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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.  The patient and the computer in the primary care consultation 
Objective
Studies of the doctor–patient relationship have focused on the elaboration of power and/or authority using a range of techniques to study the encounter between doctor and patient. The widespread adoption of computers by doctors brings a third party into the consultation. While there has been some research into the way doctors view and manage this new relationship, the behavior of patients in response to the computer is rarely studied. In this paper, the authors use Goffman's dramaturgy to explore patients' approaches to the doctor's computer in the consultation, and its influence on the patient–doctor relationship.
Design
Observational study of Australian general practice. 141 consultations from 20 general practitioners were videotaped and analyzed using a hermeneutic framework.
Results
Patients negotiated the relationship between themselves, the doctor, and the computer demonstrating two themes: dyadic (dealing primarily with the doctor) or triadic (dealing with both computer and doctor). Patients used three signaling behaviors in relation to the computer on the doctor's desk (screen watching, screen ignoring, and screen excluding) to influence the behavior of the doctor. Patients were able to draw the doctor to the computer, and used the computer to challenge doctor's statements.
Conclusion
This study demonstrates that in consultations where doctors use computers, the computer can legitimately be regarded as part of a triadic relationship. Routine use of computers in the consultation changes the doctor–patient relationship, and is altering the distribution of power and authority between doctor and patient.
doi:10.1136/jamia.2010.006486
PMCID: PMC3116262  PMID: 21262923
Physician patient relationship; medical informatics; qualitative research; office visits; computers; patient-centered medicine
4.  Physician Awareness of Drug Cost: A Systematic Review 
PLoS Medicine  2007;4(9):e283.
Background
Pharmaceutical costs are the fastest-growing health-care expense in most developed countries. Higher drug costs have been shown to negatively impact patient outcomes. Studies suggest that doctors have a poor understanding of pharmaceutical costs, but the data are variable and there is no consistent pattern in awareness. We designed this systematic review to investigate doctors' knowledge of the relative and absolute costs of medications and to determine the factors that influence awareness.
Methods and Findings
Our search strategy included The Cochrane Library, EconoLit, EMBASE, and MEDLINE as well as reference lists and contact with authors who had published two or more articles on the topic or who had published within 10 y of the commencement of our review. Studies were included if: either doctors, trainees (interns or residents), or medical students were surveyed; there were more than ten survey respondents; cost of pharmaceuticals was estimated; results were expressed quantitatively; there was a clear description of how authors defined “accurate estimates”; and there was a description of how the true cost was determined. Two authors reviewed each article for eligibility and extracted data independently. Cost accuracy outcomes were summarized, but data were not combined in meta-analysis because of extensive heterogeneity. Qualitative data related to physicians and drug costs were also extracted. The final analysis included 24 articles. Cost accuracy was low; 31% of estimates were within 20% or 25% of the true cost, and fewer than 50% were accurate by any definition of cost accuracy. Methodological weaknesses were common, and studies of low methodological quality showed better cost awareness. The most important factor influencing the pattern and accuracy of estimation was the true cost of therapy. High-cost drugs were estimated more accurately than inexpensive ones (74% versus 31%, Chi-square p < 0.001). Doctors consistently overestimated the cost of inexpensive products and underestimated the cost of expensive ones (binomial test, 89/101, p < 0.001). When asked, doctors indicated that they want cost information and feel it would improve their prescribing but that it is not accessible.
Conclusions
Doctors' ignorance of costs, combined with their tendency to underestimate the price of expensive drugs and overestimate the price of inexpensive ones, demonstrate a lack of appreciation of the large difference in cost between inexpensive and expensive drugs. This discrepancy in turn could have profound implications for overall drug expenditures. Much more focus is required in the education of physicians about costs and the access to cost information. Future research should focus on the accessibility and reliability of medical cost information and whether the provision of this information is used by doctors and makes a difference to physician prescribing. Additionally, future work should strive for higher methodological standards to avoid the biases we found in the current literature, including attention to the method of assessing accuracy that allows larger absolute estimation ranges for expensive drugs.
From a review of data from 24 studies, Michael Allan and colleagues conclude that doctors often underestimate the price of expensive drugs and overestimate the price of those that are inexpensive.
Editors' Summary
Background.
Many medicines are extremely expensive, and the cost of buying them is a major (and increasing) proportion of the total cost of health care. Governments and health-care organizations try to find ways of keeping down costs without reducing the effectiveness of the health care they provide, but their efforts to control what is spent on medicines have not been very successful. There are often two or more equally effective drugs available for treating the same condition, and it would obviously help keep costs down if, when a doctor prescribes a medicine, he or she chose the cheapest of the effective drugs available. This choice could result in savings for whoever is paying for the drugs, be it the government, the patient, or a medical insurance organization.
Why Was This Study Done?
Doctors who prescribe drugs cannot be expected to know the exact cost of each drug on the market, but it would he helpful if they had some impression of the cost of a treatment and how the various alternatives compare in price. However, systems deciding how drugs are priced are often very complex. (This is particularly the case in the US.) The researchers wanted to find out how aware doctors are regarding drug costs and the difference between the alternatives. They also wanted to know what factors affected their awareness.
What Did the Researchers Do and Find?
They decided to do a systematic review of all the research already conducted that addressed this issue so that the evidence from all of them could be considered together. In order to do such a review they had to specify precise requirements for the type of study that they would include and then comprehensively search the medical literature for such studies. They found 24 studies that met their requirements. From these studies, they concluded that doctors were usually not accurate when asked to estimate the cost of drugs; doctors came up with estimates that were within 25% of the true cost less than one-third of the time. In particular doctors tended to underestimate the cost of expensive drugs and overestimate the cost of the cheaper alternatives. A further analysis of the studies showed that many doctors said they would appreciate more accurate information on costs to help them choose which drugs to prescribe but that such information was not readily available.
What Do These Findings Mean?
The researchers concluded that their systematic review demonstrates a lack of appreciation by prescribing doctors of the large difference in cost between inexpensive and expensive drugs, and that this finding has serious implications for overall spending on drugs. They call for more education and information to be provided to doctors on the cost of medicines together with better processes to help doctors in making such decisions.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040283.
