by experts (n = 10). First-year GPTs (23) collected 222 PFCs, from which the data were used to assess the construct validity (factor analysis), internal consistency, response rates and ceiling effects.

Results

The PFC adequately covers the corresponding ‘communicator’ competency (face and content validity). Factor analysis showed a one-dimensional construct. The internal consistency was high (Cronbach's alpha 0.89). For the single items, the response rate varied from 89.2% to 100%; the maximum score (ceiling effect) varied from 45.5% to 89.2%.

Conclusion

The PFC appears to be a valid, internally consistent instrument.

Practical implications

The PFC may be a valuable learning tool with which GPTs, other physicians and medical students can acquire feedback from patients regarding their consultation skills.     

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.     

Patients'' experiences of GP consultations for psychological problems: a qualitative study

BACKGROUND: The vast majority of patients with psychological problems are seen solely by their GP, but little is known about patients' perspectives regarding the variety of consultation skills that may be used in routine GP consultations with these patients. AIM: To identify which aspects of GP consultations patients presenting with psychological problems experience as helpful or unhelpful. DESIGN: Qualitative study. SETTING: Nine general practices in north central London. METHOD: Twenty patients, who had discussed psychological problems as a significant part of their index GP consultation, were asked in detail using the tape-assisted recall (TAR) method, about aspects of the consultation they had experienced as helpful or unhelpful. RESULTS: All patients described how the relationship with the GP helped or hindered them in discussing their problems; this was central to their experience of the consultation. An underlying attitude of genuine interest and empathy, within a continuing relationship, was highly valued. Patients also described how the GP helped them make sense of, or resolve their problems, and supported their efforts to change. CONCLUSION: These patient accounts suggest that routine GP consultations for psychological problems can have a powerful impact, at least short-term. The GP role in providing a safe place where patients feel they are listened to and understood should not be underestimated, particularly in the mental health context. Further research is required to investigate the longer-term impact of different GP behaviours on patient health outcomes. The TAR method has potential applications in primary care research and in the training of GPs and other health professionals.     

Potential for suicide prevention in primary care? An analysis of factors associated with suicide.

BACKGROUND: General practitioners (GPs) need to be aware of the risk factors for suicide. GP records may provide clues to identifying the relative importance of such risk factors. AIMS: To identify, in suicide cases and matched controls, the patterns of consultation, diagnosis, and treatment of mental illness, and recording of risk factors for suicide. To examine the usefulness of data routinely collected by GPs in computerized databases to investigate treatment of patients in general practice prior to suicide. METHOD: Case control study using GP records from the General Practice Research Database (GPRD). Three controls selected for each case, matched for age, sex, and duration of registration with practice. Information extracted of the prevalence of major disease; diagnosis of, and treatment, or referral for, mental illness; frequency of recording of recent life events; and consultations with the GP in the 12 months prior to death. RESULT: Of the 339 suicide cases recorded, 80% were male, which is similar to the national percentage for this age group. Females were more likely than males to have a history of mental illness and to have been diagnosed and treated for mental illness in the 12 months before death (59% versus 35%), and women were more likely to have previously attempted suicide (47% versus 27%). There was no significant difference between males and females in period of time since last contact with GP practice, but females consulted more frequently. Twenty-nine per cent of cases had not consulted their GP in the six months prior to death. In multivariate analysis, the following were identified as independent risk factors: history of attempted suicide; untreated serious mental illness (odds ratio > 20); recent (past 12 months) marital life event; alcohol abuse; frequent consultations with GP; and previous mental illness. Recording of life events by GPs was poor. CONCLUSIONS: Females at risk of suicide are more likely than males to have been diagnosed and treated for mental illness. It is likely that GPs are under-diagnosed and under-treating males at risk. Data from the GPRD give comparable results to those from other studies. The GPRD is a potentially useful tool for research into relatively uncommon events in general practice.     

Acquisition of clinical skills in postgraduate training for general practice.

BACKGROUND: Postgraduate training in general practice aims to develop clinical competence. However, little is known about its effect on trainees' development of clinical skills. AIM: To assess the acquisition of clinical skills during a 3-year training programme and to evaluate whether a satisfactory level is achieved towards the end of training. DESIGN OF STUDY: Cross-sectional design. SETTING: Dutch postgraduate training in general practice from 1995 to 1998. METHOD: Clinical skills were assessed using a written knowledge test of skills and by an Objective Structured Clinical Examination (OSCE). The written test was administered to trainees in all 3 years. Trainees at completion of their training took the OSCE. The results of both tests were compared with a standard of adequacy and to a reference group of general practitioner (GP) trainers. RESULTS: An increase in the level of clinical skills and pass rate was found throughout the training, being most prominent during the first 6 months. At completion of their training, trainees scored higher than the GPs on the written test (48% versus 39%) and on the OSCE (69% versus 63%). Eighty-eight per cent of the trainees would have passed the written test against 70% of the GPs and 94% would have passed the OSCE against 80% of the GPs. CONCLUSION: A 3-year postgraduate training period in general practice contributes to a satisfactory acquisition of clinical skills. Further research into when and where acquisition takes place, and the role of the GP trainer, is needed.