Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The shortest consultation ever seen
- Amine Boualem (13 April 2002)
-
Is that a wheel I see before me?
- Chris L. Manning (15 April 2002)
-
Increasing consultation time may not be straightforward and outcomes must be evaluated
- Phil MJ Wilson, Mark Stirling, and Alex McConnachie (19 April 2002)
-
¿Spain is different? Talking about length.
- Rafael Ordovás (24 April 2002)
-
length and context in Spain
- Ana Mª Costa-Alcaraz (4 May 2002)
-
Towards longer consultations in general practice
- Arnold G Zermansky, Prof D.K Raynor and D.Petty; Prof N Freemantle Univ of Birmingham (16 May 2002)
-
The third consultation dimension – focusing on content
- Joachim P Sturmberg (19 June 2002)
-
Scotland's GPs say that time and stress are limiting holistic care
- Stewart W Mercer, Harutoma Hasegawa. David Reilly, Annemieke Bikker (13 September 2002)
|
|
|||
|
Amine Boualem, Overseas doctor
Send response to journal:
|
Dear Doctors I am an overseas doctor living in Plymouth.Last week ,i was asked by a friend who is an asylum seeker to go with him to his GP in town for translation. It was his first appointment with his doctor. My friend was suffering from a serious headache and a hearing impairement. It amazing,the consultation lasted 10 minutes. I translated the symptoms mentionned by my friend and the doctor ended with a prescripton of Ibuprofene and Ephedrine Hydrochloride as treatment for a sinusitis. The GP did not take any medical history from the patient before the prescription.The patient could have a high blood pressure or a gastric ulcer.... The GP had just clinicaly examined the ears with his autoscop and order an audiometry for the next week. Is this a the British standard consultation,when your doctor ignore the rest of your body and ignore your medical history? Where is the relationship Doctor-Patient? I think it is a jeopardy and some doctors are organising their timing as if they are working in the pit of a-Formula one- motor racing. Best Regards. |
|||
|
|
|||
|
Chris L. Manning, Chair Depression Alliance. Ce PriMHE. Member of Mental Health Taskforce Teddington TW11 9HG
Send response to journal:
|
Dear Sir How refreshing to feel the splash from a heavyweight anchor being thrown into the seas of change as the NHS Lollipop drifts daily nearer the rocks. I do not see how on earth we can really expect to improve morale and life-long learning if we persist in taking everyone back to the prediluvian days out of which continuity of care (if not carer) and quality time and space for consultation emerged. It is no accident that people, both service users and providers, mention these elements of primary care more often than any other in the numerous conversations I have with them every week. It is high tide and we might just be able to refloat this old tub if enough people realise that it is not just about more money, but looking after the most precious resources of all, those who man the pumps and plumb the depths. It is not just about changing structures and functions and placing the same old mind-set Lemming-blockers in new jobs in PCTs, but changing attitudes and behaviours, building a culture of shared respect and involvement, moving away from blame and pillory. It is about highest common factors that are shared across all disciplines, plauditing and nurturing aspiration, not just the lowest common denominators of audit, perspiration and performance. It is about re -establishing the crucial and central role of families, friends and community at the heart of our culture and helping people to understand that well-being and quality of life are within the provenance of enduring cultural values and that many key politicians have become rudderless managers. The King's Fund is right to recommend the de-politicisation and de- centralisation of control of the NHS in reality, not in rhetoric. This should be extended to all areas of the country's infrastructure, especially education and transport, where evidence-based decision-making have never been much in evidence. WE are the heroes and it is amazing what ALL of us can do once liberated from learned helplessness and Westminster Dependence Syndrome (both very important societal opiates for those intent on power)and the thought viruses of "why can't THEY do something about.." and "what is the point of me..". Doctor usually does not "know best" and these days, may often not even know any better. We simply must look imaginatively at the ways in which we can help people not to "become" patients or chronic users of services because they have nothing better to do or because their communities are defunct. We should be defined by who we are and what we believe, not what we do or what disease we have..where is the incentive for recovery in that? The prescriptions for the future will, like ripping out the Broad Street pump, be biopsychosocial and the sooner we start preparing our children and the students of the day for this reality the better. When I am ill or whatever, I want someone with the skill to meet that need; I care not a sparrow's fart for their title. We simply must look after THEIR caring instincts too, otherwise we really should be recruiting those who will mindlesslessly implement the dictats of bean-counting cyborgs. I actually know people who are not going to start developing CAMHS services because they are waiting for the NSF..Breathe in..breathe out..says a Millbank voice in my ear? A great paper. I will taking it everywhere with me and God help anyone who gets in the way! Yours recidivistically Chris Manning |
