The rituals of medicine : exploring the General Practice Consultation using simulated consultations

The consultation is a distinguishing feature of general practice compared to other medical disciplines. The relationship between the doctor and patient is crucial to the successful outcome of the consultation. Despite suggestions in the literature that interruptions to the consultation are detrimental to this relationship, there is a lack of research to support this claim.The overall aim of this study was to explore the consulting style of General Practitioners (GPs) and the impact of interruptions to the consultation to further understand GP behaviour and the doctor-patient relationship during the consultation. The implication of the study was to raise awareness for GPs of their consulting style and interaction with patients, potentially leading to changes in behaviour, resulting in better outcomes from consultations.This research involved six GPs consulting six actor-patients during two video recorded simulated consultation workshops. This research consisted of three studies. The first involved observation of GP behaviour during the simulated consultations, and the impact of interruptions to the consultation; the second involved GP and patient perceptions of behaviour during the consultations, and the impact of the interruptions; and the third involved obtaining GP and patient perspectives of behaviour and interruptions to the consultations, prompted by video footage from the consultations.In Study 1, evidence was found to support a GP consultation style whereby individual GPs showed similar behaviours during each consultation despite consulting a variety of patients. Variability in GPs ability to cope with interruptions to the consultation, and the little time spent by GPs establishing a relationship with patients regardless of the consultation being interrupted was highlighted. The findings of Study 2 supported previous reports of the frequent occurrence of interruptions to the consultation. Differences between GPs beliefs and patient perceptions of the impact of interruptions to the consultation to the doctor-patient relationship were highlighted. In Study 3, the opening sequence of the consultation was found to be of importance to the doctor-patient relationship and the outcome of the consultation.Overall, the findings of this study showed GPs inability to describe their behaviour, and a lack of awareness of their behaviour during the consultation. As a result, GPs may be missing vital cues from patients during the consultation regarding their thoughts and concerns, which may have negative consequences for the doctor-patient relationship. These implications, however, require further research. This study concluded that reflection, and mindfulness could be applied to GP consultation behaviour, using video techniques, in order to raise GP self- awareness of behaviour, improve communication, and the way that GPs relate to patients, and to improve outcomes of general practice consultations

Deploying a clinical innovation in the context of actor-patient consultations in general practice: A prelude to a formal clinical trial

<p>Abstract</p> <p>Background</p> <p>Innovations to be deployed during consultations with patients may influence the clinical performance of the medical practitioner. This study examined the impact on General Practitioners' (GPs) consultation performance of novel computer software, designed for use while consulting the patient.</p> <p>Methods</p> <p>Six GPs were video recorded consulting six actor-patients in a simulated clinical environment. Two sessions were recorded with six consultations per GP. Five cases presented cancer symptoms which warranted a referral for specialist investigation. Practitioners were invited to use a novel software package to process referrals made during the consultations in the second session. Two assessors independently reviewed the consultation performance using the Leicester Assessment Package (LAP). Inter-rater agreement was assessed by a Bland-Altman plot of the difference in score against the average score.</p> <p>Results</p> <p>Sixty of the seventy two consultations were successfully recorded. Each video consultation was scored twice by two assessors leaving 120 LAP scores available for analysis. There was no evidence of a difference in the variance with increasing score (Pitmans test p = 0.09). There was also no difference in the mean differences between assessor scores whether using the software or not (T-test, P = 0.49)</p> <p>Conclusion</p> <p>The actor-patient consultation can be used to test clinical innovations as a prelude to a formal clinical trial. However the logistics of the study may impact on the validity of the results and need careful planning. Ideally innovations should be tested within the context of a laboratory designed for the purpose, incorporating a pool of practitioners whose competencies have been established and assessors who can be blinded to the aims of the study.</p

