Consulting patterns: comparison between doctors' perceptions and patients' behaviour

Changes in the structure of a practice and the gender of the partners were accompanied by the abandonment of a personal list system. Doctors' opinions about the consulting behaviour of patients in the practice were determined by questionnaire. The notes of 100 patients registered with each of the six partners were examined to determine the nature and number of consultations with each doctor for the years 1980 and 1984. Doctors were found to be unaware of the reasons for which patients consulted different partners. In addition, doctors' opinions about how patients should consult did not correlate with patients' consulting behaviour. It was also found that women consulted the female partners in the practice more commonly than the male partners only after the number of women partners in the practice had increased from one to two.     

Diagnostic delay in narcolepsy type 1: combining the patients' and the doctors' perspectives

Narcolepsy type 1 is a neurological disorder characterized by a unique syndrome, including the pathognomonic symptom of cataplexy. The diagnosis can be confirmed by objective measures, such as typical findings in the multiple sleep latency test, reduced or undetectable levels of orexin (hypocretin) in the cerebrospinal fluid, and linkage to a specific HLA haplotype. Nevertheless, the mean time that elapses from symptom onset to the correct diagnosis ranges between 10 and 20 years, and the causes and correlates of this delay are poorly understood. Diagnostic delay was assessed on 52 well‐defined patients with narcolepsy type 1, evaluating clinical, electrophysiological and neurochemical parameters and the results of a 41‐item questionnaire developed to obtain the patients' perspective on various aspects of the diagnostic process. The mean time gap between disease onset and first medical consultation was 3.2 ± 5.1 years; the mean diagnostic delay was 8.9 ± 11.0 years. Prior to correct diagnosis, patients received a wide variety of misdiagnoses. The self‐ratings of the patients revealed that the undiagnosed symptoms caused high levels of anxiety and unjustified criticism by family, friends and employers. Multiple regression analysis identified higher cerebrospinal fluid orexin levels (β = 0.311, P = 0.01), and a longer interval between the onset of excessive daytime sleepiness and cataplexy (β = 0.368, P = 0.002) as independent associates of longer diagnostic delay. The diagnostic delay decreased over the last decades (β = ?0.672, P < 0.001). In conclusion, delayed diagnosis of narcolepsy type 1 is very common, associated with many adverse consequences, and requires educational efforts to improve awareness on narcolepsy among healthcare providers and the general population.     

Holding relationships in primary care: a qualitative exploration of doctors' and patients' perceptions

BackgroundOngoing doctor-patient relationships are integral to the patient-centred ideals of UK general practice, particularly for patients with chronic conditions or complex health problems. ‘Holding’, a doctor-patient relationship defined as establishing and maintaining a trusting, constant, reliable relationship that is concerned with ongoing support without expectation of cure, has previously been suggested as a management strategy for such patients.AimTo explore urban GPs'' and patients'' experiences of the management of chronic illness, with a particular focus on holding relationships.MethodParticipating GPs recruited registered patients with chronic illness with whom they felt they had established a holding relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.ResultsGP responders considered holding to be a small but routine part of theirwork. Benefits described included providing support to patients but also containing demands on secondary care. Patient responders, all with complex ongoing needs, described the relationship with their GP as a reassuring, positive, and securing partnership. Both GP and patient responders emphasised the importance of pre-existing knowledge of past life-story, and valued holding as a potential tool for changing health-related behaviour. Difficulties with holding work included fears of dependency, and problems of access.ConclusionHolding relationships are a routine part of general practice, valued by both GPs and patients. Naming and valuing holding work may legitimise this activity in the management of people with chronic and complex health problems.     