A brief guide to systematic reviews has been published by the BMJ (British Medical Journal)
The Web site of the Cochrane Collaboration is a more detailed source of information on systematic reviews; in particular there is a newcomers' guide and information for health-care consumers
The Kaiser Family Foundation, a nonprofit, private operating foundation focusing on the major health care issues in the US, has a section on prescription drugs and their costs
doi:10.1371/journal.pmed.0040283
PMCID: PMC1989748  PMID: 17896856
5.  Doctors' perceptions of palliative care for heart failure: focus group study 
BMJ : British Medical Journal  2002;325(7364):581-585.
Objectives
To identify doctors' perceptions of the need for palliative care for heart failure and barriers to change.
Design
Qualitative study with focus groups.
Setting
North west England.
Participants
General practitioners and consultants in cardiology, geriatrics, palliative care, and general medicine.
Results
Doctors supported the development of palliative care for patients with heart failure with the general practitioner as a central figure. They were reluctant to endorse expansion of specialist palliative care services. Barriers to developing approaches to palliative care in heart failure related to three main areas: the organisation of health care, the unpredictable course of heart failure, and the doctors' understanding of roles. The health system was thought to work against provision of holistic care, exacerbated by issues of professional rivalry and control. The priorities identified for the future were developing the role of the nurse, better community support for primary care, and enhanced communication between all the health professionals involved in the care of patients with heart failure.
Conclusions
Greater consideration should be given to the care of patients dying with heart failure, clarifying the roles of doctors and nurses in different specialties, and reshaping the services provided for them. Many of the organisational and professional issues are not peculiar to patients dying with heart failure, and addressing such concerns as the lack of coordination and continuity in medical care would benefit all patients.
What is already known on this topicPatients with heart failure have unmet needs for health care at the end of lifeSpecialist palliative care services see few patients with heart failureThe national service framework for coronary heart disease endorses the provision of palliative care for heart failureLittle evidence exists on how this care should be provided, and doctors' views are not knownWhat this study addsBarriers to adopting a palliative care approach in heart failure care relate to the current organisation of health services, the difficulties of prognostication, and doctors' understanding of roles and responsibilitiesDoctors believe that the general practitioner should be the central figure in palliative care for heart failure, supported by specialistsDoctors' future priorities are developing the role of nurses, increasing essential community services, such as district nursing, and improving communication with colleagues
PMCID: PMC124557  PMID: 12228136
6.  New Insight into the Role of Patients During Medical Appointments: A Synthesis of Three Qualitative Studies 
The Patient  2014;7(3):313-318.
Background
The complexity of the doctor-patient relationship requires in-depth research to enable a better understanding of the nature of the doctor’s appointment.
Objective
To explore how patients can facilitate their medical appointments, and how they can be responsible for their relationship with their doctors.
Methods
A synthesis of our previous three qualitative studies of doctor-patient relationships focussed on the consultations. The analysis involved three qualitative studies based on in-depth interviews with 94 patients of family doctors in Poland.
Results
A detailed analysis of these data allowed us to distinguish several different ways in which patients participate in medical consultation, namely: 1. facilitating the visit; 2. having an impact on both patient and doctor perception of satisfaction with the visit; and 3. showing concern for the doctor, understanding the doctor’s situation and having empathy.
Conclusion
This study concerning patient-doctor interactions shows that each participant can explicitly provide emotional support for the other, despite the evident asymmetry in the roles of doctor and patient. Patients can substantially contribute to the personalisation of their relationship with the doctor, which is often facilitated by the repetition and regularity of the interaction.
doi:10.1007/s40271-014-0056-1
PMCID: PMC4141969  PMID: 24664461
7.  Patient Perspectives on Online Health Information and Communication With Doctors: A Qualitative Study of Patients 50 Years Old and Over 
Background
As health care systems around the world shift toward models that emphasize self-care management, there is increasing pressure for patients to obtain health information online. It is critical that patients are able to identify potential problems with using the Internet to diagnose and treat a health issue and that they feel comfortable communicating with their doctor about the health information they acquire from the Internet.
Objective
Our aim was to examine patient-identified (1) problems with using the Internet to identify and treat a health issue, (2) barriers to communication with a doctor about online health information seeking, and (3) facilitators of communication with a doctor about patient searches for health information on the Internet.
Methods
For this qualitative exploratory study, semistructured interviews were conducted with a sample of 56 adults age 50 years old and over. General concerns regarding use of the Internet to diagnose and treat a health issue were examined separately for participants based on whether they had ever discussed health information obtained through the Internet with a doctor. Discussions about barriers to and facilitators of communication about patient searches for health information on the Internet with a doctor were analyzed using thematic analysis.
Results
Six higher-level general concerns emerged: (1) limitations in own ability, (2) credibility/limitations of online information, (3) anxiety, (4) time consumption, (5) conflict, and (6) non-physical harm. The most prevalent concern raised by participants who communicated with a doctor about their online health information seeking related to the credibility or limitations in online information. Participants who had never communicated with a doctor about their online health information seeking most commonly reported concerns about non-physical harm. Four barriers to communication emerged: (1) concerns about embarrassment, (2) concerns that the doctor doesn’t want to hear about it, (3) belief that there is no need to bring it up, and (4) forgetting to bring it up. Facilitators of communication included: (1) having a family member present at doctor visits, (2) doctor-initiated inquiries, and (3) encountering an advertisement that suggested talking with a doctor.
Conclusions
Overall, participants displayed awareness of potential problems related to online health information seeking. Findings from this study point to a set of barriers as well as facilitators of communication about online health information seeking between patients and doctors. This study highlights the need for enhanced patient communication skills, eHealth literacy assessments that are accompanied by targeted resources pointing individuals to high-quality credible online health information, and the need to remind patients of the importance of consulting a medical professional when they use online health resources to diagnose and treat a health issue.
doi:10.2196/jmir.3588
PMCID: PMC4319073  PMID: 25586865
health communication; Internet; online health information seeking; barriers to patient-doctor communication; adults 50 years old and over; qualitative research
8.  Doctors accessing mental-health services: an exploratory study 
BMJ Open  2011;1(1):e000017.
Objective
To develop a more in-depth understanding of how doctors do and do not access mental healthcare from the perspectives of doctors themselves and people they have contact with through the process.
Design
Qualitative methodology was used with semistructured interviews transcribed and analysed using Grounded Theory. Participants were 11 doctors with experience as patients of psychiatrists, four doctor and four non-doctor personal contacts (friends, family and colleagues) and eight treating psychiatrists.