Factors Influencing Speed of Cancer Diagnosis in Rural WA

Introduction: The speed of diagnosis impacts on prognosis and survival in all types of cancer. In most cases survival and prognosis are significantly worse in rural and remote Australian populations who have less access to diagnostic and therapeutic services than metropolitan communities in this country. Research suggests that in general delays in diagnosis were a factor of misdiagnosis, the confounding effect of existing conditions and delayed or misleading investigation of symptoms. The aim of this study is to further explore the factors that impact on the speed of diagnosis in rural Western Australia with direct reference to General Practitioners (GPs) working in this setting. Methods: The methodology consisted of a structured discussion of specific cases. GPs based in two rural locations in Western Australia were asked to identify up to eight clinical cases for discussion. A diversity of cases was requested encompassing those with timely and delayed diagnosis of cancer. Focus groups were held with the practitioners to identify which factors under six headings delayed or facilitated the diagnosis in each case. A structured summary of the discussion was relayed to a wider group of GPs to seek additional views or comments on specific factors that impact on the speed of cancer diagnosis in rural and remote locations in Australia. Results: A number of factors affecting the speed of diagnosis were identified: the demographic shift towards a frailer and older population, presenting with multiple and complex diseases, increases the challenge to identify early cancer symptoms; seasonal and demanding work patterns leading to procrastination in presenting for medical are; unhelpful scheduling of specialist appointments; and the varying impact of informal networks and social relationships. Conclusion: Within the limitations of this study we have generated a number of hypotheses that require formal evaluation: (1) GPs working within informal professional and social networks are better informed about their patients\u27 health needs and have an advantage in making early diagnosis; (2) Despite the other differences in the population characteristics decentralising services would improve the prospect for timely diagnosis; and (3) Careful coordination of specialist appointments would improve the speed of diagnosis for rural patients. . would improve the speed of diagnosis for rural patients. procrastination in presenting for medical care; unhelpful scheduling of specialist appointments; and the varying impact of informal networks and social relationships. Conclusion: Within the limitations of this study we have generated a number of hypotheses that require formal evaluation: (1) GPs working within informal professional and social networks are better informed about their patients\u27 health needs and have an advantage in making early diagnosis; (2) Despite the other differences in the population characteristics decentralising services would improve the prospect for timely diagnosis; and (3) Careful coordination of specialist appointments would improve the speed of diagnosis for rural patients. procrastination in presenting for medical care; unhelpful scheduling of specialist appointments; and the varying impact of informal networks and social relationships. Conclusion: Within the limitations of this study we have generated a number of hypotheses that require formal evaluation: (1) GPs working within informal professional and social networks are better informed about their patients\u27 health needs and have an advantage in making early diagnosis; (2) Despite the other differences in the population characteristics decentralising services would improve the prospect for timely diagnosis; and (3) Careful coordination of specialist appointments would improve the speed of diagnosis for rural patients. most cases survival and prognosis are significantly worse in rural and remote Australian populations who have less access to diagnostic and therapeutic services than metropolitan communities in this country. Research suggests that in general delays in diagnosis were a factor of misdiagnosis, the confounding effect of existing conditions and delayed or misleading investigation of symptoms. The aim of this study is to further explore the factors that impact on the speed of diagnosis in rural Western Australia with direct reference to General Practitioners (GPs) working in this setting. Methods: The methodology consisted of a structured discussion of specific cases. GPs based in two rural locations in Western Australia were asked to identify up to eight clinical cases for discussion. A diversity of cases was requested encompassing those with timely and delayed diagnosis of cancer. Focus groups were held with the practitioners to identify which factors under six headings delayed or facilitated the diagnosis in each case. A structured summary of the discussion was relayed to a wider group of GPs to seek additional views or comments on specific factors that impact on the speed of cancer diagnosis in rural and remote locations in Australia. Results: A number of factors affecting the speed of diagnosis were identified: the demographic shift towards a frailer and older population, presenting with multiple and complex diseases, increases the challenge to identify early cancer symptoms; seasonal and demanding work patterns leading to procrastination in presenting for medical care; unhelpful scheduling of specialist appointments; and the varying impact of informal networks and social relationships. Conclusion: Within the limitations of this study we have generated a number of hypotheses that require formal evaluation: (1) GPs working within informal professional and social networks are better informed about their patients\u27 health needs and have an advantage in making early diagnosis; (2) Despite the other differences in the population characteristics decentralising services wouldimprove the prospect for timely diagnosis; and (3) Careful coordination of specialist appointments would improve the speed of diagnosis for rural patients

