When undertaking this review we deliberately used broad inclusion criteria in an effort to scope the evidence relating to consultation length and management of psychological problems. We initially hoped to answer the important question: "Do longer consultations result in improved outcomes in the management of psychological problems in general practice?" Unfortunately, there was insufficient data to answer this question conclusively and there were a number of important limitations in studies identified.
We identified 29 relevant papers from a mix of western countries, but, despite the consultation being a crucial component of general practice work, all studies reviewed were observational and non-randomised studies. We were unable to identify a single randomised controlled trial where the consultation length had been altered to measure effects on the diagnosis or the management of psychological problems.
Apart from one paper by Stirling et al [9
], on accuracy of psychological diagnosis, there were no studies found that explored association between outcome measurements or management options of psychological problems and length of consultation.
Another major weakness is that none of the included studies followed patients to assess progress, all studies involved single visits.
Despite this, there were three possible conclusions. The strength of evidence for these conclusions varies and will be discussed.
1. Consultations with a recorded diagnosis of psychological problems take longer
Despite the mean consultation length varying between countries, evidence from 14 studies from 10 different countries, with a wide range of health systems, payment systems, cultural backgrounds, doctor demand and training demonstrated that consultations with a recorded diagnosis of psychological problems take longer than those without. The studies supporting this conclusion varied in size and methods used. The studies included large and small studies, representative and non-representative samples, consultations were timed in a variety of ways and the diagnosis of psychological problems was made sometimes by the doctor, sometimes by the patient and sometimes by an independent observer.
There were a number of possible confounding factors that may have resulted in changes to the number of recorded diagnoses of psychological problems between longer consultations and "average" consultations.
It may be that in longer consultations, doctors had more time to record more thorough notes.
Although this is a possible explanation, it is disputed by the studies that included patient questionnaires [9
], and where the diagnosis of psychological problems was made by independent observers from videotapes [41
If we accept that the increase in recorded diagnoses of psychological problems was a real increase, the issue then arises as to whether the consultations took longer because of the diagnosis of a psychological problem, or if the diagnosis was made more often by doctors who tended to have longer consultations? This question is explored further using evidence from this review on the possible effects of the consultation styles, doctor attributes and patient attributes on the length of consultation.
Consultation length and doctors' style
We found evidence from five relevant studies to support the hypothesis that doctors with consultation styles that took more time were more likely to make a psychological diagnosis. Several "doctor styles" were explored and all these styles result in more psychological diagnoses and took more time.
As well, the evidence from the two intervention studies clearly demonstrated changes in consultation style when the doctor had more time [50
]. Unfortunately, the intervention studies had limitations as both studies only collected data from one practice each, one [50
] in the inner city and the other [51
] in a suburban practice. Also, no information was given on the attitudes, ages or styles of the doctors involved in either study.
These studies raise the interesting question about whether it is the time or the doctors' style that was most important in diagnosing psychological problems. More evidence, including randomised controlled trials, is necessary to clarify this hypothesis.
Consultation length and doctor factors
We looked for evidence that reported on doctors' attributes apart from consultation style that may increase the likelihood of a diagnosis of psychological problems and of longer consultations. Two of these studies highlighted the importance of a positive attitude to psychological problems [38
] on the diagnosis rate and Howe commented that doctors sometimes make a "choice" about whether to diagnose and manage the psychological problems presenting in a consultation depending on their "time and energy" [44
]. This raises the question as to whether this attitude is part of the doctor's character or due to training, and hence whether the selection criteria for medicine and the training are appropriate. It also raised the likely effect of time pressure on a doctors' ability to offer optimal care.
Evidence was presented on other "doctor attributes" that are associated with longer consultations, particularly doctors' age, gender and training. However, this evidence is conflicting and does not clearly demonstrate confounding factors.
Consultation lengths and patient factors
We then looked for data on the patient attributes, apart from psychological problems, which may be associated with an increase in the length of consultations. It appears that increasing patient age is associated with longer consultations [27
]. This is important information for health policy-makers who are dealing with ageing populations.
We found that five out of seven studies reported that women patients had longer consultations [17
], especially women patients with psychosocial problems [43
] and that women had twice number of consultations with psychosocial diagnoses [29
]. This raises the question about why women have longer consultations, could they be better at expressing their psychological distress, or do they actually have a higher rate of psychological distress?
There appeared to be an association between increased socioeconomic deprivation and greater psychological distress, but also with shorter consultations[9
]. This "inverse care law" has been further examined by Furler et al who demonstrated that patients in "lower socioeconomic areas receive less longer consultations than those in more advantaged areas" [55
While it is clear that an increased recording of psychological diagnosis is associated with longer consultations, more research needs to be done to elucidate how these various factors can be explained and to determine the factors that would enable the most time-efficient, most accurate, method of diagnosis of psychological problems.
2.GPs report that time was one of the main barriers to addressing psychosocial problems
The evidence is obtained from six observational, cross-sectional studies [28
]. The numbers varied from 11 to 1700 doctors but only one study stated that it was representative and none of the studies had analysis involving confidence intervals. Hence, this evidence can only be hypothesis forming.
Despite these weaknesses, the evidence suggests that general practitioners consider it is lack of time, and not lack of knowledge, that is preventing them from achieving better outcomes for psychological problems. Howe raises the interesting question of the doctor's choice in the consultation, about whether to pursue the psychological aspects of a consultation depending on other factors, "time and energy" [44
]. As Howe put it, GPs "know what to do, but it's not possible to do it." This choice is also reflected in the study by Howie et al where "slower doctors" could work faster if they were under time pressure [26
This is important information for health policy makers to consider as often it is a perceived lack of skills in general practice that is blamed for deficiencies in the management of psychological illness.
It does, however, contradict other research that shows that GPs will considerably improve the rate of detection of psychological distress with simple training[56
]. It is likely that both training and time are important.
3. There was evidence of improved diagnosis of psychological problems in longer consultations
] provides the only evidence on containing consultation outcomes, in his study on the accuracy of detection of psychological distress; however, there is no reliable evidence that taking longer is related to improved outcomes in management of psychological problems. It is obvious that more research needs to be done in this area.