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1.  Clinical essentialising: a qualitative study of doctors’ medical and moral practice 
While certain substantial moral dilemmas in health care have been given much attention, like abortion, euthanasia or gene testing, doctors rarely reflect on the moral implications of their daily clinical work. Yet, with its aim to help patients and relieve suffering, medicine is replete with moral decisions. In this qualitative study we analyse how doctors handle the moral aspects of everyday clinical practice. About one hundred consultations were observed, and interviews conducted with fifteen clinical doctors from different practices. It turned out that the doctors’ approach to clinical cases followed a rather strict pattern across specialities, which implied transforming patients’ diverse concerns into specific medical questions through a process of ‘essentialising’: Doctors broke the patient’s story down, concretised the patient’s complaints and categorised the symptoms into a medical sense. Patients’ existential meanings were removed, and the focus placed on the patients’ functioning. By essentialising, doctors were able to handle a complex and ambiguous reality, and establish a medically relevant problem. However, the process involved a moral as well as a practical simplification. Overlooking existential meanings and focusing on purely functional aspects of patients was an integral part of clinical practice and not an individual flaw. The study thus questions the value of addressing doctors’ conscious moral evaluations. Yet doctors should be aware that their daily clinical work systematically emphasises beneficence at the expense of others—that might be more important to the patient.
doi:10.1007/s11019-009-9193-z
PMCID: PMC2848348  PMID: 20336384
Beneficence; Clinical decision-making; Dehumanising; Empirical research; Grounded theory; Medical ethics; Moral practice; Professional values; Qualitative
2.  Depersonalised doctors: a cross-sectional study of 564 doctors, 760 consultations and 1876 patient reports in UK general practice 
BMJ Open  2012;2(1):e000274.
Objectives
The objectives of this study were to assess burnout in a sample of general practitioners (GPs), to determine factors associated with depersonalisation and to investigate its impact on doctors' consultations with patients.
Design
Cross-sectional, postal survey of GPs using the Maslach Burnout Inventory (MBI). Patient survey and tape-recording of consultations for a subsample of respondents stratified by their MBI scores, gender and duration of General Medical Council registration.
Setting
UK general practice.
Participants
GPs within NHS Essex.
Primary and secondary outcome measures
Scores on MBI subscales (depersonalisation, emotional exhaustion, personal accomplishment); scores on Doctors' Interpersonal Skills Questionnaire and patient-centredness scores attributed to tape-recorded consultations by independent observers.
Results
In the postal survey, 564/789 (71%) GPs completed the MBI. High levels of emotional exhaustion (261/564 doctors, 46%) and depersonalisation (237 doctors, 42%) and low levels of personal accomplishment (190 doctors, 34%) were reported. Depersonalisation scores were related to characteristics of the doctor and the practice. Male doctors reported significantly higher (p<0.001) depersonalisation than female doctors. Doctors registered with the General Medical Council under 20 years had significantly higher (p=0.005) depersonalisation scores than those registered for longer. Doctors in group practices had significantly higher (p=0.001) depersonalisation scores than single-handed practitioners. Thirty-eight doctors agreed to complete the patient survey (n=1876 patients) and audio-record consultations (n=760 consultations). Depersonalised doctors were significantly more likely (p=0.03) to consult with patients who reported seeing their ‘usual doctor’. There were no significant associations between doctors' depersonalisation and their patient-rated interpersonal skills or observed patient-centredness.
Conclusions
This is the largest number of doctors completing the MBI with the highest levels of depersonalisation reported. Despite experiencing substantial depersonalisation, doctors' feelings of burnout were not detected by patients or independent observers. Such levels of burnout are, however, worrying and imply a need for action by doctors themselves, their medical colleagues, professional bodies, healthcare organisations and the Department of Health.
Article summary
Article focus
A cross-sectional survey was designed to assess levels of burnout in a census sample of GPs in Essex, UK, and to determine which doctor- or practice-related variables predicted higher levels of burnout.
In the substudy, patients rated the interpersonal skills of their doctor and independent observers assessed the degree of patient-centredness in a sample of the doctors' audio-taped consultations.
Key messages
High levels of burnout were reported in the census survey—46% doctors reported emotional exhaustion, 42% reported depersonalisation and 34% reported low levels of personal accomplishment.
Doctors' depersonalisation scores could be predicted by a range of variables relating to the individual doctor and their practice, but higher depersonalisation scores were not associated with poorer patient ratings of the doctors' interpersonal skills or a reduction in the patient-centredness of their consultations.
While the professional practice and patient-centredness of consultations of the GPs in this study were not affected by feelings of burnout, there is a need to offer help and support for doctors who are experiencing this.
Strengths and limitations of this study
A high response rate (71%) was achieved in the census sample of GPs completing the MBI and a subsample of 38 doctors who satisfied the predetermined sample stratification consented to further assessment (patient survey and audio-taping of consultations).
The study was, however, limited to one county in the UK and thus cannot be extrapolated to other parts of the UK.