Does smoking status affect the likelihood of consulting a doctor about respiratory symptoms? A pilot survey in Western Australia

<p>Abstract</p> <p>Background</p> <p>Smokers attribute respiratory symptoms, even when severe, to everyday causes and not as indicative of ill-health warranting medical attention. The aim of this pilot study was to conduct a structured vignette survey of people attending general practice to determine when they would advise a person with respiratory symptoms to consult a medical practitioner. Particular reference was made to smoking status and lung cancer.</p> <p>Methods</p> <p>Participants were recruited from two general practices in Western Australia. Respondents were invited to complete self-administered questionnaires containing nine vignettes chosen at random from a pool of sixty four vignettes, based on six clinical variables. Twenty eight vignettes described cases with at least 5% risk of cancer. For analysis these were dubbed 'cancer vignettes'. Respondents were asked if they would advise a significant other to consult a doctor with their respiratory symptoms. Logistic regression and non-parametric tests were used to analyse the data.</p> <p>Results</p> <p>Three hundred questionnaires were distributed and one hundred and forty completed responses were collected over six weeks. The majority (70.3%) of respondents were female aged forty and older. A history of six weeks' of symptoms, weight loss, cough and breathlessness independently increased the odds of recommending a consultation with a medical practitioner by a factor of 11.8, 2.11, 1.40 and 4.77 respectively. A history of smoking independently increased the odds of the person being thought 'likely' or 'very likely' to have cancer by a factor of 2.46. However only 32% of cancer vignettes with a history of cigarette smoking were recognised as presentations of possible cancer.</p> <p>Conclusion</p> <p>Even though a history of cigarette smoking was more likely to lead to the suggestion that a symptomatic person may have cancer we did not confirm that smokers would be more likely to be advised to consult a doctor, even when presenting with common symptoms of lung cancer.</p

Effective communication and information provision in radiotherapy - the role of radiation therapists

Introduction: Health professionals have a duty of care to radiotherapy patients in providing them with adequate information before treatment. There is a lack of research that describes the roles of radiation therapists and radiation oncology nurses in providing information to patients. This study aimed to: (1) explore how radiation therapists communicate with breast cancer patients during a radiotherapy planning appointment; (2) determine what information is provided during this appointment and (3) explore radiation therapists perspectives on their role in providing patient information and support. Methods: The following methodologies were used: self-report questionnaires; simulated radiotherapy planning sessions and joint interpretive forums. Statistical analysis was used to analyse the questionnaires and the simulated planning sessions and forums were analysed qualitatively. Results: A total of 110 radiation therapists participated in the survey. We simulated two radiotherapy planning appointments and held two forums. Four themes emerged: role definitions, reducing patient anxiety and distress, barriers and strategies for effective communication and confidence in patient communication. Conclusion: Radiation therapists play an important role in communicating with patients and providing information, particularly if patients exhibit anxiety and distress. Further research is required to determine whether patients information needs can be met with additional information provided by radiation therapists

Investigating the impact of extraneous distractions on consultations in general practice: Lessons learned

<p>Abstract</p> <p>Background</p> <p>Extraneous distractions may influence the flow of general practice consultations. This study piloted a methodology to examine the impact of interrupting general practitioners (GPs) while consulting actor-patients.</p> <p>Methods</p> <p>Six GPs were video recorded consulting six actor-patients each presenting a different clinical scenario in a simulated surgery. Five cases presented red flag cancer symptoms. Half the consultations were interrupted. Two independent assessors, blinded to the occurrence of interruptions, assessed consultation performance using the Leicester Assessment Package (LAP) for clinical competence.</p> <p>Results</p> <p>24 of 36 consultations were video recorded with sufficient audio-visual clarity to allow scoring. The association between LAP score and three variables could be studied: a variety of interruptions, different GPs and various scenarios. Agreement between assessors on GP performance was poor and showed an increased bias with increasing LAP score. Despite this, the interruption did not significantly impact on assessor LAP scores (Mean difference: 0.22, P = 0.83) even after controlling for assessor, different GPs and scenarios.</p> <p>Conclusion</p> <p>Extraneous distractions had no impact on GP performance in this underpowered pilot study, a conclusion which needs to be confirmed in a larger study. However several important lessons were learned. Recorded actor-patient clinical sessions are logistically challenging. GPs whose skills were not previously assessed were working in unfamiliar surroundings dealing with relatively straight forward diagnostic challenges and may have anticipated the interruptions. In a redesign of this experiment it may be possible to eliminate some of these limitations.</p

