Quantifying positive communication: Doctor’s language and patient anxiety in primary care consultations

Objective

Positive communication is advocated for physicians during consultations with patients presenting medically unexplained symptoms (MUS), but studies generally focus on what is said rather than how it is said. This study quantified language use differences of general practitioners (GPs), and assessed their relation to patient anxiety.

Touch in primary care consultations: qualitative investigation of doctors’ and patients’ perceptions

Background

Good communication skills are integral to successful doctor–patient relationships. Communication may be verbal or non-verbal, and touch is a significant component, which has received little attention in the primary care literature. Touch may be procedural (part of a clinical task) or expressive (contact unrelated to a procedure/examination).

Aim

To explore GPs’ and patients’ experiences of using touch in consultations.

Design and setting

Qualitative study in urban and semi-rural areas of north-west England.

Method

Participating GPs recruited registered patients with whom they felt they had an ongoing relationship. Data were collected by semi-structured interviews and subjected to constant comparative qualitative analysis.

Results

All participants described the importance of verbal and non-verbal communication in developing relationships. Expressive touch was suggested to improve communication quality by most GPs and all patients. GPs reported a lower threshold for using touch with older patients or those who were bereaved, and with patients of the same sex as themselves. All patient responders felt touch on the hand or forearm was appropriate. GPs described limits to using touch, with some responders rarely using anything other than procedural touch. In contrast, most patient responders believed expressive touch was acceptable, especially in situations of distress. All GP responders feared misinterpretation in their use of touch, but patients were keen that these concerns should not prevent doctors using expressive touch in consultations.

Conclusion

Expressive touch improves interactions between GPs and patients. Increased educational emphasis on the conscious use of expressive touch would enhance clinical communication and, hence, perhaps patient wellbeing and care.     

Counseling overweight in primary care: An analysis of patient–physician encounters

Objective

The aim of this study was to assess general practitioners’ (GPs’) and patients’ practices and attitudes regarding overweight encountered during preventive counseling talks.

Methods

Twelve GPs audiotaped their preventive counseling talks with overweight patients, including the assessment of individual risk profiles and further medical recommendations. Fifty-two dialogues were transcribed and submitted to qualitative content analysis.

Results

Dietary advice and increased physical activity are mostly discussed during talks. Recommendations appear to be more individual if patients are given the chance to reflect on causes of their overweight during counseling talks.

Conclusions

A dialogue approach affects the strength and quality of weight loss counseling in primary care. However, physicians and overweight patients rarely agreed on weight loss goals during the physician–patient talks.

Practical implications

Patient centeredness, particularly the integration of patients’ perceptions towards weight management, might be an important step towards improving weight counseling in primary care.     

Electronic patient-provider communication: will it offset office visits and telephone consultations in primary care?

BACKGROUND AND AIM: Electronic patient-provider communication promises to improve efficiency and effectiveness of clinical care. This study aims to explore whether a secure web-based messaging system is an effective way of providing patient care in general practices. METHOD: We conducted a randomised controlled trail and recruited 200 patients from the waiting area in one primary clinic in Norway. Participants were randomised to either the intervention group, which received access to a secure messaging system, or the control group receiving standard care without such access. Primary outcome measures were number of online consultations, telephone consultations and office visits in the two groups. Data were derived from patient records and collected 1 year prior to (baseline), and 1 year after the intervention. RESULTS: Forty-six percent of the patients who were given access to the messaging system (n=99) used the online communication system on at least one occasion (ranging from 1 to 17 messages per patient per year). A total of 147 electronic messages were sent to six general practitioners during a 1-year trial period. Eleven percent of the messages were to schedule an appointment. In 10% of the messages, the GP was unable to respond adequately and recommended an office visit. The reduction in office visits over time was greater for the intervention group than for the control group (P=0.034). There was however no significant difference in the number of telephone consultations between the groups during the study (P=0.258). CONCLUSION: The use of a secure electronic messaging system reduced the number of office visits at the general practice, but not phone consultations.     

Integration of complementary and alternative medicine in primary care: What do patients want?

Objective

To explore patients’ perspectives towards integration of Complementary and Alternative Medicine (CAM) in primary care.

Methods

A mixed-methods approach was used. This included a survey on use, attitudes and disclosure of CAM, an e-panel consultation and focus group among patients with joint diseases.

Results

A total of 416 patients responded to the survey who suffered from osteoarthritis (51%), rheumatoid arthritis (29%) or fibromyalgia (24%). Prevalence of CAM use was 86%, of which 71% visited a CAM practitioner. Manual therapies, acupuncture and homeopathy were most frequently used. A minority (30%) actively communicated CAM use with their General Practitioner (GP). The majority (92%) preferred a GP who informed about CAM, 70% a GP who referred to CAM, and 42% wanted GPs to collaborate with CAM practitioners. Similar attitudes were found in the focus group and upon e-panel consultation.

Conclusions

Most patients in primary care want a GP who listens, inquires about CAM and if necessary refers to or collaborates with CAM practitioners.

Practice implications

To meet needs of patients, primary care disease management would benefit from an active involvement of GPs concerning CAM communication/referral. This study presents a model addressing the role of patients and GPs within such an integrative approach.     

