The analysis brought forward six categories of outcome. From the patient's perspective, the outcome of a consultation is about
- cure or symptom relief
- change in self-perception
Each category contains what patients refer to as being important in their way of thinking and perception of the outcome of their latest consultation. The categories partly overlap, but are still distinct concepts.
Except for change in self-perception, the categories represent the evident needs and requests patients have when consulting. As far as the outcomes are "about" evident needs, the specific outcomes may be presented either positively or negatively; positively when the need in question is satisfied, and negatively when not.
In the following the categories will be exemplified by quotations.
Cure or symptom relief
In this category are statements where the outcome was cure or symptom relief; either as experienced or as expected but without being obtained. This is a desired outcome but often not possible as many patients have symptoms or diseases that cannot be cured. The patients presenting this outcome often had acute or semi acute symptoms and/or disease.
The patients who had been cured did not perceive a change in self-perception, probably because they had not been confronted enough with the illness experience.
Citation: Nike (woman, age 55):"I had a pain in the elbow for several months. I work with a physiotherapist and I had been asking over and over again if she could do something. -No she said. I went to a doctor and actually he gave me a diagnosis immediately. I got treatment and I was cured. So I was very satisfied."
This category was relevant in all the statements about consultation outcomes. Understanding may be increased or may be a matter of frustration. All patients expressed that they wanted to "know what they had"; some wanted to know more even though they "knew what they had". The patients considered knowledge about their state to be a main outcome of the consultation. They requested knowledge of "what they had" based on their own condition, in their own circumstances and with their own understanding. An understanding might imply quite different things for different patients with a similar medical condition but may also vary over a period of time for the same patient. The name of the disease or a diagnosis was not always what they needed. Neither was the cause always a prerequisite for understanding, although the doctor may have found the explanation of the cause so obvious that there should be nothing left to wonder about.
Understanding is necessary to manage to live on with the health problems and the concern caused by them.
Citation Mari (woman age 46):"A diagnosis for me is completely unessential. What I want is that they realize why I have pain. So I can get rid of it."
Patients, who felt that they had not acquired an understanding of their condition, were dissatisfied with the outcome even if they had been cured.
Lejla (woman, age 39):"But I mean, just relieving the pain does not help, you also have to know why you have it. It doesn't help just to be relieved you must know in some way how to handle it to be able to prevent more pain."
Understanding must not be mixed up with explanation because an explanation in the abstract that does not respond to one's experienced needs is of no benefit.
Citation: Siri (woman 18):"They never explained why I got this skin infection, they just said it is some staphylo- or strepto-something."
In other situations, though, information about the condition and nothing more, may lead to a new understanding, which was then the outcome of the consultation.
Citation Erik (man age 63):"I have some stuff that goes from my kidneys into the blood, I don't know the name of it, I don't have to because I am not the doctor, but it could get worse if I stopped taking my antihypertensive, it could be dangerous for me and it would really be rotten to get kidney problems."
The patients had often had thoughts about their symptoms /disease before the consultation, and maybe also fantasies of how it could develop. The GP had observed and listened, added some tests in a few cases, but had then not taken any action beyond confirmation. An outcome for some patients was that their fears or fantasies were confirmed or unconfirmed.
Citation Anette (woman 33):"-So I asked that doctor -Do I have fibromyalgia? Because I had been thinking and wondering. – Yes she said that has been established. – Yes thank you, then I know, I said. I got to know this half a year ago when my ordinary doctor was not here, and I had had this pain for four and a half years but I had never got round to asking before." (This citation referred to a consultation half a year earlier)
A confirmation of a disease, even when serious, is at the same time a confirmation of an experience, and therefore not only negative. The prevailing uncertainty when the doctor does not know, or does not respond to the worrying experience, may however in itself be a torment. Outcomes of this nature, presented by patients who were thrown into uncertainty, were also placed in this category. They had been referred, and were waiting for further treatment or assessments. They did not know what they could expect and were left in a state of confusion. They did not express satisfaction, dissatisfaction or any other feelings with regard to the consultation. The uncertainty of the situation dominated.
Nils (man, age 73):"You will see then, you know, if it is the kidneys that are.... The function of the kidneys has been a little poor .... I get so tired all of a sudden and that's not good...I am not exactly ready to die yet...But you won't know from one day to another. I have to find out the reason for my being so tired. I mostly want to lie down, but you can't lie down all the time. You have to keep moving.
For others the confirmation dealt with the fact that they were doing the right thing. Their judgement was recognized by the doctor.
