Factors associated with the provision of anti-smoking advice in general practice consultations.

Guidelines urge general practitioners (GPs) to discuss smoking with patients as frequently as possible. Using data collected before and after consultations, this study confirms that GPs are more likely to discuss smoking in the context of smoking-related problems. Encouraging GPs to make greater use of problem-orientated opportunities to discuss smoking may have more effect on rates of advice giving than urging them to advise all smokers.     

Anti-smoking advice in general practice consultations: general practitioners'' attitudes, reported practice and perceived problems.

BACKGROUND: Anti-smoking advice from general practitioners has proven efficacy. However, general practitioners do not exploit a large proportion of opportunities to discuss smoking with patients. AIM: A study aimed to explore general practitioners attitudes towards discussing smoking with patients and to assess how these influence the quantity of anti-smoking advice that general practitioners report giving during routine consultations. It also aimed to determine the extent to which general practitioners report using evidence-based interventions against smoking and to discover the problems they experience when discussing smoking with patients. METHOD: A postal survey of all 468 general practitioners on the Leicestershire Family Health Services Authority list was conducted. General practitioners' attitudes were assessed by scoring 13 attitude statements using a six-point Likert-type scale. They were also asked to rank (from a list of 12 items) the five approaches that they found most productive and (from a list of 11 items) the five problems that they most commonly encountered when giving anti-smoking advice to patients. RESULTS: A total of 327 questionnaires (70%) were returned. Most respondents (97%) thought that their advice was more effective when linked to patients' presenting problems and 65% reported that linking their anti-smoking advice to patients' presenting complaints was one of their three most preferred approaches to discussing smoking. Advising all presenting smokers to quit was considered by 40% of respondents to be an appropriate use of time but 76% reported that patients' lack of motivation was one of the three most commonly encountered problems. An analysis of the ratings of the 13 statements suggested that general practitioners who reported the greatest smoking cessation activity during routine consultations held more positive attitudes towards discussing smoking with patients. CONCLUSION: This study suggests that general practitioners believe that their anti-smoking advice is more effective when linked to patients' presenting complaints, and this belief appears to be reflected in the way in which general practitioners approach smoking cessation with patients. The findings may indicate that general practitioners are unlikely to accept a role in a population-based anti-smoking strategy which demands that they discuss smoking with all presenting smokers.     

Qualitative study investigating the process of giving anti-smoking advice in general practice

General practitioners' (GPs') anti-smoking advice promotes patients' smoking cessation but little is known about how GPs use their short consultations to give advice. We used semi-structured interviews with 27 UK GPs to investigate how GPs believe they should advise smokers to stop and the reasons underpinning these beliefs. GPs reported a limited repertoire of techniques for dealing with smokers who were not motivated to stop. They also reported using confrontational advice-giving styles with patients who continued to smoke despite suffering from smoking-related illnesses. GPs might find it easier and more rewarding to discuss smoking with patients if they possessed a greater range of skills for dealing with non-motivated smokers.     

Factors associated with the provision of anti-smoking advice by general practitioners.

The acceptability of advice about smoking in the consultation has recently been questioned. We report a study that explored patients' attitudes to general practitioners' (GPs) anti-smoking advice and the characteristics of patients with whom GPs chose to discuss smoking. Patients who recalled the advice were generally positive about stopping smoking. This could be explained by the observation that GPs were more likely to advise smokers who perceived their problems to be smoking-related and were more motivated to stop smoking. The implications of this finding are discussed.     

Anti-smoking advice from general practitioners: is a population-based approach to advice-giving feasible?

General practitioners' (GPs') advice against smoking has a small, beneficial effect on patients' smoking. Consequently, GPs have been urged to adopt a population-based approach to advice-giving that involves discussing smoking repeatedly with the maximum possible number of smokers. This discussion paper assesses how far GPs' current clinical practice is from a population-based approach to advice-giving and finds that GPs prefer a problem-orientated approach to advising those who present with smoking-related problems. Discussion focuses on the feasibility of suggesting that GPs adopt a population-based approach instead.     