Results
Participants described experiencing unrealistic expectations and a harsh work environment with poor self care and denial and minimisation of signs of mental health difficulties. Doctor contacts described particular difficulty in responding effectively to doctor friends, family and colleagues in need of mental healthcare. In contrast, non-doctor personal contacts were more able to identify and speak about concerns but not necessarily to enable accessing adequate mental-health services.
Conclusions
Three areas with potential to address in supporting doctors' accessing of appropriate healthcare have been identified: (1) processes to enable doctors to maintain high standards of functioning with less use of minimisation and denial; (2) improving the quality and effectiveness of informal doctor-to-doctor conversations about mental-health issues among themselves; (3) role of non-doctor support people in identifying doctors' mental-health needs and enabling their access to mental healthcare. Further research in all these areas has the potential to contribute to improving doctors' access to appropriate mental healthcare and may be of value for the general population.
Article summary
Article focus
Doctors' accessment of adequate mental healthcare is less than optimal.
Family and community contacts have an important role in accessing mental healthcare.
Our understanding of the processes related to doctors accessing mental healthcare can be improved by exploring perspectives of doctor patients, their support people and treating psychiatrists.
Key messages
Doctors' unrealistic expectations of themselves and associated minimisation and denial of a range of self care needs may function as a barrier to accessing mental healthcare.
Addressing how doctors respond to other doctors in informal conversations indicating mental healthcare needs may be helpful in improving access to care.
Non-doctor support people may have a valuable role in enabling doctors to access appropriate mental healthcare.
All these areas need further research.
Strengths and limitations of this study
This is the first study of its kind and generates new insights in an important area.
Because of challenges in recruiting doctors with experience as patients of psychiatrists, a hard-to-reach group, the sample is small and not broadly representative.
doi:10.1136/bmjopen-2010-000017
PMCID: PMC3191385  PMID: 22021726
Child & adolescent psychiatry; adult psychiatry; physicians' health; accessing healthcare; impaired physician; mental health
9.  'It gives you an understanding you can't get from any book.' The relationship between medical students' and doctors' personal illness experiences and their performance: a qualitative and quantitative study 
Background
Anecdotes abound about doctors' personal illness experiences and the effect they have on their empathy and care of patients. We formally investigated the relationship between doctors' and medical students' personal illness experiences, their examination results, preparedness for clinical practice, learning and professional attitudes and behaviour towards patients.
Methods
Newly-qualified UK doctors in 2005 (n = 2062/4784), and two cohorts of students at one London medical school (n = 640/749) participated in the quantitative arm of the study. 37 Consultants, 1 Specialist Registrar, 2 Clinical Skills Tutors and 25 newly-qualified doctors participated in the qualitative arm. Newly-qualified doctors and medical students reported their personal illness experiences in a questionnaire. Doctors' experiences were correlated with self-reported preparedness for their new clinical jobs. Students' experiences were correlated with their examination results, and self-reported anxiety and depression. Interviews with clinical teachers, newly-qualified doctors and senior doctors qualitatively investigated how personal illness experiences affect learning, professional attitudes, and behaviour.
Results
85.5% of newly-qualified doctors and 54.4% of medical students reported personal illness experiences. Newly-qualified doctors who had been ill felt less prepared for starting work (p < 0.001), but those who had only experienced illness in a relative or friend felt more prepared (p = 0.02). Clinical medical students who had been ill were more anxious (p = 0.01) and had lower examination scores (p = 0.006). Doctors felt their personal illness experiences helped them empathise and communicate with patients. Medical students with more life experience were perceived as more mature, empathetic, and better learners; but illness at medical school was recognised to impede learning.
Conclusion
The majority of the medical students and newly qualified doctors we studied reported personal illness experiences, and these experiences were associated with lower undergraduate examination results, higher anxiety, and lower preparedness. However reflection on such experiences may have improved professional attitudes such as empathy and compassion for patients. Future research is warranted in this area.
doi:10.1186/1472-6920-7-50
PMCID: PMC2211477  PMID: 18053231
10.  Meanings of existential uncertainty and certainty for people diagnosed with cancer and receiving palliative treatment: a life-world phenomenological study 
BMC Palliative Care  2014;13:28.
Background
Many people around the world are getting cancer and living longer with the disease. Thanks to improved treatment options in healthcare, patients diagnosed with advanced gastrointestinal cancer can increasingly live for longer. Living with cancer creates existential uncertainty, but what does this situation mean for the individual? The purpose of the study is to interpret meanings of existential uncertainty and certainty for people diagnosed with advanced gastrointestinal cancer and receiving palliative treatment.
Methods
This study is part of a larger project in which 7 men and 7 women aged between 49 and 79 participated in a study of information and communication for people with advanced gastrointestinal cancer. A total of 66 interviews were conducted with participants who were followed up over time. The narrative interviews were transcribed verbatim and the texts were analysed in three steps: naive reading, structural analysis and interpreted whole by utilizing a phenomenological life-world approach.
Results
This study has identified different spheres in which people diagnosed with advanced gastrointestinal cancer vacillate between existential uncertainty and certainty: bodily changes, everyday situations, companionship with others, healthcare situations and the natural environment. Existing in the move between existential uncertainty and certainty appears to change people’s lives in a decisive manner. The interview transcripts reveal aspects that both create existential certainty and counteract uncertainty. They also reveal that participants appear to start reflecting on how the new and uncertain aspects of their lives will manifest themselves –a new experience that lays the foundation for development of knowledge, personal learning and growth.
Conclusions
People diagnosed with advanced gastrointestinal cancer and receiving palliative care expressed thoughts about personal learning initiated by the struggle of living with an uncertain future despite their efforts to live in the present. Their personal learning was experienced through a changed life for themselves and having to confront their own pending death and develop self-insight regarding finality of life. Healthcare professionals can try to support people receiving palliative treatment for cancer by diversifying avenues for their personal growth, thus helping them manage their existential uncertainty and gravitate towards greater existential certainty.
doi:10.1186/1472-684X-13-28
PMCID: PMC4059734  PMID: 24936149
Existential uncertainty and existential certainty; Life-world phenomenology; Nursing; Palliative care; Personal growth; Qualitative research; Spirituality
11.  Consultation length in general practice: cross sectional study in six European countries 
BMJ : British Medical Journal  2002;325(7362):472.
Objectives
To compare determinants of consultation length discussed in the literature with those found in consultations with general practitioners from different European countries; to explore the determinants of consultation length, particularly the effect of doctors' and patients' perceptions of psychosocial aspects.
Design
Analysis of videotaped consultations of general practitioners from the Eurocommunication study and of questionnaires completed by doctors and by patients.
