Verbal exchange structure of general practice consultations with patients presenting psychological problems

The consultations of 88 patients presenting with psychological problems to primary care medical practitioners were tape- recorded, coded, and factor- analyzed to identify their constituent verbal exchanges. A verbal exchange is a set of speech act categories that tend to occur together and are used for some subtask within an encounter. The verbal exchange structure of these consultations replicated that of previously studied medical consultations except that they had some distinctive features in common with previously studied psychotherapy sessions. Patient- centered exchanges called Social Exposition and Emotional Exposition, which may serve psychotherapeutic purposes, were relatively prominent in those consultations rated relatively positively by patients and by external raters.     

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.     

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.     

Fear-avoidance in recovered burn patients: association with psychological and somatic symptoms

Fear-avoidance, an important model in the understanding of chronic pain, has not yet been studied in patients with burns. The purpose of this study was to investigate if recovered burn patients have fear-avoidance beliefs and to explore the association with psychological and somatic symptoms. Eighty-four recovered burn patients completed self-report questionnaires. The results showed that there were fear-avoidance beliefs, but not to a large extent. Beta coefficients from multiple regression analyses indicated a strong association between fear-avoidance and problems with work, heat sensitivity and arousal symptoms. The model was capable of explaining 73 per cent of the variance in fear-avoidance beliefs.     

The workload of general practitioners does not affect their awareness of patients' psychological problems

OBJECTIVE: To investigate if general practitioners (GPs) with a higher workload are less inclined to encourage their patients to disclose psychological problems, and are less aware of their patients' psychological problems. METHODS: Data from 2095 videotaped consultations from a representative selection of 142 Dutch GPs were used. Multilevel regression analyses were performed with the GPs' awareness of the patient's psychological problems and their communication as outcome measures, the GPs' workload as a predictor, and GP and patient characteristics as confounders. RESULTS: GPs' workload is not related to their awareness of psychological problems and hardly related to their communication, except for the finding that a GP with a subjective experience of a lack of time is less patient-centred. Showing eye contact or empathy and asking questions about psychological or social topics are associated with more awareness of patients' psychological problems. CONCLUSION: Patients' feelings of distress are more important for GPs' communication and their awareness of patients' psychological problems than a long patient list or busy moment of the day. GPs who encourage the patient to disclose their psychological problems are more aware of psychological problems. PRACTICE IMPLICATIONS: We recommend that attention is given to all the communication skills required to discuss psychological problems, both in the consulting room and in GPs' training. Additionally, attention for gender differences and stress management is recommended in GPs' training.     

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.     

Patterns of engagement between GPs and adolescents presenting with psychological difficulties: a qualitative study

Background

Psychological difficulties are common in adolescence with general practice attendees having higher rates than reported in community surveys. Yet GP identification of common mental health problems in this age group is limited. Anxiety and uncertainty around professional practice have been found among GPs and they vary in their degree of engagement with adolescents presenting with psychological difficulties.

Aim

To explore which factors influence the degree of GP engagement.

Design and setting

Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities.

Method

Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis.

Results

In total 19 GPs were recruited: 10 were female, the age range was 29–59 years, with a modal range of 40–49 years. The participants collectively described a sense of their professional competence being challenged, yet reacted with varying degrees of engagement. Three themes appeared to shape a GP’s response: performance in the clinical encounter; view of adolescents and their health needs; and the GP’s own preferred epistemological framework.

Conclusion

The findings suggest that better patterns of engagement between GPs and adolescents are supported by medical education which includes input and feedback from adolescents; education about the science and psychology of adolescence; more effective working across disciplinary boundaries; and recognition of the importance of addressing psychological difficulties early.     

Relationship between new and return consultations and workload in general practice.

General practitioners (GPs) in Tayside, with higher weekly surgery workloads, tended to have a greater proportion of return consultations compared with GPs with smaller workloads. By reducing the number of return consultations, GPs could have a notable effect on their workload and alleviate the, oft-quoted, stress induced by the perceived increase in demand for patient care.     

What do GPs need to know? The use of knowledge in general practice consultations.

In the course of the consultation in primary care, the general practitioner integrates knowledge of different types that are drawn from different sources. As a consequence of the way practitioners develop expertise, this use of knowledge is often hidden from the conscious mind of the practitioner and often hidden from direct observation. On the other hand, understanding of this use of knowledge is crucial to several necessary developments of the profession of general practice. A method involving collaboration between researcher and practitioner sheds new light on this knowledge-in-use.     