|||
|
|
|||
|
Phil MJ Wilson, Senior Research Fellow and GP Department of General Practice, University of Glasgow, G12 ORR, Mark Stirling, and Alex McConnachie
Send response to journal:
|
Freeman et al (1) emphasise the desirability of longer consultations in British general practice. A pilot study performed with six Glasgow general practitioners shows that breaking the habit of short consultations may be difficult and longer consultations may lead to higher health service costs. Our pilot study was designed to inform the design of a randomised controlled trial of the effect of increased booking interval on identification of patient psychological distress (2). Each doctor's surgery was randomised to either a normal booking interval (10 minutes per patient) or 1.5 times the normal time. To enable practices to cope with the resulting reduced number of consultations, one of us (MS) offered locum sessions to make up the shortfall. The process was continued until there were 65 consultations at each booking interval for each practitioner. The General Health Questionnaire 12 was given to each patient after the consultation as a measure of psychological distress, and the doctor completed a six-point scale to estimate the patient’s degree of psychological distress and a brief inventory of consultation events. Each consultation was timed by a research assistant. Data were collected from 781 consultations. When booking interval was increased from 10 to 15 minutes consultation length only increased by 12% from 8.7 minutes to 9.7 minutes. Long booking interval significantly increased the number of consultations in which the doctor carried out investigations (19.38% v 27.85%; p = 0.0069). It also significantly increased the number of consultations in which the doctor asked the patient to arrange a repeat appointment (43.81% v 53.67%; p = 0.0072). There was no significant effect on proportion of consultations in which prescriptions were issued (51.03% v 54.68%; p = 0.341), physical examination carried out (66.75% v 66.84%; p = 0.959), or referral made (13.95% v 10.69%; p = 0.201). There were no significant differences between identification of psychological distress at long or normal booking intervals. For consultations in which the GHQ is positive, the odds ratio for identification between long and short booking interval is 1.00 (95% CI 0.63 to 1.59). Our results show that although booking interval increased by 50%, consultation length increased by only 12%. This raises the obvious question of what the doctors did with the extra time. It has been argued that increasing the length of consultations may save time and resources in the long run. These results suggest that the opposite is true; doctors ask more patients to make further appointments after the longer consultations and perform more investigations. Perhaps doctors given more time with patients simply uncover more problems which require further consultations. Increased booking intervals also made no difference to the recognition of psychological distress. Our results must be interpreted with caution. It is possible that a longer intervention might lead to a more significant change in habits and consequently cause more major changes in the doctors' consulting behaviour. The lack of impact of increased booking interval on the recognition of psychological distress may also suggest that structural constraints are insufficient to explain low rates of recognition of distress by general practitioners. The costs and benefits of increasing consultation intervals require careful evaluation: health service costs may be significantly higher than those simply resulting from paying for more general practitioners’ time for the consultations. (1) Freeman GK, Horder JP, Howie JGR, Hungin AP, Hill AP, Shah NC, Wilson A. Evolving general practice consultations in Britain: issues of length and context. BMJ 2002; 880-2 (2) Stirling M, Wilson P, McConnachie A. Consultation length, deprivation and identification of psychological distress in general practice. BJGP 2001; 51: 456-460 |
|||
|
|
|||
|
Rafael Ordovás, Family practice doctor Valencia(Spain)
Send response to journal:
|