Setting
General practices in six European countries.
Participants
190 general practitioners and 3674 patients.
Results
In a multilevel analysis with three levels (country, general practitioner, and patient), country and doctor variables contributed a similar amount to the total variance in consultation length (23% and 22%, respectively) and patient variables accounted for 55% of the variance. The variables used in the multilevel analysis explained 25% of the total variation. The country in which the doctor practised, combined with the doctors' variables, was as important for the variance in consultation length as the variation between patients. Consultations in which psychosocial problems were considered important by the doctor and the patient lasted longer than consultations about biomedical problems only. The doctor's perception had more influence in this situation than the patient's. Consultation length is influenced by the patients' sex (women got longer consultations), whether the practice was urban or rural, the number of new problems discussed in the consultation (the more problems the longer the consultation), and the patient's age (the older the patient the longer the consultation). As a doctor's workload increased, the length of consultations decreased. The general practitioner's sex or age and patient's level of education were not related to the length of consultation.
Conclusion
Consultation length is determined by variables related to the doctor and the doctor's country as well as by those related to patients. Women consulting in an urban practice with problems perceived as psychosocial have longer consultations than other patients.
What is already known on this topicPatients are satisfied with care from general practice but often say that consultations are too shortStudies have investigated the determinants of consultation length, but different studies use different methods to determine the exact length of consultationDeterminants identified by studies in one country cannot be extrapolated to those in anotherWhat this study addsConsultation length varies from country to countryCharacteristics of patients have as much effect on consultation length as the characteristics of countries and doctors combinedConsultations are longest for women patients seeing general practitioners in urban practices about problems that doctor and patient perceive as psychosocial
PMCID: PMC119444  PMID: 12202329
12.  Professional Uncertainty and Disempowerment Responding to Ethnic Diversity in Health Care: A Qualitative Study 
PLoS Medicine  2007;4(11):e323.
Background
While ethnic disparities in health and health care are increasing, evidence on how to enhance quality of care and reduce inequalities remains limited. Despite growth in the scope and application of guidelines on “cultural competence,” remarkably little is known about how practising health professionals experience and perceive their work with patients from diverse ethnic communities. Using cancer care as a clinical context, we aimed to explore this with a range of health professionals to inform interventions to enhance quality of care.
Methods and Findings
We conducted a qualitative study involving 18 focus groups with a purposeful sample of 106 health professionals of differing disciplines, in primary and secondary care settings, working with patient populations of varying ethnic diversity in the Midlands of the UK. Data were analysed by constant comparison and we undertook processes for validation of analysis. We found that, as they sought to offer appropriate care, health professionals wrestled with considerable uncertainty and apprehension in responding to the needs of patients of ethnicities different from their own. They emphasised their perceived ignorance about cultural difference and were anxious about being culturally inappropriate, causing affront, or appearing discriminatory or racist. Professionals' ability to think and act flexibly or creatively faltered. Although trying to do their best, professionals' uncertainty was disempowering, creating a disabling hesitancy and inertia in their practice. Most professionals sought and applied a knowledge-based cultural expertise approach to patients, though some identified the risk of engendering stereotypical expectations of patients. Professionals' uncertainty and disempowerment had the potential to perpetuate each other, to the detriment of patient care.
Conclusions
This study suggests potential mechanisms by which health professionals may inadvertently contribute to ethnic disparities in health care. It identifies critical opportunities to empower health professionals to respond more effectively. Interventions should help professionals acknowledge their uncertainty and its potential to create inertia in their practice. A shift away from a cultural expertise model toward a greater focus on each patient as an individual may help.
From a qualitative study, Joe Kai and colleagues have identified opportunities to empower health professionals to respond more effectively to challenges in their work with patients from diverse ethnic communities.
Editors' Summary
Background.
Communities are increasingly diverse in terms of ethnicity (belonging to a group of people defined by social characteristics such as cultural tradition or national origin) and race (belonging to a group identified by inherited physical characteristics). Although health professionals and governments are striving to ensure that everybody has the same access to health care, there is increasing evidence of ethnic inequalities in health-care outcomes. Some of these inequalities reflect intrinsic differences between groups of people—Ashkenazi Jews, for example, often carry an altered gene that increases their chance of developing aggressive breast cancer. Often, however, these differences reflect inequalities in the health care received by different ethnic groups. To improve this situation, “cultural competence” has been promoted over recent years. Cultural competence is the development of skills by individuals and organizations that allow them to work effectively with people from different cultures. Health professionals are now taught about ethnic differences in health beliefs and practices, religion, and communication styles to help them provide the best service to all their patients.
Why Was This Study Done?
Numerous guidelines aim to improve cultural competency but little is known about how health professionals experience and perceive their work with patients from diverse ethnic groups. Is their behavior influenced by ethnicity in ways that might contribute to health care disparities? For example, do doctors sometimes avoid medical examinations for fear of causing offence because of cultural differences? If more were known about how health professionals handle ethnic diversity (a term used here to include both ethnicity and race) it might be possible to reduce ethnic inequalities in health care. In this qualitative study, the researchers have explored how health professionals involved in cancer care are affected by working with ethnically diverse patients. A qualitative study is one that collects nonquantitative data such as how doctors “feel” about treating people of different ethnic backgrounds; a quantitative study might compare clinical outcomes in different ethnic groups.
What Did the Researchers Do and Find?
The researchers enrolled 106 doctors, nurses, and other health-related professionals from different health-service settings in the Midlands, an ethnically diverse region of the UK. They organized 18 focus groups in which the health professionals described their experiences of caring for people from ethnic minority backgrounds. The participants were encouraged to recall actual cases and to identify what they saw as problems and strengths in their interactions with these patients. The researchers found that the health professionals wrestled with many challenges when providing health care for patients from diverse ethnic backgrounds. These challenges included problems with language and with general communication (for example, deciding when it was acceptable to touch a patient to show empathy). Health professionals also worried they did not know enough about cultural differences. As a result, they said they often felt uncertain of their ability to avoid causing affront or appearing racist. This uncertainty, the researchers report, disempowered the health professionals, sometimes making them hesitate or fail to do what was best for their patient.
What Do These Findings Mean?