There was a differential response rate by the gender of the participant. Male doctors who were registered with the General Medical Council for >20 years were less likely to respond to the survey than their female counterparts.
doi:10.1136/bmjopen-2011-000274
PMCID: PMC3274717  PMID: 22300669
3.  What Do Patients Choose to Tell Their Doctors? Qualitative Analysis of Potential Barriers to Reattributing Medically Unexplained Symptoms 
BACKGROUND
Despite both parties often expressing dissatisfaction with consultations, patients with medically unexplained symptoms (MUS) prefer to consult their general practitioners (GPs) rather than any other health professional. Training GPs to explain how symptoms can relate to psychosocial problems (reattribution) improves the quality of doctor–patient communication, though not necessarily patient health.
OBJECTIVE
To examine patient experiences of GPs’ attempts to reattribute MUS in order to identify potential barriers to primary care management of MUS and improvement in outcome.
DESIGN
Qualitative study.
PARTICIPANTS
Patients consulting with MUS whose GPs had been trained in reattribution. A secondary sample of patients of control GPs was also interviewed to ascertain if barriers identified were specific to reattribution or common to consultations about MUS in general.
APPROACH
Thematic analysis of in-depth interviews.
RESULTS
Potential barriers include the complexity of patients’ problems and patients’ judgements about how to manage their presentation of this complexity. Many did not trust doctors with discussion of emotional aspects of their problems and chose not to present them. The same barriers were seen amongst patients whose GPs were not trained, suggesting the barriers are not particular to reattribution.
CONCLUSIONS
Improving GP explanation of unexplained symptoms is insufficient to reduce patients’ concerns. GPs need to (1) help patients to make sense of the complex nature of their presenting problems, (2) communicate that attention to psychosocial factors will not preclude vigilance to physical disease and (3) ensure a quality of doctor–patient relationship in which patients can perceive psychosocial enquiry as appropriate.
doi:10.1007/s11606-008-0872-x
PMCID: PMC2659146  PMID: 19089505
doctor–patient communication; medically unexplained symptoms; reattribution
4.  What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes 
Background
Efforts to address depression in primary care settings have focused on the introduction of care guidelines emphasising pharmacological treatment. To date, physician adherence remains low. Little is known of the types of information exchange or other negotiations in doctor-patient consultations about depression that influence physician decision making about treatment.
Aim
The study sought to understand conversational influences on physician decision making about treatment for depression.
Design
A secondary analysis of consultation data collected in other studies. Using a maximum variation sampling strategy, 30 transcripts of primary care consultations about distress or depression were selected from datasets collected in three countries. Transcripts were analysed to discover factors associated with prescription of medication.
Method
The study employed two qualitative analysis strategies: a micro-analysis approach, which examines how conversation partners shape the dialogue towards pragmatic goals; and a narrative analysis approach of the problem presentation.
Results
Patients communicated their conceptual representations of distress at the outset of each consultation. Concepts of depression were communicated through the narrative form of the problem presentation. Three types of narratives were identified: those emphasising symptoms, those emphasising life situations, and mixed narratives. Physician decision making regarding medication treatment was strongly associated with the form of the patient’s narrative. Physicians made few efforts to persuade patients to accept biomedical attributions or treatments.
Conclusion
Results of the study provide insight into why adherence to depression guidelines remains low. Data indicate that patient agendas drive the ‘action’ in consultations about depression. Physicians appear to be guided by common-sense decision-making algorithms emphasising patients’ views and preferences.
doi:10.3399/bjgp12X616373
PMCID: PMC3252540  PMID: 22520683
conceptual models; decision making; depression; discourse analysis; doctor-patient relations; narrative analysis; illness representation
5.  Medical Professionalism: Conflicting Values for Tomorrow's Doctors 
Journal of General Internal Medicine  2010;25(12):1330-1336.
Background
New values and practices associated with medical professionalism have created an increased interest in the concept. In the United Kingdom, it is a current concern in medical education and in the development of doctor appraisal and revalidation.
Objective
To investigate how final year medical students experience and interpret new values of professionalism as they emerge in relation to confronting dying patients and as they potentially conflict with older values that emerge through hidden dimensions of the curriculum.
Methods
Qualitative study using interpretative discourse analysis of anonymized student reflective portfolios. One hundred twenty-three final year undergraduate medical students (64 male and 59 female) from the University of Cambridge School of Clinical Medicine supplied 116 portfolios from general practice and 118 from hospital settings about patients receiving palliative or end of life care.
Results
Professional values were prevalent in all the portfolios. Students emphasised patient-centered, holistic care, synonymous with a more contemporary idea of professionalism, in conjunction with values associated with the ‘old’ model of professionalism that had not be directly taught to them. Integrating ‘new’ professional values was at times problematic. Three main areas of potential conflict were identified: ethical considerations, doctor-patient interaction and subjective boundaries. Students explicitly and implicitly discussed several tensions and described strategies to resolve them.