Cultural diversity in the predictors of adolescent cigarette smoking: The relative influence of peers

A culturally diverse sample of 4375 adolescents completed a self-report inventory assessing their current amount of smoking, and several psychosocial predictors of smoking (e.g., depression, anger, stress, smoking among peers, etc). Results revealed that Whites smoke more than Blacks, Asians, and less acculturated Latinos but not more than highly acculturated Latinos. Stepwise regression analyses of the predictors of smoking found significant ethnic and acculturation differences in the relative predictive power of 18 well-known risk factors. Smoking among peers was the best predictor of smoking for White adolescents (accounting for 23.5% of the variance) but accounted for only 15% of the variance for Latino youth, 9.6% of the variance for Asian youth, and none of the variance for Black youth. Results are discussed in terms of their implications for smoking prevention programs that focus on resisting peer influences.This research was supported by NIDA Grant R01DA6307 to Brian Flay.     

Pre-recorded answerphone messages: influence on patients' feelings and behaviour in out of hours requests for visits.

The aim of this qualitative study was to investigate the feelings and behaviour of patients requesting out of hours visits on hearing pre-recorded answerphone messages. Actual messages which had been recorded were classified by a group of four people. Examples of each type of message were then played to a second group, of six people, who expressed their feelings about the varying messages. A third group, of 10 people, was asked to invent hypothetical emergency situations of increasing severity. For each of the emergency situations their proposed actions on hearing the different types of answerphone message were recorded. The results showed that people preferred short messages telling them what to do in an emergency and the time of the next surgery. They also felt that the message should be recorded by a doctor and not a receptionist and be delivered in a 'neutral' tone. Proposed actions were not influenced by the content of the message or the person recording the message. The most important factor in deciding which action to take was the tone of the message. A 'strict' rather than a 'neutral' tone tended to discourage patients from calling out their doctor and was more likely to lead to inappropriate responses. It is suggested that answerphone messages recorded by the doctor, stating what to do in an emergency and the time of the next surgery, delivered in a neutral rather than a strict tone, will lead to the most appropriate responses from patients.     

Treatment decision making in prostate cancer: patients' participation in complex decisions

OBJECTIVE: (1) To explore to what degree prostate cancer (PC) patients felt they had participated in treatment decision making (TDM). (2) To determine whether perceived roles during TDM were associated with medical and sociodemographic variables. (3) To examine to what extent satisfaction with TDM was related to perceived role or medical and sociodemographic variables. METHODS: Patients (n=126) were recruited in hospitals and from the Dutch PC patient organization. The relationship between patients' role and stage of disease, treatment modality, age, social status and education was determined, as well as patients' satisfaction with TDM. RESULTS: Most patients felt they had participated in TDM (autonomous 18%, collaborative 60%). Older patients and those with advanced disease more frequently reported not having been involved in decision making. Satisfaction with TDM was related to age and role in TDM but not to stage of disease or treatment modality. Younger men were least content when they had not been involved in decision making. CONCLUSION: Patients' level of participation and satisfaction with TDM appears to be related to medical and sociodemographic variables. PRACTICE IMPLICATIONS: Satisfaction with TDM may be related to patients' age and assumed role. It is recommended to take this into account when planning treatment for prostate cancer patients.     

Cancer communication patterns and the influence of patient characteristics: disparities in information-giving and affective behaviors