These findings reveal that health professionals often experience considerable uncertainty when caring for ethnically diverse patients, even after training in cultural competency. They also show that this uncertainty can lead to hesitancy and inertia, which might contribute to ethnic health care inequalities. Because the study participants were probably already interested in ethnic diversity and health care, interviews with other health professionals (and investigations of patient experiences) are needed to confirm these findings. Nevertheless, the researchers suggest several interventions that might reduce health care inequalities caused by ethnic diversity. For example, health professionals should be encouraged to recognize their uncertainty and should have access to more information and training about ethnic differences. In addition, there should be a shift in emphasis away from relying on knowledge-based cultural information towards taking an “ethnographic” approach. In other words, health professionals should be helped to feel able to ask their patients about what matters most to them as individuals about their illness and treatment.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040323.
Information on cultural competence and health care is available from the US National Center for Cultural Competence (in English and Spanish) and DiversityRx
PROCEED (Professionals Responding to Cancer in Ethnic Diversity) is a multimedia training tool for educators within the health and allied professions developed from the results of this study; a press release on PROCEED is available from the University of Nottingham
Transcultural Health Care Practice: An educational resource for nurses and health care practitioners is available on the web site of the UK Royal College of Nursing
doi:10.1371/journal.pmed.0040323
PMCID: PMC2071935  PMID: 18001148
13.  How does the thought of cancer arise in a general practice consultation? Interviews with GPs 
Background
Only a few patients on a GP's list develop cancer each year. To find these cases in the jumble of presented problems is a challenge.
Objective
To explore how general practitioners (GPs) come to think of cancer in a clinical encounter.
Design
Qualitative interviews with Norwegian GPs, who were invited to think back on consultations during which the thought of cancer arose. The 11 GPs recounted and reflected on 70 such stories from their practices. A phenomenographic approach enabled the study of variation in GPs’ ways of experiencing.
Results
Awareness of cancer could arise in several contexts of attention: (1) Practising basic knowledge: explicit rules and skills, such as alarm symptoms, epidemiology and clinical know-how; (2) Interpersonal awareness: being alert to changes in patients’ appearance or behaviour and to cues in their choice of words, on a background of basic knowledge and experience; (3) Intuitive knowing: a tacit feeling of alarm which could be difficult to verbalize, but nevertheless was helpful. Intuition built on the earlier mentioned contexts: basic knowledge, experience, and interpersonal awareness; (4) Fear of cancer: the existential context of awareness could affect the thoughts of both doctor and patient. The challenge could be how not to think about cancer all the time and to find ways to live with insecurity without becoming over-precautious.
Conclusion
The thought of cancer arose in the relationship between doctor and patient. The quality of their interaction and the doctor's accuracy in perceiving and interpreting cues were decisive.
doi:10.3109/02813432.2012.688701
PMCID: PMC3443936  PMID: 22747066
Cancer; diagnosis; doctor–patient relations; general practice; Norway; phenomenography; qualitative research
14.  Inclusion of Ethical Issues in Dementia Guidelines: A Thematic Text Analysis 
PLoS Medicine  2013;10(8):e1001498.
Background
Clinical practice guidelines (CPGs) aim to improve professionalism in health care. However, current CPG development manuals fail to address how to include ethical issues in a systematic and transparent manner. The objective of this study was to assess the representation of ethical issues in general CPGs on dementia care.
Methods and Findings
To identify national CPGs on dementia care, five databases of guidelines were searched and national psychiatric associations were contacted in August 2011 and in June 2013. A framework for the assessment of the identified CPGs' ethical content was developed on the basis of a prior systematic review of ethical issues in dementia care. Thematic text analysis and a 4-point rating score were employed to assess how ethical issues were addressed in the identified CPGs. Twelve national CPGs were included. Thirty-one ethical issues in dementia care were identified by the prior systematic review. The proportion of these 31 ethical issues that were explicitly addressed by each CPG ranged from 22% to 77%, with a median of 49.5%. National guidelines differed substantially with respect to (a) which ethical issues were represented, (b) whether ethical recommendations were included, (c) whether justifications or citations were provided to support recommendations, and (d) to what extent the ethical issues were explained.
Conclusions
Ethical issues were inconsistently addressed in national dementia guidelines, with some guidelines including most and some including few ethical issues. Guidelines should address ethical issues and how to deal with them to help the medical profession understand how to approach care of patients with dementia, and for patients, their relatives, and the general public, all of whom might seek information and advice in national guidelines. There is a need for further research to specify how detailed ethical issues and their respective recommendations can and should be addressed in dementia guidelines.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
In the past, doctors tended to rely on their own experience to choose the best treatment for their patients. Faced with a patient with dementia (a brain disorder that affects short-term memory and the ability tocarry out normal daily activities), for example, a doctor would use his/her own experience to help decide whether the patient should remain at home or would be better cared for in a nursing home. Similarly, the doctor might have to decide whether antipsychotic drugs might be necessary to reduce behavioral or psychological symptoms such as restlessness or shouting. However, over the past two decades, numerous evidence-based clinical practice guidelines (CPGs) have been produced by governmental bodies and medical associations that aim to improve standards of clinical competence and professionalism in health care. During the development of each guideline, experts search the medical literature for the current evidence about the diagnosis and treatment of a disease, evaluate the quality of that evidence, and then make recommendations based on the best evidence available.
Why Was This Study Done?
Currently, CPG development manuals do not address how to include ethical issues in CPGs. A health-care professional is ethical if he/she behaves in accordance with the accepted principles of right and wrong that govern the medical profession. More specifically, medical professionalism is based on a set of binding ethical principles—respect for patient autonomy, beneficence, non-malfeasance (the “do no harm” principle), and justice. In particular, CPG development manuals do not address disease-specific ethical issues (DSEIs), clinical ethical situations that are relevant to the management of a specific disease. So, for example, a DSEI that arises in dementia care is the conflict between the ethical principles of non-malfeasance and patient autonomy (freedom-to-move-at-will). Thus, healthcare professionals may have to decide to physically restrain a patient with dementia to prevent the patient doing harm to him- or herself or to someone else. Given the lack of guidance on how to address ethical issues in CPG development manuals, in this thematic text analysis, the researchers assess the representation of ethical issues in CPGs on general dementia care. Thematic text analysis uses a framework for the assessment of qualitative data (information that is word-based rather than number-based) that involves pinpointing, examining, and recording patterns (themes) among the available data.
What Did the Researchers Do and Find?