It´s a nice surprise to find recent BMJ articles and editorials talking about doctor´s happiness, the search for the lost compact and the desirable consultation length. Disbalance between doctors and patients expectations, and a changing compact are similar in Spain. But the surprise is greater when a comparison between English and Spanish doctors conditions is made. Spanish GP doctors (from the National Health Service) consultation length is at the end of a list of european health services (WHO Regional Office for Europe Health 1998 Survey):less than ten minutes, and less than five in some situations,so the "hamster´s wheel" syndrome is widespread. We can talk about a very risky situation, for both patients and doctors, in terms of malpractice and burn out. Two years ago, a movement started among GPs throughout the country searching for the improvement of the doctor patient relationship in a best work environment. The name of this movement is: "Plataforma 10 minutos" and a webpage supports it: www.diezminutos.org. I want to congratulate other countries' colleges for helping to improve the doctor´s working conditions and create a healthy discussion between the involved actors. Rafael Ordovás
|
|||
|
|
|||
|
Ana Mª Costa-Alcaraz, Family practice doctor Centro de Salud Nazaret- Valencia-Spain
Send response to journal:
|
Editor, Referring to the debate started with the article of Freeman(1), I report on the situation in Spain. • National health system is summoning, since the seventies, posts for resident physicians (MIR). These physicians work hardly during a period between 3 and 7 years (depending on the speciality) with a low remuneration, due to their contract of formation. Colleagues who play the role of form masters don’t have for it any economical acknowledgement nor reduction of work charges that could make the guidance easier. For a long time past, more posts for physician in formation are being summoning than posts which afterwards can be filled. This last fact has happened, in a more exaggerated way, in relation to family medicine, whose residents are, at present, essential to fill emergency services in hospitals. So, what began to assure professional qualification of those who afterwards would work for public health, has become in a way of getting cheap manpower. It has to be pointed out that primary attention budgets have not increased sine 1993. However, since that year, percentage of public health budget dedicated to managers posts is increasing in a continuous way (1, 2) • Some political responsibles, as Provincial Health Agent in Granada, impose times for consultation of just 3-5 minutes, stating in public incompetence of professionals who don’t accept such sortage of time (3) • A syndicate (CCOO) has informed against the Regional Government of Valencia President by default of laboral rules for risks prevention (4) • Another syndicate (SMA) reports the huge number of physicians that suffer burn-out (5) • Another syndicate (SIMAP) has informed against Spain and Regional Government of Valencia by not having fulfilled sentence of European Community Justice Tribunal, from 3 of october of 2000 (Rec.2000, p.I-7963) (6), related to physicians work conditions. Many Spanish physicians, specially those in primary attention, identify with Dr. Susheel (7) and Freeman et al (8) statements. We are not car manufacturers to be imposed piecework! Patients need an apropriate climate so that they can be attended with respect! We need proper work conditions and professional acknowledgement by governors! The rate of burnout is too high amongst Spanish physicians (9, 10, 11) Ana Mª Costa-Alcaraz; www.diezminutos.org Family physician Tutor Member of the Bioethic Group of the SVMFiC 1. Evolving general practice consultation in Britain: issues of length and context Freeman GK, Horder JP, Howie JGR, Hungin AP, Hill AP, Shah NC, et al. BMJ 2002; 324: 880-882 2. Health care systems in transition" -Spain- European Observatory on Health care systems 2000 WHO Regional Office for Europe 3. Capacete L http://www.diezminutos.org/colaboraciones/OMS.htm 4. El Ideal. Granada 28 abril 2002. In: http://www.diezminutos.org 5. El Médico 2002. In: http://www.diezminutos.org/noticias/2002/ccoodenuncia.html 6. Institutional Hounding. In: http://www.diezminutos.org/acoso.html 7. Bruselas admite nuestra demanda. In: http://www.simap.es 8. Susheel Oommen J Health For all - For doctors too ! bmj.com, 5 Apr 2002 9. Freeman GK, Horder JP, Howie JGR, Hungin AP, Hill AP, Shah NC, et al. Evolving general practice consultation in Britain: issues of length and context. BMJ 2002; 324: 880-882 10. De Pablo R, Suberviola J. Prevalence of burnout or professional exhaustion syndrome in primary care doctors. Aten Primaria 1998; 22: 580- 584 11. Olivar C, González S, Martínez MM. Factors relating to work satisfaction and professional wear and tear in primary care doctors in Asturias. Aten Primaria 1999; 24: 352-359 12. Cebriá J, Segura J, Corbella S, Sos P, Comas O, García M, et al. Personality Traits And «Burnout» In Family Doctors. Aten Primaria 2001; 27: 459-468 |
|||
|
|
|||
|
Arnold G Zermansky, GP Visiting Senior Research Fellow School of Healthcare Studies, University of Leeds, LS2 9UT, Prof D.K Raynor and D.Petty; Prof N Freemantle Univ of Birmingham
Send response to journal:
|