OBJECTIVE: To examine whether patient characteristics are associated with communication patterns between oncologists and breast cancer patients. METHODS: The study was conducted at 14 practices with 58 oncologists with 405 newly diagnosed patients with no prior history of breast cancer. The initial consultation between oncologist and patient was audiotaped and a detailed communication analysis performed. Interviews were conducted with patients and physicians immediately before and after consultations. RESULTS: Disparities were found across all patient demographics. Younger patients asked more questions as did those who were white had more than a high school education and when they reported an income that was high or medium income, compared to low (p<0.01). Patient proactive behavior, such as volunteering information to the physician unasked, was similarly related with all demographic predictors as was physician tendency to ask patients questions. Despite the inherently emotional nature of this encounter, there was surprisingly little overt discussion about how the patient felt about her diagnosis and how she was coping. Both patients and physicians spent time trying to establish an interpersonal relationship with each other, although patients spent more time. Patients differed in the number of relationship building utterances by age, education and income and physicians spent more time engaged in relationship building with white than non-white patients (p<0.01) and more educated and affluent patients (p<0.05). CONCLUSION: This study indicates that patient demographic factors, such as race, income level, education and age seem to influence the amount of time physicians spend in almost all communication categories with patients. One recurring difference across most communication categories was race. Racial differences occurred in almost every one of the communication categories examined. White patients had many more utterances in almost every communication category than their non-white counterparts. These differences may mean a less adequate decision-making process for patients who are members of racial or ethnic minorities, patients who are less affluent, older, and have less education. PRACTICE IMPLICATIONS: This study found that providers communicate differently with patients by age, race, education and income. These differences in communication may lead to disparities in patient outcomes. Communication skills training should explicitly train clinicians to recognize these tendencies. Patients with different demographics characteristics may also required education that is tailored to them.     

The influence of physicians' demographic characteristics and their patients' demographic characteristics on physician practice: implications for education and research.

In recent years, interest in improving health care to diverse patient populations has stimulated the development of academic and clinical resources to improve physicians' cultural competence. These efforts have focused on increasing physicians' sensitivity to the roles patients' ethnicity and culture play in health care. However, the influence of physicians' own demographic characteristics on their practice of medicine is an important, yet relatively overlooked, consideration among efforts to improve cross-cultural care. There is a strong presumption in the medical literature that clinicians are neutral operators governed by objective science and are unaffected by personal variables. Yet, there is a body of research that finds physicians' practice patterns are influenced by their own demographic characteristics, and patient care is affected by the demographic concordance or discordance of the physician-patient dyad. The author discusses this existing literature to illustrate the presence and importance of the impact of physicians' demographic characteristics on the care they provide and discusses strategies to mitigate this influence. Greater attention to understanding the way in which physician demographic characteristics influence clinical care using multidisciplinary and multimodal approaches provides an opportunity to improve the quality of medical education and improve the quality and efficacy of medical care.     

Motivation and frustration in cardiology trial participation: the patient perspective

OBJECTIVE:

The participation of humans in clinical cardiology trials remains essential, but little is known regarding participant perceptions of such studies. We examined the factors that motivated participation in such studies, as well as those that led to participant frustration.

METHODS:

Patients who had participated in hypertension and coronary arterial disease (phases II, III, and IV) clinical trials were invited to answer a questionnaire. They were divided into two groups: Group I, which included participants in placebo-controlled clinical trials after randomization, and Group II, which included participants in clinical trials in which the tested treatment was compared to another drug after randomization and in which a placebo was used in the washout period.

RESULTS:

Eighty patients (47 patients in Group I and 33 patients in Group II) with different socio-demographic characteristics were interviewed. Approximately 60% of the patients were motivated to participate in the trial with the expectation of personal benefit. Nine participants (11.2%) expressed the desire to withdraw, which was due to their perception of risk during the testing in the clinical trial (Group I) and to the necessity of repeated returns to the institution (Group II). However, the patients did not withdraw due to fear of termination of hospital treatment.

CONCLUSIONS:

Although this study had a small patient sample, the possibility of receiving a benefit from the new tested treatment was consistently reported as a motivation to participate in the trials.     

Involving patients with depression in research: survey of patients' attitudes to participation

Background

Clinicians report barriers to involving their patients in mental health research and have concerns that participation may have negative effects.

Aim

To investigate patients'' views on participating in a primary care randomised controlled trial (RCT) comparing two antidepressant drugs.

Design of study

Cross-sectional survey.

Setting

General practices, England.

Method

Six hundred and one trial participants were surveyed about their reasons for, and experience of, participating.