The researchers identified 12 national CPGs on dementia care by searching guideline databases and by contacting national psychiatric associations. They developed a framework for the assessment of the ethical content in these CPGs based on a previous systematic review of ethical issues in dementia care. Of the 31 DSEIs included by the researchers in their analysis, the proportion that were explicitly addressed by each CPG ranged from 22% (Switzerland) to 77% (USA); on average the CPGs explicitly addressed half of the DSEIs. Four DSEIs—adequate consideration of advanced directives in decision making, usage of GPS and other monitoring techniques, covert medication, and dealing with suicidal thinking—were not addressed in at least 11 of the CPGs. The inclusion of recommendations on how to deal with DSEIs ranged from 10% of DSEIs covered in the Swiss CPG to 71% covered in the US CPG. Overall, national guidelines differed substantially with respect to which ethical issues were included, whether ethical recommendations were included, whether justifications or citations were provided to support recommendations, and to what extent the ethical issues were clearly explained.
What Do These Findings Mean?
These findings show that national CPGs on dementia care already address clinical ethical issues but that the extent to which the spectrum of DSEIs is considered varies widely within and between CPGs. They also indicate that recommendations on how to deal with DSEIs often lack the evidence that health-care professionals use to justify their clinical decisions. The researchers suggest that this situation can and should be improved, although more research is needed to determine how ethical issues and recommendations should be addressed in dementia guidelines. A more systematic and transparent inclusion of DSEIs in CPGs for dementia (and for other conditions) would further support the concept of medical professionalism as a core element of CPGs, note the researchers, but is also important for patients and their relatives who might turn to national CPGs for information and guidance at a stressful time of life.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001498.
Wikipedia contains a page on clinical practice guidelines (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The US National Guideline Clearinghouse provides information on national guidelines, including CPGs for dementia
The Guidelines International Network promotes the systematic development and application of clinical practice guidelines
The American Medical Association provides information about medical ethics; the British Medical Association provides information on all aspects of ethics and includes an essential tool kit that introduces common ethical problems and practical ways to deal with them
The UK National Health Service Choices website provides information about dementia, including a personal story about dealing with dementia
MedlinePlus provides links to additional resources about dementia and about Alzheimers disease, a specific type of dementia (in English and Spanish)
The UK Nuffield Council on Bioethics provides the report Dementia: ethical issues and additional information on the public consultation on ethical issues in dementia care
doi:10.1371/journal.pmed.1001498
PMCID: PMC3742442  PMID: 23966839
15.  Why Reassurance Fails in Patients with Unexplained Symptoms—An Experimental Investigation of Remembered Probabilities 
PLoS Medicine  2006;3(8):e269.
Background
Providing reassurance is one of physicians' most frequently used verbal interventions. However, medical reassurance can fail or even have negative effects. This is frequently the case in patients with medically unexplained symptoms. It is hypothesized that these patients are more likely than patients from other groups to incorrectly recall the likelihoods of medical explanations provided by doctors.
Methods and Findings
Thirty-three patients with medically unexplained symptoms, 22 patients with major depression, and 30 healthy controls listened to an audiotaped medical report, as well as to two control reports. After listening to the reports, participants were asked to rate what the doctor thinks the likelihood is that the complaints are caused by a specific medical condition.
Although the doctor rejected most of the medical explanations for the symptoms in his verbal report, the patients with medically unexplained complaints remembered a higher likelihood for medical explanations for their symptoms. No differences were found between patients in the other groups, and for the control conditions. When asked to imagine that the reports were applicable to themselves, patients with multiple medical complaints reported more concerns about their health state than individuals in the other groups.
Conclusions
Physicians should be aware that patients with medically unexplained symptoms recall the likelihood of medical causes for their complaints incorrectly. Therefore, physicians should verify correct understanding by using check-back questions and asking for summaries, to improve the effect of reassurance.
Those patients for whom there is no medical explanation for their symptoms are likely to have more difficulty than other patients in remembering information intended to reassure them about their condition.
Editors' Summary
Background.
Being told by the doctor that that niggling headache or persistent stomach ache is not caused by a medical condition reassures most patients. But for some—those with a history of medically unexplained complaints—being told that tests have revealed no underlying cause for their symptoms provides little or no reassurance. Such patients have what is sometimes called “somatization syndrome.” In somatization, mental factors such as stress manifest themselves as physical symptoms. Patients with somatization syndrome start to report multiple medically unexplained symptoms as young adults. These symptoms, which change over time, include pain at different sites in the body and digestive, reproductive, and nervous system problems. What causes this syndrome is unknown and there is no treatment other than helping patients to control their symptoms.
Why Was This Study Done?
Patients with medically unexplained complaints make up a substantial and expensive part of the workload of general medical staff. Part of this expense is because patients with somatization syndrome are not reassured by their medical practitioners telling them there is no physical cause for their symptoms, which leads to requests for further tests. It is unclear why medical reassurance fails in these patients, but if this puzzle could be solved, it might help doctors to deal better with them. In this study, the researchers tested the idea that these patients do not accept medical reassurance because they incorrectly remember what their doctors have told them about the likelihood that specific medical conditions could explain their symptoms.
What Did the Researchers Do and Find?
The researchers recruited patients with medically unexplained symptoms and, for comparison, patients with depression and healthy individuals. All the participants were assessed for somatization syndrome and their general memory tested. They then listened to three audiotapes. In one, a doctor gave test results to a patient with abdominal pain (a medical situation). The other two tapes dealt with a social situation (the lack of an invitation to a barbecue) and a neutral situation (a car breakdown). Each tape contained ten messages, including four that addressed possible explanations for the problem. Two were unambiguous and negative—for example, “the reason for your complaints is definitely not stomach flu.” Two were ambiguous but highly unlikely—“we don't think that you have bowel cancer; this is very unlikely.” The researchers then assessed how well the participants remembered the likelihood that any given explanation was responsible for the patient's symptoms, the missing invitation, or the broken-down car. The patients with somatization syndrome overestimated the likelihood of medical causes for symptoms, particularly (and somewhat surprisingly) when the doctor's assessment had been unambiguous. By contrast, the other participants correctly remembered the doctor's estimates as low. The three study groups were similar in their recall of the likelihood estimates from the social or neutral situation. Finally, when asked to imagine that the medical situation was personally applicable, the patients with unexplained symptoms reacted more emotionally than the other study participants by reporting more concerns with their health.
What Do These Findings Mean?