Conclusions
The conflicts outlined arise from the mix of values associated with different models of professionalism. Analysis indicates that ‘new’ models are not simply replacing existing elements. Whilst this analysis is of accounts from students within one UK medical school, the experience of conflict between different notions of professionalism and the three broad domains in which this conflict arises are relevant in other areas of medicine and in different national contexts.
doi:10.1007/s11606-010-1485-8
PMCID: PMC2988149  PMID: 20740324
medical professionalism; medical education; qualitative research; students’ reflections
6.  Doctor–patient communication in a Southeast Asian setting: the conflict between ideal and reality 
Doctor–patient communication has been extensively studied in non-Western contexts and in relation to patients’ cultural and education backgrounds. This study explores the perceived ideal communication style for doctor–patient consultations and the reality of actual practice in a Southeast Asian context. We conducted the study in a teaching hospital in Indonesia, using a qualitative and a quantitative design. In-depth interviews were conducted with ten internal medicine specialists, ten internal medicine residents, 16 patients in two groups based on education level and ten most senior medical students. The contributions of doctors and patients to the communication during consultations were observed and rated quantitatively by thirty internal medicine residents, 393 patients with different educational backgrounds and ten senior medical students. The ‘informed and shared decision making’ is the central observation in this quantitative study. The results of the interviews showed that Southeast Asian stakeholders are in favor of a partnership style of communication and revealed barriers to achieving this: doctors and patients are not prepared for a participatory style and high patient load due to an inefficient health care system does not allow sufficient time for this type of communication. The results of the quantitative study showed a sharp contrast between observed and ideal communication styles. A paternalistic style seems to prevail, irrespective of patients’ educational background. We found a sharp conflict between ideal and reality concerning doctor–patient communication in a Southeast Asian context. Further studies should examine ways to change the prevailing communication style in the desired direction.
doi:10.1007/s10459-010-9242-7
PMCID: PMC3074074  PMID: 20658353
Doctor–patient communication; Intercultural communication; Patients’ educational background; The continuum of partnership style
7.  Decision-Making of Older Patients in Context of the Doctor-Patient Relationship: A Typology Ranging from “Self-Determined” to “Doctor-Trusting” Patients 
Background. This qualitative study aims to gain insight into the perceptions and experiences of older patients with regard to sharing health care decisions with their general practitioners. Patients and Methods. Thirty-four general practice patients (≥70 years) were asked about their preferences and experiences concerning shared decision making with their doctors using qualitative semistructured interviews. All interviews were analysed according to principles of content analysis. The resulting categories were then arranged into a classification grid to develop a typology of preferences for participating in decision-making processes. Results. Older patients generally preferred to make decisions concerning everyday life rather than medical decisions, which they preferred to leave to their doctors. We characterised eight different patient types based on four interdependent positions (self-determination, adherence, information seeking, and trust). Experiences of a good doctor-patient relationship were associated with trust, reliance on the doctor for information and decision making, and adherence. Conclusion. Owing to the varied patient decision-making types, it is not easy for doctors to anticipate the desired level of patient involvement. However, the decision matter and the self-determination of patients provide good starting points in preparing the ground for shared decision making. A good relationship with the doctor facilitates satisfying decision-making experiences.
doi:10.1155/2013/478498
PMCID: PMC3652207  PMID: 23691317
8.  "Seeing a doctor is just like having a date": a qualitative study on doctor shopping among overactive bladder patients in Hong Kong 
BMC Family Practice  2014;15:27.
Background
Although having a regular primary care provider is noted to be beneficial to health, doctor shopping has been documented as a common treatment seeking behavior among chronically ill patients in different countries. However, little research has been conducted into the reasons behind doctor shopping behavior among patients with overactive bladder, and even less into how this behavior relates to these patients’ illness and social experiences, perceptions, and cultural practices. Therefore, this study examines overactive bladder patients to investigate the reasons behind doctor shopping behavior.
Methods
My study takes a qualitative approach, conducting 30 semi-structured individual interviews, with 30 overactive bladder patients in Hong Kong.
Results
My study found six primary themes that influenced doctor shopping behavior: lack of perceived need, convenience, work-provided medical insurance, unpleasant experiences with doctors, searching for a match doctor, and switching between biomedicine and traditional Chinese medicine. Besides the perceptual factors, participants’ social environment, illness experiences, personal cultural preference, and cultural beliefs also intertwined to generate their doctor shopping behavior. Due to the low perceived need for a regular personal primary care physician, environmental factors such as time, locational convenience, and work-provided medical insurance became decisive in doctor shopping behavior. Patients’ unpleasant illness experiences, stemming from a lack of understanding among many primary care doctors about overactive bladder, contributed to participants’ sense of mismatch with these doctors, which induced them to shop for another doctor.
Conclusions
Overactive bladder is a chronic bladder condition with very limited treatment outcome. Although patients with overactive bladder often require specialty urology treatment, it is usually beneficial for the patients to receive continuous, coordinated, comprehensive, and patient-centered support from their primary care providers. Primary care doctors’ understanding on patients with overactive bladder with empathetic attitudes is important to reduce the motivations of doctor shopping behavior among these patients.
doi:10.1186/1471-2296-15-27
PMCID: PMC3936809  PMID: 24502367
Hong Kong; Doctor shopping; Perceptions; Social environment; Illness and treatment experiences; Personal cultural preference; Cultural beliefs; Overactive bladder patients
9.  The cultural context of patient’s autonomy and doctor’s duty: passive euthanasia and advance directives in Germany and Israel 
The moral discourse surrounding end-of-life (EoL) decisions is highly complex, and a comparison of Germany and Israel can highlight the impact of cultural factors. The comparison shows interesting differences in how patient’s autonomy and doctor’s duties are morally and legally related to each other with respect to the withholding and withdrawing of medical treatment in EoL situations. Taking the statements of two national expert ethics committees on EoL in Israel and Germany (and their legal outcome) as an example of this discourse, we describe the similarity of their recommendations and then focus on the differences, including the balancing of ethical principles, what is identified as a problem, what social role professionals play, and the influence of history and religion. The comparison seems to show that Israel is more restrictive in relation to Germany, in contrast with previous bioethical studies in the context of the moral and legal discourse regarding the beginning of life, in which Germany was characterized as far more restrictive. We reflect on the ambivalence of the cultural reasons for this difference and its expression in various dissenting views on passive euthanasia and advance directives, and conclude with a comment on the difficulty in classifying either stance as more or less restrictive.