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

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

A qualitative study of GPs'' views of treating obesity

BACKGROUND: Due to the increased prevalence of obesity GPs now have a key role in managing obese patients. AIM: To explore GPs' views about treating patients with obesity. SETTING: An inner London primary care trust. DESIGN OF STUDY: A qualitative study using semi-structured interviews. METHOD: Twenty-one GPs working in an inner London primary care trust were interviewed about recent obese patients and obesity in general. An interpretative phenomenological approach was used for data analysis. RESULTS: GPs primarily believed that obesity was the responsibility of the patient, rather than a medical problem requiring a medical solution. They also believed that in contrast to this, obese patients wanted to hand responsibility over to their doctor. This contradiction created conflict for the GPs, which was exacerbated by a sense that existing treatment options were ineffective. Further, this conflict was perceived as potentially detrimental to the doctor-patient relationship. GPs described a range of strategies that they used to maintain a good relationship including offering anti-obesity drugs, in which they had little faith, as a means of meeting patients' expectations; listening to the patients' problems, despite not having a solution to them; and offering an understanding of the problems associated with being overweight. CONCLUSION: GPs believe that although patients want them to take responsibility for their weight problems, obesity is not within the GP's professional domain. Until more effective interventions have been developed GPs may remain unconvinced that obesity is a problem requiring their clinical expertise and may continue to resist any government pressure to accept obesity as part of their workload.     

GP treatment decisions for patients with depression: an observational study

BACKGROUND: GPs are prescribing more antidepressants than previously, but not in accordance with guidelines. The reasons why they prescribe are not well understood. AIM: To explore associations between GP treatment and severity of depression, patients' life difficulties, previous history of illness and treatment, and patient attitudes. DESIGN: Observational study in two phases, 3 years apart. SETTING: Seven practices in Southampton, UK. METHOD: Adult attenders who consented were screened for depression in the waiting room. After the consultation, the 17 participating GPs completed questionnaires on the perceived presence and severity of depression, patients' life difficulties, previous problems and treatment, patient attitudes towards antidepressants, and their treatment decisions. Patients returned postal questionnaires on sociodemographics, life events, physical health, and attitudes towards antidepressants. RESULTS: Of 694 patients screened in the two phases, the GPs rated 101 (15%) as depressed, acknowledged depression in 44 cases (6%), and offered treatment in 27 (4%), including antidepressants in 14 (2%). Offers of antidepressants were more likely in both phases where the GPs rated the depression as moderate rather than mild, and where they perceived a positive patient attitude to antidepressants. However, GP ratings of severity did not agree well with the validated screening instrument, and their assessments of patients' attitudes to treatment were only moderately related to patients' self-reports. CONCLUSIONS: In line with current guidelines, GPs base prescribing decisions on the perceived severity of depression, taking patients' preferences into account, but they do not accurately identify which patients are likely to benefit from treatment. Better ways to assess depression severity and patient attitudes towards antidepressants are needed in order to target treatment more appropriately.     

Doctor-patient communication in different European health care systems: relevance and performance from the patients' perspective

Our aim is to investigate differences between European health care systems in the importance attached by patients to different aspects of doctor-patient communication and the GPs' performance of these aspects, both being from the patients' perspective. 3658 patients of 190 GPs in six European countries (Netherlands, Spain, United Kingdom, Belgium, Germany, Switzerland) completed pre- and post-visit questionnaires about relevance and performance of doctor-patient communication. Data were analyzed by variance analysis and by multilevel analysis. In the non-gatekeeping countries, patients considered both biomedical and psychosocial communication aspects to be more important than the patients in the gatekeeping countries. Similarly, in the patients' perception, the non-gatekeeping GPs dealt with these aspects more often. Patient characteristics (gender, age, education, psychosocial problems, bad health, depressive feelings, GPs' assessment of psychosocial background) showed many relationships. Of the GP characteristics, only the GPs' psychosocial diagnosis was associated with patient-reported psychosocial relevance and performance. Talking about biomedical issues was more important for the patients than talking about psychosocial issues, unless the patients presented psychosocial problems to the GP. Discrepancies between relevance and performance were apparent, especially with respect to biomedical aspects. The implications for health policy and for general practitioners are discussed.     