These results support the researchers' hypothesis that people with somatization syndrome remember the chance that a given symptom has a specific medical cause incorrectly. This is not because of a general memory deficit or an inability to commit health-related facts to memory. The results also indicate that these patients react emotionally to medical situations, so they may find it hard to cope when a doctor fails to explain all their symptoms. Some of these characteristics could, of course, reflect the patients' previous experiences with medical professionals, and the experiment will need to be repeated with additional taped situations and more patients before firm recommendations can be made to help people with somatization syndrome. Nevertheless, given that medical reassurance and the presentation of negative results led to overestimates of the likelihood of medical explanations for symptoms in patients with somatization syndrome, the researchers recommend that doctors bear this bias in mind. To reduce it, they suggest, doctors could ask patients for summaries about what they have been told. This would make it possible to detect when patients have misremembered the likelihood of various medical explanations, and provide an opportunity to correct the situation.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030269.
• MedlinePlus encyclopedia entry on somatization disorder
• Wikipedia page on somatization disorder (note that Wikipedia is a free online encyclopedia that anyone can edit)
• Prodigy Knowledge's information for patients on somatization and somatoform disorders
doi:10.1371/journal.pmed.0030269
PMCID: PMC1523375  PMID: 16866576
16.  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
17.  Computer support for recording and interpreting family histories of breast and ovarian cancer in primary care (RAGs): qualitative evaluation with simulated patients 
BMJ : British Medical Journal  1999;319(7201):32-36.
Objectives
To explore general practitioners’ attitudes towards and use of a computer program for assessing genetic risk of cancer in primary care.
Design
Qualitative analysis of semistructured interviews and video recordings of simulated consultations.
Participants
Purposive sample of 15 general practitioners covering a range of computer literacy, interest in genetics, age, and sex.
Interventions
Each doctor used the program in two consultations in which an actor played a woman concerned about her family history of cancer. Consultations were videotaped and followed by interviews with the video as a prompt to questioning.
Main outcome measures
Use of computer program in the consultation.
Results
The program was viewed as an appropriate application of information technology because of the complexity of cancer genetics and a sense of “guideline chaos” in primary care. Doctors found the program easy to use, but it often affected their control of the consultation. They needed to balance their desire to share the computer screen with the patient, driven by their concerns about the effect of the computer on doctor-patient communication, against the risk of premature disclosure of bad news.
Conclusions
This computer program could provide the necessary support to assist assessment of genetic risk of cancer in primary care. The potential impact of computer software on the consultation should not be underestimated. This study highlights the need for careful evaluation when developing medical information systems.
Key messagesGeneral practitioners are under increasing pressure to advise their patients about genetic predisposition to various diseasesComputers could help doctors to give genetic advice by simplifying the construction and assessment of family trees and implementing referral guidelinesThis qualitative evaluation explored the context in which a computer program for assessing genetic risk of cancer would be used in general practice and issues surrounding its integration into a consultationMost of the doctors found the program easy to use, but it affected their control of the consultation—because of their desire to share the computer screen with the patient and their inability to anticipate the information that would be displayedThe study identified important issues relating to the use of computers in consultations which may be of use in testing software for primary care in the future
PMCID: PMC28153  PMID: 10390458
18.  The power of consoling presence - hospice nurses’ lived experience with spiritual and existential care for the dying 
BMC Nursing  2014;13:25.
Background
Being with dying people is an integral part of nursing, yet many nurses feel unprepared to accompany people through the process of dying, reporting a lack of skills in psychosocial and spiritual care, resulting in high levels of moral distress, grief and burnout. The aim of this study is to describe the meaning of hospice nurses’ lived experience with alleviating dying patients’ spiritual and existential suffering.
Methods
This is a qualitative study.
Hospice nurses were interviewed individually and asked to narrate about their experiences with giving spiritual and existential care to terminally ill hospice patients. Data analysis was conducted using phenomenological hermeneutical method.
Results
The key spiritual and existential care themes identified, were sensing existential and spiritual distress, tuning inn and opening up, sensing the atmosphere in the room, being moved and touched, and consoling through silence, conversation and religious consolation.
Conclusions
Consoling existential and spiritual distress is a deeply personal and relational practice. Nurses have a potential to alleviate existential and spiritual suffering through consoling presence. By connecting deeply with patients and their families, nurses have the possibility to affirm the patients’ strength and facilitate their courage to live a meaningful life and die a dignified death.
doi:10.1186/1472-6955-13-25
PMCID: PMC4160718  PMID: 25214816
Dying; Spiritual and existential care; Hospice nursing; Consolation; Phenomenological hermeneutical study
19.  The General Medical Council: frame of reference or arbiter of morals? 
Journal of Medical Ethics  1977;3(3):110-114.
Many members of the public think of the General Medical Council (GMC) as the body which tries doctors: the doctors' law courts, as it were. And, except in the more sober of newspapers and news reports, the 'offences ' which receive the most publicity are those concerning alleged improper relations between doctors and patients. Professor Sir Denis Hill, in the following paper, which he read in the spring of this year to the annual conference of the London Medical Group devoted to a discussion of human sexuality, chose to examine the whole function of the General Medical Council as a frame of moral reference for doctors. Judging allegations of professional misconduct by doctors is the function of the Council's Disciplinary Committee. Judging sexual misconduct forms only a small part of their work. The GMC's responsibility covers the whole notion of morals and morality as it concerns doctors in their professional work. Sir Denis Hill stresses the modern thinking that morality must be learned and that attitudes are always shifting as society alters its norms of what is moral conduct. That is not to say that all that was previously considered not to be moral has now become acceptable but rather that other concepts have entered the field of moral debate. Therefore the GMC must constantly review the frame of reference it offers to doctors and the public may be surprised to learn that that process is never static. Sir Denis Hill in this paper is speaking personally and not as a member of the General Medical Council or of any of that body's special committees.
PMCID: PMC1154576  PMID: 926129
20.  Patients' perceptions of entitlement to time in general practice consultations for depression: qualitative study 
BMJ : British Medical Journal  2002;325(7366):687.
Objective:
To investigate patients' perceptions of entitlement to time in general practice consultations for depression.
Design:
Qualitative study based on interviews with patients with mild to moderate depression.
Setting:
Eight general practices in the West Midlands and the regional membership of the Depression Alliance.
Participants:
32 general practice patients and 30 respondents from the Depression Alliance.