doi:10.1007/s11019-010-9262-3
PMCID: PMC2949555  PMID: 20680469
Culture; End of life; Expert ethics committees; Doctors’ duties; German law; Living will; Israeli Law; Patients’ rights; Religion
10.  Clinical practice patterns among native and immigrant doctors doing out-of-hours work in Norway: a registry-based observational study 
BMJ Open  2012;2(4):e001153.
Objectives
To evaluate whether immigrant and native Norwegian doctors differ in their practice patterns.
Design
Observational study.
Setting
Out-of-hours (OOH) emergency primary healthcare in Norway, 2008.
Participants
All primary care physicians doing OOH work, altogether 4165 physicians.
Main outcome measures
Number of patient contacts per doctor. Use of laboratory tests, minor surgery, sickness certification and length of consultations. Use of diagnoses related to psychiatric and sexual health. Choice of management strategy with psychiatric patients (psychotherapy or hospitalisation).
Results
21.4% of the physicians were immigrants, and they had 30.6% of the patient contacts. Immigrant doctors from Asia, Africa and Latin America had most patient contacts, 633 (95% CI 549 to 716), while native Norwegian doctors had 306 (95% CI 288 to 325). In multivariate analyses, immigrant physicians did not differ significantly from native Norwegians regarding use of laboratory tests, minor surgery or length of consultations, but immigrant doctors wrote more sickness certificates, OR 1.75 (95% CI 1.24 to 2.47) for immigrant doctors from Europe, North America and Oceania versus native Norwegian doctors and OR 1.56 (95% CI 1.15 to 2.11) for immigrant doctors from Asia, Africa and Latin America versus native Norwegians. Immigrant physicians from Europe, North America and Oceania used more diagnoses related to pregnancy, family planning and female genitals, OR 1.55 (95% CI 1.11 to 2.16), versus native Norwegian physicians. Immigrant doctors from Asia, Africa and Latin America used less psychiatric diagnoses, OR 0.71 (95% CI 0.53 to 0.95), versus native Norwegian doctors but did not differ significantly in their management of recognised psychiatric illness.
Conclusions
Immigrant doctors make an important contribution to OOH emergency primary healthcare in Norway. The authors found only modest evidence that their clinical practice patterns are different from that of native Norwegian doctors.
Article summary
Article focus
Western countries receive an increasing number of immigrant doctors.
Concern has been raised regarding their skills.
We studied immigrant doctors' clinical performance.
Key messages
Immigrant doctors from Asia, Africa and Latin America did more OOH work than native Norwegian doctors.
Immigrant doctors wrote more sickness certificates per consultation.
Otherwise, there were only minor differences in practice patterns between immigrant and native Norwegian doctors.
Strengths and limitations of this study
Large and complete material.
Avoids problem with case mix.
Limited information about immigrant doctors' educational background.
doi:10.1136/bmjopen-2012-001153
PMCID: PMC3400071  PMID: 22798255
11.  Qualitative study of interpretation of reassurance among patients attending rheumatology clinics: “just a touch of arthritis, doctor?” 
BMJ : British Medical Journal  2000;320(7234):541-544.
Objectives
To examine commonly used methods of reassurance by clinicians and explore their effect on patients.
Design
Qualitative study of tape recordings of in-depth, semistructured interviews with patients before and after consultation and of their consultations with doctors.
Setting
NHS specialist rheumatology clinics in two large British cities.
Participants
35 patients selected by consultant rheumatologists from general practitioner referral letters (28 women, 7 men; 24 with inflammatory arthropathies, 11 other rheumatological complaints).
Main outcome measures
Patients' perceptions of reassurance.
Results
Reassurance was an important part of consultations, whether the diagnosis was clear or uncertain. Clinicians tried to reduce anxiety by emphasising the mildness, early stage, or non-seriousness of the disorder and the likelihood that patients would recover. Patients interpreted reassurance in the context of their own views and perceptions. Doctors' emphasis on the mildness or earliness of the condition raised the spectre of future pain and disability rather than providing reassurance. Patients who felt that their problems were properly acknowledged felt more reassured.
Conclusions
Typical patterns of reassurance were not successful because of the differences in perspective of patients and doctors. A key to successful reassurance seemed to be the doctor's ability to acknowledge patients' perspectives of their difficulties.
PMCID: PMC27296  PMID: 10688559
12.  Changes in the quality of doctor–patient communication between 1982 and 2001: an observational study on hypertension care as perceived by patients and general practitioners 
BMJ Open  2011;1(1):e000203.
Background
The rise of evidence-based medicine may have implications for the doctor–patient interaction. In recent decades, a shift towards a more task-oriented approach in general practice indicates a development towards more standardised healthcare.