General practitioners and their possible role in providing spiritual care: a qualitative study.

We interviewed the general practitioners (GPs) of 40 patients with life-threatening illnesses over the course of the last year of life. We asked them to identify their patients' holistic needs, and to discuss whether they considered that they had a role in providing 'spiritual care'. The GPs varied greatly in their understanding of their patients' experiences and needs. Most said that they had a role in providing spiritual care, but hesitated to raise spiritual issues with patients, mentioning lack of time, a feeling that they should wait for a cue, or being unprepared or unskilled.     

Keeping morality out and the GP in. Consultations in Danish general practice as a context for smoking cessation advice

OBJECTIVE: To describe consultations in Danish general practice as a context for a mass strategy of smoking cessation advice. METHODS: The focus of the study was on consultations for health problems that were not related to smoking. Interviews with eleven patients and their six GPs were grounded in observation of their own consultations. RESULTS: Patients and GPs agreed that the GP should adopt an attitude of moral acceptance towards patients. Ideals of moral acceptance of patients in general practice consultations were challenged by the prevailing negative moral values associated with smoking. A general aim of mutuality in the conversation in consultations could not always be achieved in smoking cessation advice. Achieving mutuality was especially a problem when smoking cessation advice was repeated at short intervals. CONCLUSION: Two elements of Danish general practice consultations were challenged by smoking cessation advice to patients without smoking-related illness: the ideal of moral acceptance of patients in general practice consultations held by GPs and patients and the wish for mutuality in the conversation during consultations. PRACTICE IMPLICATIONS: A conversation about smoking based on motivational interviewing would fit in the context of Danish general practice. Relieving the conversation of blocks due to moral implications, however, is still a challenge.     

Copying general practitioner referral letters to patients: a study of patients' views.

Over the past decade there has been a significant shift towards greater involvement of patients in their health care and this has highlighted many areas relating to doctor-patient communication. One area of communication that has not been extensively researched is the referral letter between general practitioners (GPs) and their patients. This small study of patients' views suggests that patients value receiving a copy of their GP outpatient letter, appreciating greater understanding of, and involvement in, the referral process.     

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.     

Triggering anti-smoking advice by GPs: mode of action of an intervention stimulating smoking cessation advice by GPs

OBJECTIVE: To assess the mode of action of an intervention (GP desktop resource, GDR) that increased the frequency of general practitioner (GP) advice to stop smoking. METHODS: Analyses were undertaken to differentiate between three hypotheses regarding the mode of action of the GDR. That the GDR acts: (1) by altering GPs' attitudes, (2) independently of attitudes in prompting GPs to intervene with smokers or (3) by altering the relationship between attitudes and behaviour. RESULTS: The GDR was an independent predictor of the number of patients advised to stop smoking (beta = .345, p < .001). Concern about the doctor-patient relationship was the only attitude variable that independently predicted advice giving, in this case negatively (beta = -.465, p < .001). Possession of the GDR did not alter GPs' views on whether intervening with smokers harmed the doctor-patient relationship, but did weaken the relationship between this attitude item and the number of patients advised to stop smoking (beta = .595, p < .001 for the interaction). CONCLUSION: This study is the first to show that concern over the doctor-patient relationship was an independent predictor of advice giving while in other studies it has merely been noted as something that GPs express concern about. A simple device designed to trigger action on the part of GPs appeared to work by mitigating the negative effect of an attitudinal barrier to action. It would be interesting to explore this phenomenon more generally in relation to health promotion activities on the part of health professionals. PRACTICE IMPLICATIONS: Recommendations that GPs engage in health promotion activities with their patients need to consider that GPs' concerns over harming the doctor-patient relationship may deter them from making such interventions. The GDR appears to be effective in prompting GPs to advise their smoking patients to stop and its widespread distribution to GPs should be considered.     