Reassured or fobbed off? Perspectives on infertility consultations in primary care: a qualitative study

Background

Infertility affects 9% of couples in the UK. Most couples who visit their GP because they are worried about their fertility will ultimately conceive, but a few will not. Treatment usually happens in secondary care, but GPs can have an invaluable role in starting investigations, referring, and giving support throughout treatment and beyond.

Aim

To inform clinical practice by exploring primary care experiences of infertility treatment among females and males, and discussing findings with a reference group of GPs to explore practice experience.

Design and setting

A qualitative patient interview and GP focus group study. Interviews were conducted in patients homes in England and Scotland; the focus group was held at a national conference.

Method

An in-depth interview study was conducted with 27 females and 11 males. A maximum variation sample was sought and interviews were transcribed for thematic analysis. Results were discussed with a focus group of GPs to elicit their views.

Results

Feeling that they were being taken seriously was very important to patients. Some felt that their concerns were not taken seriously, or that their GP did not appear to be well informed about infertility. The focus group of GPs highlighted the role of protocols in their management of patients who are infertile, as well as the difficulty GPs faced in communicating both reassurance and engagement.

Conclusion

Simple things that GPs say and do, such as describing the ‘action plan’ at the first consultation, could make a real difference to demonstrating that they are taking the fertility problem seriously.     

‘I need her to be a doctor’: patients’ experiences of presenting health information from the internet in GP consultations

Background

Patients are increasingly using the internet for health-related information and may bring this to a GP consultation. There is scant information about why patients do this and what they expect from their GP.

Aim

The aim was to explore patients’ motivation in presenting information, their perception of the GP’s response and what they wanted from their doctor.

Design and setting

Qualitative study based in North London involving patients with experience of bringing health information from the internet to their GP.

Method

Semi-structured face-to-face and telephone interviews using a critical incident technique, recorded, transcribed verbatim, and subjected to thematic analysis by a multidisciplinary team of researchers.

Results

Twenty-six interviews were completed. Participants reported using the internet to become better informed about their health and hence make best use of the limited time available with the GP and to enable the GP to take their problem more seriously. Patients expected their GP to acknowledge the information; discuss, explain, or contextualise it; and offer a professional opinion. Patients tended to prioritise the GP opinion over the internet information. However, if the GP appeared disinterested, dismissive or patronising patients reported damage to the doctor–patient relationship, occasionally to the extent of seeking a second opinion or changing their doctor.

Conclusion

This is the first in-depth qualitative study to explore why patients present internet information to their GP within the consultation and what they want when they do this. This information should help GPs respond appropriately in such circumstances.     

What is the association between quality of treatment for depression and patient outcomes? A cohort study of adults consulting in primary care

Background

The association between adequate treatment for a Major Depressive Episode (MDE) and improvements in depressive symptoms is not well established in naturalistic practice conditions. The main objective of this study was to examine the association between receiving at least one minimally adequate treatment for MDE (i.e. according to clinical guidelines) in the previous 12 months and evolution of depressive symptoms at 6- and 12-months. Associations with receiving pharmacotherapy and/or psychotherapy and the role of severity of depression were examined.

Methods

This cohort study included 908 adults meeting criteria for previous-year MDE and consulting at one of 65 primary care clinics in Quebec, Canada. Multilevel analyses were performed.

Results

Results show that (i) receiving at least one minimally adequate treatment for depression was associated with greater improvements in depression symptoms at 6 and at 12 months; (ii) adequate pharmacotherapy and adequate psychotherapy were both associated with greater improvements in depression symptoms, and (iii) the association between adequate treatment and improvement in depression symptoms varied as a function of severity of symptoms at the time of inclusion in the cohort with worse symptoms at the time of inclusion being associated with greater reductions at 6 and 12 months.

Limitations

Measures are self-reported. Participants were recruited at different stages over the course of their MDE.

Conclusions

This study shows that adequate treatment for depression is associated with improvements in depressive symptoms in naturalistic primary care practice conditions, but that those with more severe depressive symptoms are more likely to receive adequate treatment and improve across time.     

Positive predictive values of ��5% in primary care for cancer: systematic review

Background

The positive predictive value (PPV) for cancer of symptoms, signs, and non-diagnostic test results of patients routinely consulting a GP (unselected primary care populations) can help to determine when malignancy should be excluded. Comparisons with other illness indicate that a value of 5% or more may be regarded as highly predictive.

Aim

To identify symptoms, signs, and non-diagnostic test results in unselected primary care populations that are highly predictive of cancer.

Design of study

Systematic review.

Setting

Primary care.

Method

Fourteen bibliographic databases were searched, using terms for primary care, cancer, and predictive values. Reference lists of relevant papers were hand-searched. Data were extracted and the quality of each paper was assessed using predefined criteria, and checked by a second reviewer.

Results

Twenty-five studies were identified. PPVs of 5% or more in specific age and sex groups were reported for: rectal bleeding, change in bowel habit, and iron deficiency anaemia and colorectal cancer; haematuria and urological cancer; malignant rectal examination and prostate cancer; haemoptysis and lung cancer; dysphagia and oesophageal cancer; breast lump and breast cancer; and postmenopausal bleeding and gynaecological cancer.