Objective
To examine whether this shift is accompanied by changes in perceived quality of doctor–patient communication.
Design
GP observers and patient observers performed quality assessments of Dutch General Practice consultations on hypertension videotaped in 1982–1984 and 2000–2001. In the first cohort (1982–1984) 81 patients were recorded by 23 GPs and in the second cohort (2000–2001) 108 patients were recorded by 108 GPs. The GP observers and patient observers rated the consultations on a scale from 1 to 10 on three quality dimensions: medical technical quality, psychosocial quality and quality of interpersonal behaviour. Multilevel regression analyses were used to test whether a change occurred over time.
Results
The findings showed a significant improvement over time on all three dimensions. There was no difference between the quality assessments of GP observers and patient observers. The three different dimensions were moderately to highly correlated and the assessments of GP observers showed less variability in the second cohort.
Conclusions
Hypertension consultations in general practice in the Netherlands received higher quality assessments by general practitioners and patients on medical technical quality, psychosocial quality and the quality of interpersonal behaviour in 2000–2001 as compared with the 1980s. The shift towards a more task-oriented approach in hypertension consultations does not seem to detract from individual attention for the patient. In addition, there is less variation between general practitioners in the quality assessments of more recent consultations. The next step in this line of research is to unravel the factors that determine patients' quality assessments of doctor–patient communication.
Article summary
Article focus
Doctor–patient communication in hypertension consultations has become more business-like and task-oriented in the past few decades.
Shifts in communication styles in general practice may have produced changes in quality assessments of doctor–patient communication by general practitioners and patients.
Key messages
Compared with 20 years earlier (1982–1984), hypertension consultations recorded in 2000–2001 received higher quality assessments by GP observers and patient observers on three distinct quality dimensions: medical technical quality, psychosocial quality and the quality of interpersonal behaviour.
There was less variation between general practitioners in the quality assessments of more recent consultations.
Strengths and limitations of this study
Videotaped real-life general practice consultations from two distinct periods were analysed, which means that the findings refer to actual behaviour in general practice.
The quality assessments were made according to the same protocol in both periods.
Assessments of the GPs were executed by contemporary peers, while the assessments of patients were performed retrospectively. However, the concurrence of assessments of patient observers and GP observers in their different contexts reinforces our conclusions.
The generalisability of the findings is restricted to hypertension consultations, which involve a high proportion of repeat visits.
doi:10.1136/bmjopen-2011-000203
PMCID: PMC3191582  PMID: 22021787
13.  Concerns over confidentiality may deter adolescents from consulting their doctors. A qualitative exploration 
Journal of Medical Ethics  2006;32(3):133-137.
Objectives
Young people who are concerned that consultations may not remain confidential are reluctant to consult their doctors, especially about sensitive issues. This study sought to identify issues and concerns of adolescents, and their parents, in relation to confidentiality and teenagers' personal health information.
Setting
Recruitment was conducted in paediatric dermatology and general surgery outpatient clinics, and on general surgery paediatric wards. Interviews were conducted in subjects' own homes.
Methods
Semistructured interviews were used for this exploratory qualitative study. Interviews were carried out with 11 young women and nine young men aged 14–17. Parents of 18 of the young people were interviewed separately. Transcripts of tape recorded interviews provided the basis for a framework analysis.
Results
Young women were more concerned than young men, and older teenagers more concerned than younger teenagers, about people other than their general practitioner (GP) having access to their health information. Young people with little experience of the healthcare system were less happy than those with greater knowledge of the National Health Service (NHS) for non‐medical staff to access their health information. As they grow older, adolescents become increasingly concerned that their health information should remain confidential.
Conclusion
Young people's willingness to be open in consultations could be enhanced by doctors taking time to explain to them that their discussion is completely confidential. Alternatively, if for any reason confidentiality cannot be assured, doctors should explain why.
doi:10.1136/jme.2004.011262
PMCID: PMC2564464  PMID: 16507655
confidentiality; medical records; young people; rights of children; parental view
14.  Shifts in doctor-patient communication between 1986 and 2002: a study of videotaped General Practice consultations with hypertension patients 
BMC Family Practice  2006;7:62.
Background
Departing from the hypotheses that over the past decades patients have become more active participants and physicians have become more task-oriented, this study tries to identify shifts in GP and patient communication patterns between 1986 and 2002.
Methods
A repeated cross-sectional observation study was carried out in 1986 and 2002, using the same methodology. From two existing datasets of videotaped routine General Practice consultations, a selection was made of consultations with hypertension patients (102 in 1986; 108 in 2002). GP and patient communication was coded with RIAS (Roter Interaction Analysis System). The data were analysed, using multilevel techniques.
Results
No gender or age differences were found between the patient groups in either study period. Contrary to expectations, patients were less active in recent consultations, talking less, asking fewer questions and showing less concerns or worries. GPs provided more medical information, but expressed also less often their concern about the patients' medical conditions. In addition, they were less involved in process-oriented behaviour and partnership building. Overall, these results suggest that consultations in 2002 were more task-oriented and businesslike than sixteen years earlier.