Results

The questionnaire was completed by 252/601 (42%) participants. The most influential factors determining participation were: wanting to help others with depression (94%, 95% confidence interval [CI] = 90 to 97%) of responders rated this as ‘important’ or ‘very important’); friendly researchers (94%, 95% CI = 90 to 96%); and interest in the research (88%, 95% CI = 83 to 91%). Most were glad they took part and would consider participating in future research. Ninety-six per cent (95% CI = 92 to 98%) reported that their confidence in their GP had increased or remained unchanged since referral. Qualitative analysis of free-text responses indicated that patients found participation beneficial and liked: being altruistic, doing something positive, feeling supported by the researchers, and having time to talk. Many gained understanding of their depression and valued feedback on their progress. A minority reported negative views, which commonly related to taking antidepressants, and answering questionnaires.

Conclusion

GPs have a vital role in facilitating patient involvement in research but report barriers to referring depressed patients to RCTs. However, this data suggests that patients are willing to participate and many find this beneficial. Understanding attitudes to participation in mental health research is a crucial step in designing trials that are more acceptable to patients and GPs. This will strengthen the evidence for therapeutic approaches in primary care.     

How interpreters influence patient participation in medical consultations: The confluence of verbal and nonverbal dimensions of interpreter-mediated clinical communication

Objective

To investigate i) how the patient’s participation in interaction occurs in interpreter-mediated consultations (IMCs) when the doctor provides information to the patient or tries to elicit information from them; ii) how the interpreter’s presence in the consultation influences the patient’s participation.

Influence of patient characteristics on doctors' questioning and lifestyle advice for coronary heart disease: a UK/US video experiment.

BACKGROUND: Risk factors for coronary heart disease (CHD) vary with patient characteristics but we do not know how this influences doctors' questioning and advice giving. AIMS: To find out whether four patient characteristics - age (55 versus 75 years), sex, class, and race - influence primary care doctors' questioning style and advice giving in the United Kingdom (UK) and United States (US). DESIGN OF STUDY: A factorial experiment using video simulation of a patient consulting with CHD symptoms, designed to systematically alter their age, sex, class, and race. SETTING: Surrey, south east London and the West Midlands in the UK, and Massachusetts in the US. METHOD: A stratified random sample of 128 general practitioners (GPs) in the UK and 128 primary care doctors in the US were shown video vignettes in their practices of patient consultations, and interviewed about patient management strategies. RESULTS: Sex and age influence doctors' questioning of patients presenting with CHD. Men are asked more questions overall, particularly about smoking and drinking. Middle-aged patients are asked more about their lifestyle. Advice about smoking is given to more men than women, and to more mid-life than older patients. Women doctors question patients about their lifestyle more often, and give more advice to patients about their diet. CONCLUSION: Doctors' questioning strategies are influenced by patients' sex and age, suggesting that doctors may miss smoking- and alcohol-related factors among women and older patients with CHD. Doctors give more advice about smoking to men, despite sex equality in smoking prevalence. Therefore, doctors' information seeking and advice giving do not match known patient risk factors.     

The effects of patient characteristics and practice settings on students' participation in a primary care clerkship.

PURPOSE: To explore the effects of practice, patient, and encounter variables on students' participation in a third-year primary care clerkship. METHOD: In 1995-96, 154 students, randomly assigned to ambulatory teaching sites, completed for each patient encounter a scannable card indicating the patient's age range, gender, and insurance type, the setting of care, the type of visit, whether it was a repeat or first visit to the student, and the student's level of participation. Conventional measures of students' satisfaction (post-clerkship survey) and performance (preceptor ratings, USMLE Step 2, standardized-patient examination scores) were examined. RESULTS: The students reported significantly higher levels of participation for patient encounters taking place in clinic and emergency room settings than for those in private offices; for repeat rather than for first visits; for patients over 12 years old than for those 12 years old or younger; and for sick visits rather than for follow-ups or checkups. Students' participation had a modestly positive correlation with students' satisfaction and performance. CONCLUSION: Several practice and patient variables influence the level of students' participation in the care of ambulatory patients. The strongest predictor of active student participation is the clinical setting of the encounter. Monitoring students' self-reported levels of participation is an important tool for tracking the impact of practice variability on the quality of the learning environment in ambulatory clerkships.     