Conclusion

Robust evidence was found for eight symptoms, signs, and non-diagnostic test results as strongly indicative of cancer for specific age and sex groups in unselected primary care populations. These have the potential to improve the early diagnosis of some cancers in primary care by the use of computer warning flags, improved guidelines, audit, and appraisal.     

Acute infective conjunctivitis in primary care: who needs antibiotics? An individual patient data meta-analysis

Background

Acute infective conjunctivitis is a common problem in primary care, traditionally managed with topical antibiotics. A number of clinical trials have questioned the benefit of topical antibiotics for patients with acute infective conjunctivitis

Aim

To determine the benefit of antibiotics for the treatment of acute infective conjunctivitis in primary care and which subgroups benefit most

Design

An individual patient data meta-analysis

Method

Relevant trials were identified and individual patient data gathered for meta-analysis and subgroup analysis

Results

Three eligible trials were identified. Individual patient data were available from all primary care trials and data were available for analysis in 622 patients. Eighty per cent (246/308) of patients who received antibiotics and 74% (233/314) of controls were cured at day 7. There was a significant benefit of antibiotics versus control for cure at seven days in all cases combined (risk difference 0.08, 95% confidence interval (CI) = 0.01 to 0.14). Subgroups that showed a significant benefit from antibiotics were patients with purulent discharge (risk difference 0.09, 95% CI = 0.01 to 0.17) and patients with mild severity of red eye (risk difference 0.10, 95% CI = 0.02 to 0.18), while the type of control used (placebo drops versus nothing) showed a statistically significant interaction (P=0.03)

Conclusion

Acute conjunctivitis seen in primary care can be thought of as a self-limiting condition, with most patients getting better regardless of antibiotic therapy. Patients with purulent discharge or a mild severity of red eye may have a small benefit from antibiotics. Prescribing practices need to be updated, taking into account these results     

Variations in GP–patient communication by ethnicity,age, and gender: evidence from a national primary care patient survey

Background

Doctor–patient communication is a key driver of overall satisfaction with primary care. Patients from minority ethnic backgrounds consistently report more negative experiences of doctor–patient communication. However, it is currently unknown whether these ethnic differences are concentrated in one gender or in particular age groups.

Aim

To determine how reported GP–patient communication varies between patients from different ethnic groups, stratified by age and gender.

Design and setting

Analysis of data from the English GP Patient Survey from 2012–2013 and 2013–2014, including 1 599 801 responders.

Method

A composite score was created for doctor–patient communication from five survey items concerned with interpersonal aspects of care. Mixed-effect linear regression models were used to estimate age- and gender-specific differences between white British patients and patients of the same age and gender from each other ethnic group.

Results

There was strong evidence (P<0.001 for age by gender by ethnicity three-way interaction term) that the effect of ethnicity on reported GP–patient communication varied by both age and gender. The difference in scores between white British and other responders on doctor–patient communication items was largest for older, female Pakistani and Bangladeshi responders, and for younger responders who described their ethnicity as ‘Any other white’.

Conclusion

The identification of groups with particularly marked differences in experience of GP–patient communication — older, female, Asian patients and younger ‘Any other white’ patients — underlines the need for a renewed focus on quality of care for these groups.     

Patient priorities and the doorknob phenomenon in primary care: Can technology improve disclosure of patient stressors?

Objective

Patients with multiple chronic conditions face many stressors (e.g. financial, safety, transportation stressors) that are rarely prioritized for discussion with the primary care provider (PCP). In this pilot randomized controlled trial we examined the effects of a novel technology-based intervention called Customized Care on stressor disclosure.

The ‘added value’ GPs bring to commissioning: a qualitative study in primary care

Background

The 2012 Health and Social Care Act in England replaced primary care trusts with clinical commissioning groups (CCGs) as the main purchasing organisations. These new organisations are GP-led, and it was claimed that this increased clinical input would significantly improve commissioning practice.

Aim

To explore some of the key assumptions underpinning CCGs, and to examine the claim that GPs bring ‘added value’ to commissioning.

Design and setting

In-depth interviews with clinicians and managers across seven CCGs in England between April and September 2013.

Method

A total of 40 clinicians and managers were interviewed. Interviews focused on the perceived ‘added value’ that GPs bring to commissioning.

Results

Claims to GP ‘added value’ centred on their intimate knowledge of their patients. It was argued that this detailed and concrete knowledge improves service design and that a close working relationship between GPs and managers strengthens the ability of managers to negotiate. However, responders also expressed concerns about the large workload that they face and about the difficulty in engaging with the wider body of GPs.

Conclusion

GPs have been involved in commissioning in many ways since fundholding in the 1990s, and claims such as these are not new. The key question is whether these new organisations better support and enable the effective use of this knowledge. Furthermore, emphasis on experiential knowledge brings with it concerns about representativeness and the extent to which other voices are heard. Finally, the implicit privileging of GPs’ personal knowledge ahead of systematic public health intelligence also requires exploration.