Conclusion
The existence of a more equal relationship in General Practice, with patients as active and critical consumers, is not reflected in this sample of hypertension patients. The most important shift that could be observed over the years was a shift towards a more businesslike, task-oriented GP communication pattern, reflecting the recent emphasis on evidence-based medicine and protocolized care. The entrance of the computer in the consultation room could play a role. Some concerns may be raised about the effectiveness of modern medicine in helping patients to voice their worries.
doi:10.1186/1471-2296-7-62
PMCID: PMC1630692  PMID: 17064407
15.  Truth or fallacy? Three hour wait for three minutes with the doctor: Findings from a private clinic in rural Japan 
Introduction
While previous reports examine various aspects of Family Medicine in Japan, there is sparse research on consultation lengths. A common phrase permeates throughout Japan, sanjikan machi, sanpun shinsatsu that means, "Three hour wait, three minute visit." The purpose of this study is to examine consultation length in Japan, and how it is affected by patient variables.
Case Description
We conducted a case study of consultation length and how it varies in relation to the demographics, presenting illness, and diagnoses at a rural clinic in central Japan. Data were coded according to the standards of the International Classification of Primary Care. Descriptive statistics were obtained to identify features of the data. Further, regression analysis was performed to characterize and to quantify the association between length of consultation and various subject level characteristics.
Discussion and Evaluation
A total of 263 patients aged 0 - 93 years old had consultations during the 8-day study period. The mean consultation duration was 6.12 minutes. Of all consultations, 11.8% lasted 3 minutes or less. The mean (median) consultation time among males was 6.29 (5.2) minutes and among females was 6.03 (5.4) minutes. The duration of visits increased with age. Among different International Classification of Primary Care categories, psychological issues required the most time (mean = 10.75 min, median = 10.9 min) while urological issues required the least (mean = 5.08 min, median = 4.9 min). The majority of cases seen in the clinic were stable, chronic conditions and required shorter consultation times.
Conclusions
While the mean and median consultation length in this study extends beyond the anecdotal three minutes, the average length of consultation is still remarkably short. Trends affecting consultation length were similar to other international studies. These data present only one aspect of primary care delivery in Japan. To better understand the significance of consultation length relative to the delivery of primary care, future research should examine issues such as continuity, frequency of consultations over time and comprehensiveness of care.
doi:10.1186/1447-056X-9-11
PMCID: PMC3004828  PMID: 21092269
16.  Palliative care for older people – exploring the views of doctors and nurses from different fields in Germany 
Background
Providing appropriate palliative care for older people is a major task for health care systems worldwide, and up to now it has also been one of the most neglected. Focusing on the German health care system, we sought to explore the attitudes of health professionals regarding their understanding of palliative care for older patients and its implementation.
Methods
In a qualitative study design, focus groups were established consisting of general practitioners, geriatricians, palliative care physicians, palliative care nurses and general nurses (a total of 29 participants). The group discussions were recorded, transcribed, coded and analysed using the methodological approach of Qualitative Description.
Results
Deficiencies in teamwork and conflicting role definitions between doctors and nurses and between family practitioners and medical specialists were found to be central problems affecting the provision of appropriate palliative care for older people. It was emphasized that there are great advantages to family doctors playing a leading role, as they usually have the longest contacts to the patients. However, the professional qualifications of family doctors were to some extent criticized. The general practitioners for their part criticized the increasing specialization on the field of palliative care. All groups complained that the German compensation system gives insufficient consideration to the time-consuming care of older patients, and about excessive bureaucracy.
Conclusion
General practitioners are the central health professionals in the delivery of palliative care for older people. They should however be encouraged to involve specialized services such as palliative care teams where necessary. With the German health care reform of 2007, a legal framework has been created that allows for this. As far as its realization is concerned, it must be ensured that the spotlight remains on the needs of the patients and not on policy conflicts and rivalries between health care professionals. Older people might particularly benefit if "talking" medicine and time-consuming care were properly catered for, financially and organizationally, in the health care system.
doi:10.1186/1472-684X-8-7
PMCID: PMC2706814  PMID: 19549336
17.  Computer-based quality of life questionnaires may contribute to doctor–patient interactions in oncology 
British Journal of Cancer  2002;86(1):51-59.
It is well recognized that oncologists should consider patients' quality of life and functioning when planning and delivering anticancer treatment, but a comprehensive assessment of how a patient feels requires a thorough inquiry. A standardized measurement of patients' quality of life may support clinicians in identifying important problems for discussion during the limited time of the medical consultations. The aim of this study was to assess the feasibility of computer-administered individual quality of life measurements in oncology clinics with immediate feedback of results to clinicians and to examine the impact of the information on consultations. The study employed a prospective non-randomized design with pre-test post-test within subjects comparisons and involved three medical oncologists and 28 cancer patients receiving chemotherapy. The intervention consisted of completion of quality of life questionnaires before the consultations and informing clinicians of the results. The main outcome measures were patients' perceptions of the content of baseline and intervention consultations and satisfaction with communication. A qualitative analysis of clinicians' interviews was performed. When clinicians had the quality of life results they enquired more often about daily activities (Z=−2.71, P=0.007), emotional problems (Z=−2.11, P=0.035) and work related issues (Z=−1.89, P=0.058). There was an increase in the number of issues discussed during the intervention consultation (Z=−1.89, P=0.059). Patients were highly satisfied with both consultations. The computer measurement was well accepted by patients who felt that the questionnaires were a useful tool to tell the doctors about their problems. The clinicians perceived that the quality of life data broadened the range of the clinical inquiry and helped them identify issues for discussion. Having symptoms and functional problems expressed quantitatively on a scale was useful for detection of change over time.