Freeman et al., in their thought-provoking paper, open this long- overdue debate1. They address the question of why consultations should be longer, but do not consider how this might be achieved. The reality of primary care is that workload is increasing faster than the workforce. This is fuelled part by demography, part by increased health expectations and part by developments in treatment. The unremitting commercial gamesplaying of the pharmaceutical industry highlighted in the same issue by Moynihan et al.2 adds another turn to this screw. General practitioners are fully occupied. There is no prospect of a huge increase in general practitioner workforce in the next decade. The only way for doctors to have more time is therefore for them to stop doing things. There are a few activities that general practitioners might simply stop doing. Some may need legislative change, such as a move from repeat prescribing to repeat dispensing3. This would probably save the average GP about an hour a day. Other changes might need us to question some of our routine behaviours that are probably perpetuated by the convoluted fee structure of General Medical Services. Why do we need to see contraceptive patients twice a year? Why do we still dabble in antenatal care when midwives do it so much better? What is a “full postnatal examination” for? The most effective way of freeing up time is to delegate. Get someone else to do it – preferably someone who is better at it than you are. The extended roles of practice nurses and nurse practitioners do move in this direction, but there are so many calls on the nursing profession that we are probably close to the limit of available personnel. The largest untapped source of under-utilised skill, however, is community pharmacists. It is simply a huge waste of their vast aggregate of clinical skills that so many pharmacists are trapped behind their counters selling baby food and offering cold remedies of questionable efficacy. The future of the traditional high street pharmacy is threatened by the pincer movement of industrialised warehouse dispensing and the supermarket pharmacy. At present the latter is contributing to a manpower shortage, but the former has the potential to reverse this trend. The potential exists to re-deploy pharmacists into general practices to review patients and supervise medication, making best use of their knowledge and developing skills 4,5. By so doing they will free general practitioners to play to their own strengths, extending consultations and improving the depth and breadth of care. REFERENCES 1. Freeman GK, Horder JP, Shah NC, Howie JG, Hungin A, Hill AP and Wilson AP, Evolving general practice consultation in Britain: issues of length and context. BMJ 2002; 324:880-882. 2. Moynihan R, Heath I and Henry D, Selling sickness the pharmaceutical industry and disease mongering. BMJ 2002; 324:886-891 3. Department of Health. Pharmacy in the Future - Implementing the NHS National Plan., London 2000. 4. Zermansky AG, Petty DR, Raynor DK, Freemantle N, Vail A and Lowe C. Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice BMJ 2001; 323: 1340. 5. Mason JM, Freemantle N, Nazareth I, Eccles M, Haines A, Drummond MF. When is it cost-effective to change the behaviour of health professionals? Journal of the American Medical Association, 2001; 286: 2988-92 |
|||
|
|
|||
|
Joachim P Sturmberg, GP Wamberal, NSW 2250 - Australia
Send response to journal:
|
Dear Sir,
Congratulations to Prof Freeman and his colleagues for their stimulating paper on the consultation in Britain (1). Many of the issues raised are points of contention in Australia, too, despite the average consultation length being about 15 minutes. To further the debate, I would like to add the issue of ‘consultation content’. Three aspects are important to consider – one, a doctor’s workload based on a patient’s overall morbidity, two, the workload implications caused by a stable doctor-patient relationship and three, the way issues are approached during the consultation. The patient’s overall morbidity significantly influences the overall need for care and affects the doctor’s input into consultations. Using a case-mix approach it was possible to show the differences in consultation frequency, number of problems presented and the average number of problems dealt with in consultations over a two-year period (2). Patients with solely self-limiting and/or preventive health problems had 2.9 fewer consultations (27.8%) and presented with 5 fewer health problems (37.8%) than the average patient, whereas those with complex chronic disease presented 3.6 times more often (33.4%) and had 5.8 more health problems (44.0%). Translated into average workload per consultation the former group required attention to 1.05 and the latter 1.39 problems per consultation. These differences were even bigger if one took into account the degree of doctor-patient stability (or interpersonal continuity). A doctor’s workload was twice as high for patients who had personal provider continuity (3). What happens in a consultation is rather complex and depends as much on the efficient use of time as it depends on the doctor’s and patient’s attitudes and expectations about medical care. Basically is medicine about curing disease or caring for illness? (4) Or as Baron (5) put it ‘Have we not, in some consequential way, made disease our focus instead of sick people?’ Hence I am not at all surprised to read about the disappointments expressed by Wilson and colleagues (6). A short trial of longer consultations is unlikely to change a doctors overall focus and behaviour. It would be presumptuous to assume that more consultation time would automatically translate into diagnosing and dealing with more psychosocial health problems. For this to happen a sustained change of the medical culture associated with a shift towards patient-centred consultations has to occur. REFERENCES 1. Fremman GK, Horder JP, Howie JGR, Hunging, AP, Hill AP, Shah NC and Wilson A. Evolving general practice consultation in Britain: issues of length and context. Br Med J 2002;324:880-2 2. Sturmberg JP. General practice-specific care categories: a method to examine the impact of morbidity on general practice workload. Fam Pract 2002;19:85-92 3. Sturmberg JP. Morbidity, continuity of care and general practitioner workload: Is there a connection? Asia Pacific Family Medicine 2002; 1:12-17 4. Sturmberg JP. Preparing doctors for the ‘post-science’ medical era: Focusing back on the patient. Asia Pacific Family Medicine 2002;2: in press 5. Baron RJ. An Introduction to Medical Phenomenology: I Can’t Hear You While I’m Listening. Ann Int Med 1985;103:606-611 6. Wilson PMJ, Stirling M and McConnachie A. Increasing consultation time may not be straightforward and outcomes must be evaluated. www.bmj.com/cgi/eletters/324/7342/880 |
|||
|
|
|||
|
Stewart W Mercer, CSO Health Services Research Training Fellow Department of General Practice, University of Glasgow, 4 Lancaster Crescent, Glasgow G12 0RR, Harutoma Hasegawa. David Reilly, Annemieke Bikker
Send response to journal:
|
The recent paper by Freeman et al on consultation length in relation to quality of care in general practice in the UK,1 has provoked responses that question the benefit from, and need for, longer consultations.2,3 The need for a shift in focus to the content of the consultation, rather than time per se, has also been raised.4 We would like to add to this debate by reporting the findings of a national survey of Scotland’s GPs views on holism in primary care. We sent a postal survey to all 3713 GP Principals in Scotland in February 2001. The response rate was 62.2% (2311 GPs) after two postal reminders. Responders were similar to the total GP Principal workforce in terms of age and gender, though more part-time GPs were represented in the sample compared to the total workforce (part time: 25.3% sample versus 16.7% total GP workforce). Locality of practice was recorded as urban (46.6%), rural (19.9%) or mixed (32.4%), and socio-economic area of the practice as high deprivation (16.4%), medium/mixed (43.9%), marginal deprivation(23.2%), or no deprivation (14.7%). Nearly 9 out of 10 GPs (87.3%) felt that a holistic approach was essential to providing good health care, but only 1 in 15 (6.8%) thought the current organisation of primary care services made it possible. The main constraint on holism within the consultation was seen as the time available, followed by the GP’s own stress level. Mean values (95% confidence intervals) for constraints, rated on a scale of 0 (not limiting) to 10 (extremely limiting), were as follows; Time 7.6 (7.49 to 7.67); Stress 4.9 (4.84 to 5.04); Training 4.7 (4.66 to 4.84); Skills 4.2 (4.13 to 4.30); Motivation 3.4 (3.33 to 3.50); Attitudes of Partners 2.9 (2.82 to 3.02), and Own Personality 2.6 (2.51 to 2.66). GPs working in urban, high deprivation areas felt more constrained by time and stress than GPs in the other areas (Kruskal-Wallis H, p<.005, results not shown).Additionally, GPs working in full-time employment reported higher levels of stress than GPs working part-time ( p<.005, results not shown). Scotland’s general practitioners feel that holistic care is being critically constrained by organizational factors. Time and stress are the top two issues within the consultation. These results give voice to deep concerns among a nation’s GPs who remain committed to a holism they are struggling to deliver. 1. Freeman GK, Horder JP, Howie JGR, Pali Hungin A, Hill AP, Shah NC, Wilson A (2002). Evolving general practice consultation in Britain: issues of length and context. BMJ. 324, 880-882 2. Wilson P, McConnachie A, Stirling M (2002). Increasing consultation time may not be straightforward (letter). BMJ 325, 104. 3. Jenkins L, Britten N, Barber N, Bradley CP, Stevenson FA (2002). Consultations do not have to be longer (letter). BMJ. 325,388 4. Sturmberg JP (2002). The third consultation dimension – focusing on content (e-letter). BMJ; http://bmj.com/cgi/eletters/324/7342/880#22226 Stewart W Mercer, CSO Health Services Research Training Fellow and General Practitioner, Department of General Practice, University of Glasgow, Glasgow, G12 ORR. (stewmercer@blueyonder.co.uk) Harutomo Hasegawa, Medical Student, University of Glasgow, Glasgow, G12 8LG David Reilly, Consultant Physician, Director of ADHOM Academic Departments, Glasgow, G12 ONR and Honorary Senior Lecturer, University Department of Medicine, Glasgow, G31 2ER. Annemieke P Bikker, Research Fellow, ADHOM Academic Departments, Glasgow, G12 ONR. |
|||