Factors influencing the speed of cancer diagnosis in rural Western Australia: A General Practice perspective

Introduction. The speed of diagnosis impacts on prognosis and survival in all types of cancer. In most cases survival and prognosis are significantly worse in rural and remote Australian populations who have less access to diagnostic and therapeutic services than metropolitan communities in this country. Research suggests that in general delays in diagnosis were a factor of misdiagnosis, the confounding effect of existing conditions and delayed or misleading investigation of symptoms. The aim of this study is to further explore the factors that impact on the speed of diagnosis in rural Western Australia with direct reference to General Practitioners (GPs) working in this setting. Methods. The methodology consisted of a structured discussion of specific cases. GPs based in two rural locations in Western Australia were asked to identify up to eight clinical cases for discussion. A diversity of cases was requested encompassing those with timely and delayed diagnosis of cancer. Focus groups were held with the practitioners to identify which factors under six headings delayed or facilitated the diagnosis in each case. A structured summary of the discussion was relayed to a wider group of GPs to seek additional views or comments on specific factors that impact on the speed of cancer diagnosis in rural and remote locations in Australia. Results. A number of factors affecting the speed of diagnosis were identified: the demographic shift towards a frailer and older population, presenting with multiple and complex diseases, increases the challenge to identify early cancer symptoms; seasonal and demanding work patterns leading to procrastination in presenting for medical care; unhelpful scheduling of specialist appointments; and the varying impact of informal networks and social relationships. Conclusion. Within the limitations of this study we have generated a number of hypotheses that require formal evaluation: (1) GPs working within informal professional and social networks are better informed about their patients' health needs and have an advantage in making early diagnosis; (2) Despite the other differences in the population characteristics decentralising services would improve the prospect for timely diagnosis; and (3) Careful coordination of specialist appointments would improve the speed of diagnosis for rural patients. © 2007 Jiwa et al; licensee BioMed Central Ltd

What is the importance of the referral letter in the patient journey? A pilot survey in Western Australia

Background: Access to specialists is mediated by general practitioners in many countries. In these settings, specialists rely on information in referral letters when deciding which cases to schedule for their clinics.,/p\u3e Method: Two-hundred and seven consecutive referral letters to gastroenterologists were scored for the amount of information relayed to the specialist, using a published schedule. The \u27quality\u27 scores for these referral letters were compared for four groups of patients: patients diagnosed with histological lesion, those with no histological lesion, those who failed to attend clinic, or those who had a diagnosis unknown. Forty-two referral letters were generated with a range of quality scores. Four gastroenterologists were asked to identify which letters described patients \u27likely\u27 to have a significant or benign colorectal condition, and whether they could triage the cases for their clinic given only the information in the letters. Results: It was not possible to differentiate which letters related to patients in each of the four categories (P = 0.6). Patients who failed to attend were more symptomatic than those with a histological lesion (35.4 versus 28.2, mean difference 7.14, 95% confidence interval (CI) 14.1 to 0.15, P = 0.045). Patients referred \u27urgently\u27 were not, on the basis of the referral letters, the most symptomatic group (29.7 versus 27, mean difference 2.7, 95% CI -3.4 to 8.8, P = 0.38). The specialists failed to agree on the proportion of cases that could be triaged for their clinics. The cases that could be triaged contained more information (mean 66.38 versus 49.86, mean difference 16, 95% CI 1.3-31.7, P \u3c 0.001). Conclusion: There was no evidence for an association between the amount of information relayed and the diagnosis of a histological lesion. However, more information was helpful when deciding which patients to schedule first. By corollary, patients referred with lesser documentation of their clinical presentation may be denied \u27urgent\u27 access to the gastroenterology clinic