British Journal of Cancer (2002) 86, 51–59. DOI: 10.1038/sj/bjc/6600001 www.bjcancer.com
© 2002 The Cancer Research Campaign
doi:10.1038/sj.bjc.6600001
PMCID: PMC2746549  PMID: 11857011
quality of life; individual; cancer; computer; communication
18.  Perceptions of an older patient on the role of the family doctor in health promotion: a qualitative case study 
Introduction
Health promotion and disease prevention are important aspects of primary health care. However, limited data are available concerning the opinions of older patients towards the respective services offered by family doctors. The aim of the present study was to evaluate an older patient's perception of the role of the family doctor in promoting his health, and identify those components that are difficult to examine in quantitative research.
Methods
A qualitative case study of an 80-year-old man using an in-depth interview was carried out. The interview transcript was analyzed thematically. Our patient was an 80-year-old university-educated man, with stable social and financial circumstances, living with his wife. He had retired early on grounds of ill health (tuberculosis) and had received a disability pension prior to formal retirement. At the time of the interview, his medical problems included mild prostatic hypertrophy, scoliosis and hypertension. He considered his health status to be satisfactory. He had changed family doctor five years prior to the interview, as he had been dissatisfied with the care provided.
Results
We found that our patient expected the family doctor to be aware of, and to discuss, the following issues: physical activity, diet, management of stress and mental health, use of alcohol and tobacco, personal hygiene, health screening, use of medication, and social activity. At the same time, our patient perceived the doctor's role as supplementary to his own in terms of the appraisal and maintenance of his health.
Conclusions
Our findings provide evidence of what is important in the promotion of health among older people.
doi:10.1186/1752-1947-7-57
PMCID: PMC3599762  PMID: 23448254
Case studies; Health promotion; Older people; Primary health care
19.  Collusion in doctor-patient communication about imminent death 
Western Journal of Medicine  2001;174(4):247-253.
Objective To discover and explore the factors that result in the “false optimism about recovery” observed in patients with small cell lung cancer. Design A qualitative observational (ethnographic) study in 2 stages over 4 years. Setting Lung diseases ward and outpatient clinic in a university hospital in the Netherlands. Participants 35 patients with small cell lung cancer. Results False optimism about recovery usually developed during the first course of chemotherapy and was most prevalent when the cancer could no longer be seen on x-ray films. This optimism tended to vanish when the tumor recurred, but it could develop again, though to a lesser extent, during further courses of chemotherapy. Patients gradually found out the facts about their poor prognosis, partly by their physical deterioration and partly through contact with fellow patients in a more advanced stage of the illness who were dying. False optimism about recovery was the result of an association between physicians' activism and patients' adherence to the treatment calendar and to the “recovery plot,” which allowed them to avoid acknowledging explicitly what they should and could know. The physician did and did not want to pronounce a “death sentence,” and the patient did and did not want to hear it. Conclusion Solutions to the problem of collusion between physician and patient require an active, patient-oriented approach by the physician. Perhaps solutions have to be found outside the physician-patient relationship itself—for example, by involving “treatment brokers.”
PMCID: PMC1071348  PMID: 11290678
20.  Collusion in doctor-patient communication about imminent death: an ethnographic study 
BMJ : British Medical Journal  2000;321(7273):1376-1381.
Objective
To discover and explore the factors that result in “false optimism about recovery” observed in patients with small cell lung cancer.
Design
A qualitative observational (ethnographic) study in two stages over four years.
Setting
Lung diseases ward and outpatient clinic in university hospital in the Netherlands.
Participants
35 patients with small cell lung cancer.
Results
“False optimism about recovery” usually developed during the (first) course of chemotherapy and was most prevalent when the cancer could no longer be seen in the x ray pictures. This optimism tended to vanish when the tumour recurred, but it could develop again, though to a lesser extent, during further courses of chemotherapy. Patients gradually found out the facts about their poor prognosis, partly because of physical deterioration and partly through contact with fellow patients who were in a more advanced stage of the illness and were dying. “False optimism about recovery” was the result an association between doctors' activism and patients' adherence to the treatment calendar and to the “recovery plot,” which allowed them not to acknowledge explicitly what they should and could know. The doctor did and did not want to pronounce a “death sentence” and the patient did and did not want to hear it.
Conclusion
Solutions to the problem of collusion between doctor and patient require an active, patient oriented approach from the doctor. Perhaps solutions have to be found outside the doctor-patient relationship itself   —   for example, by involving “treatment brokers.”
PMCID: PMC27539  PMID: 11099281
21.  Doctors' emotional reactions to recent death of a patient: cross sectional study of hospital doctors 
BMJ : British Medical Journal  2003;327(7408):185.
Objectives: To describe doctors' emotional reactions to the recent death of an “average” patient and to explore the effects of level of training on doctors' reactions.
Design: Cross sectional study using quantitative and qualitative data.
Setting: Two academic teaching hospitals in the United States.