Self-referrals to the A&E department during out-of-hours: patients' motives and characteristics

OBJECTIVE: To determine self-referrals' motives to visit the accident & emergency departments (AED) and to compare their characteristics to patients contacting the GP cooperative. METHODS: Postal questionnaires were send to AED self-referrals and logistic regression analysis was used to contrast self-referrals to patients contacting the GP cooperative. RESULTS: For a study population of 62,000, during 4 months, 5547 contacts were registered with the GP cooperative, along with 808 AED contacts, 344 of whom (43%) were self-referrals. Main reasons to visit the AED were the perceived need for diagnostic facilities and the conviction that the hospital specialist was best qualified to handle the problem. Dissatisfaction with the GP cooperative among respondents was high. Self-referral to the AED was positively associated with injury, age between 15 and 64, musculoskeletal, cardiovascular and respiratory problems, and distance to the GP centre. CONCLUSION: Self-referrals emerge as patients with a strong preference for the AED, mainly based on assumptions on quality of care and necessary facilities. PRACTICE IMPLICATIONS: While self-referrals may, in part, make motivated and appropriate choices to visit the AED, new integrated care models should be studied that can adequately deflect those who are eligible for GP care.     

Provider communication and patient participation in diabetes self-care

Objective

To determine the effect size of provider communication about self-care and the provider's following treatment guidelines on the self-care behaviors of people with Type 2 diabetes (T2DM).

Methods

Data were from the TRIAD telephone surveys of Michigan patients in managed care with T2DM (n = 1438). The survey asked about the patients’ self-care and provider communication about blood glucose monitoring, exercise, foot care, flu vaccination and annual retina screening.

Results

After controlling for patient socio-demographics and disease severity, remembering having received provider information on these activities more than doubled the odds of performing blood glucose monitoring, and performing foot examinations. It also significantly increased the amount of exercise the patient performed. Provider modeling had a strong association with foot care. Counseling by a diabetes educator was positively and significantly associated with having an annual retina examination and receiving an influenza vaccination.

Conclusions

Remembering self-care information is associated with increased home based self-care by patients and their families. Consulting with a diabetes educator can substantially improve patient self-care.

Practice implications

Health care providers should encourage patient education. However, physician time is costly and most nurses do not specialize in patient education; one solution is to refer patients to a diabetes educator.     

Consultation behaviour and the influence of the media

Consultations by patients requesting influenza vaccinations were monitored in nine group practices before and after a radio broadcast encouraging patients at risk to seek vaccination. In a population of over 88,000 patients 88 consulted about influenza vaccination prior to the broadcast and 52 after. Not one consulted for vaccination as a result of the broadcast. The implications of this are discussed.     

Assessing patients' participation and quality of decision-making: insights from a study of routine practice in diverse settings

In the context of a qualitative study exploring patients' participation in decision-making, we investigated how people interpret and respond to structured questions about decision-making about their health care. Seventy-four participants who attended consultations in five clinical areas completed structured measures of decision-making and discussed their responses during interviews. They identified a range of decisions as having being made in their consultations. People who picked particular responses on measures of participation in and satisfaction with decision-making gave varied explanations for these, not all of which were consistent with the way their responses are usually interpreted. The interview data suggest that people's evaluations of decisions to follow a particular course of action were influenced by various factors including what they focused on as the alternative, their perceptions of constraints on choices, and their assessment of how good the best possible solution was. Responses to simple structured measures of participation in and satisfaction with decision-making should be interpreted with caution. They are not reliably attributable to health care providers' actions and are thus unsuitable for performance assessment purposes.