Citation Gudrun (woman 49):"She (the GP) examined me very well. I said I had been seeing a physiotherapist, and she told me to go on with the exercise that I had been taught. I told her I had been taking painkillers, aspirin and paracetamol, and she told me to go on with that, and to take it easy."
For some patients an assessment or information about their condition was the only outcome of the consultation. They had diseases that did not make them disabled but rather were to be considered as risk factors. Without having been worried they had got it confirmed that everything was well.
Citation Johnny (man age 62):"Now I have good tests on everything, everything was perfect. That was the good experience of my visit."
Some patients perceived lack of confirmation although they had expected it.
Citation Cecilia (woman, age 36):"I came to this doctor and told him about all the strange allergies I had had this last week, and showed him my wrist, that all of a sudden had become so swollen. So, he said you must have a sprain, and he gave me naproxene. I felt so misunderstood and I was so angry, that I went home and took the cortisone I had got the other day."
Some patients, who had been worried before the consultation, perceived reassurance as an outcome. Their fears were not confirmed. Once the cause of worry had been refuted, the worry itself was much diminished and almost forgotten.
A reassurance could be both explicit and implicit. An assessment saying that there is nothing dangerous going on is an explicit outcome.
Citation Nils (man 73):"I had felt extra beats from my heart and that made my pulse jump. I thought I would maybe need a pacemaker but my Doctor said I did not. It will probably disappear by itself. It was a good thing that I don't need a pacemaker."
A reassurance can also be implicit. Getting a diagnosis or an explanation of symptoms implies that it is not another, dangerous disease. The fear did not have to be mentioned. The fear of cancer was seldom openly expressed but often between the lines.
Citation Johnny (man 63):"Now I have good tests on everything... That was the good experience of my visit. I was not worried. But people around, they die. You are at the age for prostatic cancer.
Often reassurance was seen together with confirmation, especially when a worry had been confuted. But they could also be separate. Patients who had changed their image of themselves perceived confirmation but did not mention reassurance.
Change in self-perception – accepting the reality of the body
In this category we find statements from patients who had had the symptoms or the disease for a long time and now had reached the understanding that it would persist. The consultation had been the last in a row where earlier consultations had gradually prepared for a more definite change in self-perception. In this very consultation knowledge had turned into acceptance of the reality of the body and now they were ready to face their future searching for strategies to handle their situation and their lives. The illness/disease did not change but they were satisfied with the outcome.
This outcome was seen in some form in a fourth of the patients' descriptions.
Citation Hedvig (woman age 59):"It's something neurological...it's something in the brain you know...you can't know for sure what is actually the cause of it...How do you get on with your life after this? The consultation before last was about the whole of me and everything that concerns me... The last time I came here there were three ready suggestions for me; thus the sadness, but also relief. I'm not at all disappointed with that doctor or so, the sadness is about other things – about life."
A manifestation of satisfaction or dissatisfaction was to be found in most of the patients' statements. It was rather expressed as positive or negative assessments of consultation outcome than as an explicit degree of satisfaction. Statements of satisfaction or dissatisfaction often functioned as a summing up or conclusion of the patient's evaluation of the outcome. Satisfaction was never the main outcome.
The patients were satisfied when they had acquired an understanding of the condition. Patients who "knew what they had" were satisfied even though they were not relieved or cured.
Citation Curt (man age 74):"Now the last time my blood pressure had gone down so it was just 170 over 70 and that was good in my case, it had gone down.
Patients who did not know what they had were dissatisfied even if they had been cured.
Citation Mia (woman age 36):"I didn't even get to know what I had. I was so angry with myself- why had I not asked? I had to call back to the nurse and ask and she said you have tonsillitis."
Maja (woman age 20):"I went to the doctor and he bent my knees back and forth and pressed them a little, and then he gave me a prescription for pain killers. But I wanted to know what it might be. He could not answer, because he did not know. I was very dissatisfied with going there. I had realized that myself, that I had pain and needed pain killers but I wanted to know what it was. If he couldn't help me, I think it was his duty to send me to a specialist."
All the patients who had acquired an understanding were satisfied. Some were satisfied if they had received confirmation but not an understanding.
All the patients who had not acquired an understanding or received confirmation were dissatisfied. They were dissatisfied even if they had been cured. They did not feel reassured.
Patients who were dissatisfied felt that they had not been seen or heard during the consultation.
They were mostly women whose mother tongue was different from the doctor's.