Participants: 188 doctors (attending physicians (equivalent to UK consultants), residents (equivalent to UK senior house officers), and interns (equivalent to UK junior house officers)) who cared for 68 patients who died in the hospital.
Main outcome measures: Doctors' experiences in providing care, their emotional reactions to the patient's death, and their use of coping and social resources to manage their emotions.
Results: Most doctors (139/188, 74%) reported satisfying experiences in caring for a dying patient. Doctors reported moderate levels of emotional impact (mean 4.7 (SD 2.4) on a 0-10 scale) from the death. Women and those doctors who had cared for the patient for a longer time experienced stronger emotional reactions. Level of training was not related to emotional reactions, but interns reported needing significantly more emotional support than attending physicians. Although most junior doctors discussed the patient's death with an attending physician, less than a quarter of interns and residents found senior teaching staff (attending physicians) to be the most helpful source of support.
Conclusions: Doctors who spend a longer time caring for their patients get to know them better but this also makes them more vulnerable to feelings of loss when these patients die. Medical teams may benefit from debriefing within the department to give junior doctors an opportunity to share emotional responses and reflect on the patient's death.
PMCID: PMC166122  PMID: 12881257
22.  Effective improvement of doctor–patient communication: a randomised controlled trial 
Background
Doctor–patient communication is an essential component of general practice. Improvement of GPs' communication patterns is an important target of training programmes. Available studies have so far failed to provide conclusive evidence of the effectiveness of educational interventions to improve doctor–patient communication.
Aim
To examine the effectiveness of a learner-centred approach that focuses on actual needs, to improve GPs' communication with patients.
Design of study
Randomised controlled trial.
Setting
One hundred volunteer GPs in the Netherlands.
Method
The intervention identified individual GPs' deficiencies in communication skills by observing authentic consultations in their own surgery. This performance assessment was followed by structured activities in small group meetings, aimed at remedying the identified shortcomings. Outcomes were measured using videotaped consultations in the GPs' own surgery before and after the intervention. Communication skills were rated using the MAAS-Global, a validated checklist.
Results
The scores in the intervention group demonstrated a significant improvement compared with those of the control group (95% confidence interval = 0.04 to 0.75). The effect size was moderate to large (d-value = 0.66). The level of participation significantly contributed to the effectiveness. Largest improvement was found on patient-centred communication skills.
Conclusion
The approach of structured individual improvement activities based on performance assessment is more effective in improving communication skills than current educational activities.
PMCID: PMC1874521  PMID: 16882375
communication; continuing medical education; physician–patient relations; task performance; analysis
23.  Women doctors in urban general practice: the doctors. 
A large study of general practitioners in Manchester showed that women doctors were younger than men doctors, and few were single handed or worked in deprived inner city areas. They had closely similar patterns of care to their male colleagues, and although they worked slightly fewer hours in surgery, they had almost identical consultation times per patient. Women general practitioners were less active in politics and education than men.
PMCID: PMC1418537  PMID: 3918743
24.  Doctor–patient sexual relationships in medical oaths 
Journal of Medical Ethics  2006;32(12):702-705.
Background
Doctor–patient sexual relationship is considered to be unfair because the first party would be abusing the second party's vulnerability. The prohibition of this relationship is noted in the Hippocratic oath. Currently, a reprise of the use of oaths in medical schools can be observed.
Aim
To determine whether the prohibition has been maintained and how its expression has varied in the oaths during different periods.
Methods
50 oaths were studied: 13 ancient–medieval and 37 modern–contemporary. Of the 50 texts, 19 were versions of the original oaths. The oaths that pointed out the prohibited doctor–patient relationship referred to any sexual aspect or included paragraphs that began as the Hippocratic oath does were noted.
Results
Of the 24 (48%) texts that expressed the prohibition, 8 (62%) were ancient–medieval and 16 (43%) were modern–contemporary. Some expressly call it Hippocratic oath, many use general terminology (corruption or vice) and others describe it in association with other commitments (abortion and euthanasia).
Conclusions
The clause on the prohibition of the doctor–patient sexual relationship in Hippocratic oath was included to be for legal, economic and social reasons at the time. That the clause is found mostly in the ancient–medieval oaths can be attributed to the influence of the original. This commitment is generalised and associated with others by contemporary formulas. Currently, sexual relationships are the subject of legal and ethical analysis and their inclusion in the oaths is being debated.
doi:10.1136/jme.2005.014910
PMCID: PMC2563341  PMID: 17145909
25.  Consultation skills of young doctors: II--Most young doctors are bad at giving information. 
Forty young doctors, half of whom had had feedback training in interviewing as students, were assessed five years later. Each interviewed three patients and after being given results of examination, investigations, and diagnosis and prognosis returned to discuss them with each patient for 10 minutes. These discussions were filmed on videotape and evaluated. There was no difference between the scores of interview trained and control doctors. Though most gave simple information on diagnosis and treatment, few mentioned investigations, aetiology, or prognosis. Very few obtained and took any account of patients' views or expectations of these matters. Some young doctors do discover for themselves how best to give patients information and advice, but most remain extremely incompetent. This is presumably because they get no training as students in this important aspect of clinical practice. This deficiency should be corrected, and competence tested before qualification to practise.
PMCID: PMC1340569  PMID: 3087523

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