Narratives about patients with psychological problems illustrate different professional roles among general practitioners

General practitioners are not trained in psychotherapy. They are, however, experienced in hearing people's stories. This qualitative interview study aimed to explore the stories GPs recounted about psychological interventions with patients. It showed that the GPs had recounted very different types of narrative, and that the same GP recounted the same type of narrative throughout the interview. Some told detailed narratives including the patient's life situation, whereas others kept to biomedical matters. Co-creation of patients' narratives had a therapeutic function, and patients obtained agency and power in these stories. The narrative style reflected the professional identity of the GP.     

Qualitative study of patients'' perceptions of the quality of care for depression in general practice.

BACKGROUND: Research into quality of care in primary mental health care has largely focused on the role of the general practitioner (GP) in the detection and management of patients' problems. AIM: To explore depressed patients' perceptions of the quality of care received from GPs. DESIGN OF STUDY: Qualitative study using semi-structured interviews. SETTING: General practices in Greater Manchester. METHOD: Purposive sampling and semi-structured interviewing of 27 patients who had received care from 10 GPs for depression. RESULTS: Quality of care in depression depends on good communication between the doctor and the patient, but patients who are depressed often have difficulty in discussing their problems with doctors. They are also unlikely to be active in seeking care; for example, in making follow-up appointments, especially when they are uncertain that depression is a legitimate reason for seeing the doctor. Patients sometimes accept care that does not meet professional standards, either because of low expectations of what the National Health Service (NHS) can provide, or because of low self-worth associated with their problem. CONCLUSION: The depressed person may feel that they do not deserve to take up the doctor's time, or that it is not possible for doctors to listen to them and understand how they feel. Doctors need to be active in providing care that meets professional standards. We advocate a model of care in which patients with depression are followed up systematically.     

Illness behaviour and antibiotic prescription in patients with respiratory tract symptoms.

BACKGROUND: Although the vast majority of respiratory tract symptoms are self-limiting, many patients visit their GP for these symptoms and antibiotics are over-prescribed. AIM: To explore determinants of patients visiting GPs for recent cough, sore throat, or earache; for being prescribed antibiotics; and for patients' satisfaction with visiting the GP. Design of the study: Second Dutch National Survey of General Practice (DNSGP-2) with a health interview and an additional questionnaire. SETTING: A total of 7057 adult patients of 163 GPs in the Netherlands. METHOD: Characteristics of patients and GPs as well as morbidity data were derived from the DNSGP-2 and a health interview. Characteristics of the symptoms, GPs' management and patients' satisfaction were measured by an additional written questionnaire. Data were analysed by means of multivariate logistic regression. RESULTS: About 40% of the responders (n = 1083) reported cough, sore throat, or earache in the 2 weeks preceding the interview and, of them, 250 visited their GP. Of this latter group, 97 patients were prescribed antibiotics. Apart from non-medical reasons, relevant medical factors played an important role in deciding to visit the GP. Smokers and patients with cardiac disease or diabetes mellitus were not especially inclined to see their GP. Smoking behaviour, fever, and views on respiratory tract symptoms and antibiotics of patients and GPs were associated with being prescribed antibiotics. Patients' perception of having been carefully examined was associated with their satisfaction, while receiving antibiotics was not. CONCLUSION: GPs should inform patients with clear elevated risk when to visit their GP in cases of cough, sore throat, or earache. There is still a need for GPs and patients to be better informed about the limited significance of single inflammation signs (for example, fever and green phlegm) as an indication for antibiotics. Careful examination of the patient contributes to patient satisfaction.