The work hours of GPs: survey of English GPs

BACKGROUND: There is no current information about the hours worked by English GPs. AIM: To compare the reported hours worked by GPs with that of other professions and to explain the variation in GP hours worked and on call. Design of study: National postal survey of 1871 GPs in February 2004. SETTING: English general practice. METHOD: Multiple regression analyses of part-time versus full-time status, hours worked, and hours on call. RESULTS: Full-time male GPs report more hours worked (49.6; 95% CI [confidence interval] = 48.9 to 50.2) than males in other professional occupations (47.9; 95% CI = 47.6 to 48.1) and male managers (49.1; 95% CI = 48.8 to 49.5). Full-time female GPs report fewer hours (43.2; 95% CI = 42.0 to 44.3) than females in other professional occupations (44.7; 95% CI = 44.4 to 45.0) and female managers (44.1; 95% CI = 43.7 to 44.5). The number of hours worked decreased with practice list size, and increased with the number of patients per GP. GPs work longer hours in practices with older patients and with a higher proportion of patients in nursing homes. Fewer hours are worked in practices with higher 'additional needs' payments. Having children under 18 years of age increased the probability that female GPs work part-time but has no effect on the probability of male GPs working part-time. Given full-time/part-time status, having children under 18 years of age reduces the hours of male and female GPs. CONCLUSION: Male English GPs report longer hours worked than other professional groups and managers. The sex differences between GPs in hours worked are mostly attributable to the differential impact of family circumstances, particularly the number of children they have. Perversely, 'additional needs' payments are higher in practices where GPs work fewer hours.     

Telephone consultations with patients: brief study and review of the literature

The use of the telephone is described in a small, single-handed practice in Israel over a period of six months. Eighty per cent of the 350 calls were received during office hours and none after midnight. There were twice as many female as male callers. Half of the calls were made on behalf of the patient by a third party and 10 per cent were answered by the doctor's wife in his absence. Eighty per cent of the calls were concerned with medical symptoms and in half of the cases the problem was a new one. The commonest diagnoses were upper respiratory tract infection, gastro-intestinal disorders and fever. In more than half the cases, discussion and advice as to home management was sufficient to solve the problem presented. The average annual telephone consultation rate was 2.2 and the call:office visit ratio 1:2.2.

The telephone was used to the doctor's satisfaction for two main purposes—the early reporting of new symptoms, and the feedback of follow-up information. It is thought that this behaviour both reduced the surgery consultation rate and extended the range of medical surveillance.

     

Frequency of consultations and general practitioner recognition of psychological symptoms.

BACKGROUND: General practitioners (GPs) are widely reported to 'miss' half of the psychological problems present in their patients. AIMS: To describe the relationship between frequency of consultations and GP recognition of psychological symptoms. DESIGN OF STUDY: Survey of GPs and their patients. Setting: General practices in the southern part of New Zealand's North Island. METHOD: Participants were randomly selected GPs (n = 70), and their patients (n = 3414, of whom a sub-set of 386 form the basis of this study). The main measure was the comparison between GP and composite international diagnostic interview (CIDI) recognition of psychological problems. RESULTS: Of the GPs selected, 90% participated. The CIDI was completed by 70% of selected patients. In patients (n = 386) with a CIDI-diagnosed disorder, 63.7% (95% confidence interval [CI] = 53.3 to 74.1) were considered by the GP to have had psychological symptoms in the last year; 40.1% (CI = 31.0 to 49.2) to have had clinically significant psychological problems, and 33.8% (CI = 24.9 to 42.6) were given an explicit diagnosis. However, in those CIDI-diagnosed patients who had been seen five or more times during the previous year, these recognition figures increased to 80.2% (CI = 68.9 to 91.4), 59.4% (CI = 45.9 to 72.9) and 53.6% (CI = 40.1 to 67.1) respectively, and dropped to 28.8% (CI = 13.0 to 44.7), 13.6% (CI = 3.4 to 23.7), and 10.7% (CI = 1.4 to 19.9) among patients not consulting during the previous year. GPs often differed from the CIDI in their assessment of clinical significance and diagnosis. CONCLUSION: GP non-recognition of psychological problems was at a problematic level only among patients with little recent contact with the GP. Efforts to improve GP recognition of mental disorder may be more effective if they target new or infrequent attenders, and encourage patient disclosure of psychological issues.