Results:
An intense sense of time pressure and a self imposed rationing of time in consultations were key concerns among the interviewees. Anxiety about time affected patients' freedom to talk about their problems. Patients took upon themselves part of the responsibility for managing time in the consultation to relieve the burden they perceived their doctors to be working under. Respondents' accounts often showed a mismatch between their own sense of time entitlement and the doctors' capacity to respond flexibly and constructively in offering extended consultation time when this was necessary. Patients valued time to talk and would often have liked more, but they did not necessarily associate length of consultation with quality. The impression doctors gave in handling time in consultations sent strong messages about legitimising the patients' illness and their decision to consult.
Conclusions:
Patients' self imposed restraint in taking up doctors' time has important consequences for the recognition and treatment of depression. Doctors need to have a greater awareness of patients' anxieties about time and should move to allay such anxieties by pre-emptive reassurance and reinforcing patients' sense of entitlement to time. Far from acting as “consumers,” patients voluntarily assume responsibility for conserving scarce resources in a health service that they regard as a collective rather than a personal resource.
What is already known on this topicA widespread concern is that pressure of work is reducing the length of general practice consultations and that doctors can't deal adequately with patients' problems in the time availableLittle is known about patients' experience of time in consultationsWhat this study addsPatients with depression feel under such acute pressure of time that they are often inhibited from fully disclosing their problems, preventing them making best use of the consultationThere is often a disparity between patients' sense of time shortage and the amount of time their doctors are willing and able to provideDoctors should be more aware of patients' anxieties about time and allay these anxieties by providing pre-emptive reassurance as a means of reinforcing patients' sense of entitlement to consultation time
PMCID: PMC126657  PMID: 12351362
21.  The patient–doctor relationship: a synthesis of the qualitative literature on patients' perspectives 
The British Journal of General Practice  2009;59(561):e116-e133.
Background
The patient–doctor relationship is an important but poorly defined topic. In order to comprehensively assess its significance for patient care, a clearer understanding of the concept is required.
Aim
To derive a conceptual framework of the factors that define patient–doctor relationships from the perspective of patients.
Design of study
Systematic review and thematic synthesis of qualitative studies.
Method
Medline, EMBASE, PsychINFO and Web of Science databases were searched. Studies were screened for relevance and appraised for quality. The findings were synthesised using a thematic approach.
Results
From 1985 abstracts, 11 studies from four countries were included in the final synthesis. They examined the patient–doctor relationship generally (n = 3), or in terms of loyalty (n = 3), personal care (n = 2), trust (n = 2), and continuity (n = 1). Longitudinal care (seeing the same doctor) and consultation experiences (patients' encounters with the doctor) were found to be the main processes by which patient–doctor relationships are promoted. The resulting depth of patient–doctor relationship comprises four main elements: knowledge, trust, loyalty, and regard. These elements have doctor and patient aspects to them, which may be reciprocally related.
Conclusion
A framework is proposed that distinguishes between dynamic factors that develop or maintain the relationship, and characteristics that constitute an ongoing depth of relationship. Having identified the different elements involved, future research should examine for associations between longitudinal care, consultation experiences, and depth of patient–doctor relationship, and, in turn, their significance for patient care.
doi:10.3399/bjgp09X420248
PMCID: PMC2662123  PMID: 19341547
communication; continuity of patient care; physician–patient relations; qualitative research
22.  Rational Prescribing in Primary Care (RaPP): A Cluster Randomized Trial of a Tailored Intervention 
PLoS Medicine  2006;3(6):e134.
Background
A gap exists between evidence and practice regarding the management of cardiovascular risk factors. This gap could be narrowed if systematically developed clinical practice guidelines were effectively implemented in clinical practice. We evaluated the effects of a tailored intervention to support the implementation of systematically developed guidelines for the use of antihypertensive and cholesterol-lowering drugs for the primary prevention of cardiovascular disease.
Methods and Findings
We conducted a cluster-randomized trial comparing a tailored intervention to passive dissemination of guidelines in 146 general practices in two geographical areas in Norway. Each practice was randomized to either the tailored intervention (70 practices; 257 physicians) or control group (69 practices; 244 physicians). Patients started on medication for hypertension or hypercholesterolemia during the study period and all patients already on treatment that consulted their physician during the trial were included. A multifaceted intervention was tailored to address identified barriers to change. Key components were an educational outreach visit with audit and feedback, and computerized reminders linked to the medical record system. Pharmacists conducted the visits. Outcomes were measured for all eligible patients seen in the participating practices during 1 y before and after the intervention. The main outcomes were the proportions of (1) first-time prescriptions for hypertension where thiazides were prescribed, (2) patients assessed for cardiovascular risk before prescribing antihypertensive or cholesterol-lowering drugs, and (3) patients treated for hypertension or hypercholesterolemia for 3 mo or more who had achieved recommended treatment goals.
The intervention led to an increase in adherence to guideline recommendations on choice of antihypertensive drug. Thiazides were prescribed to 17% of patients in the intervention group versus 11% in the control group (relative risk 1.94; 95% confidence interval 1.49–2.49, adjusted for baseline differences and clustering effect). Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals.
Conclusions
Our tailored intervention had a significant impact on prescribing of antihypertensive drugs, but was ineffective in improving the quality of other aspects of managing hypertension and hypercholesterolemia in primary care.
Editors' Summary
Background.
An important issue in health care is “getting research into practice,” in other words, making sure that, when evidence from research has established the best way to treat a disease, doctors actually use that approach with their patients. In reality, there is often a gap between evidence and practice.
  An example concerns the treatment of people who have high blood pressure (hypertension) and/or high cholesterol. These are common conditions, and both increase the risk of having a heart attack or a stroke. Research has shown that the risks can be lowered if patients with these conditions are given drugs that lower blood pressure (antihypertensives) and drugs that lower cholesterol. There are many types of these drugs now available. In many countries, the health authorities want family doctors (general practitioners) to make better use of these drugs. They want doctors to prescribe them to everyone who would benefit, using the type of drugs found to be most effective. When there is a choice of drugs that are equally effective, they want doctors to use the cheapest type. (In the case of antihypertensives, an older type, known as thiazides, is very effective and also very cheap, but many doctors prefer to give their patients newer, more expensive alternatives.) Health authorities have issued guidelines to doctors that address these issues. However, it is not easy to change prescribing practices, and research in several countries has shown that issuing guidelines has only limited effects.
Why Was This Study Done?
The researchers wanted—in two parts of Norway—to compare the effects on prescribing practices of what they called the “passive dissemination of guidelines” with a more active approach, where the use of the guidelines was strongly promoted and encouraged.
What Did the Researchers Do and Find?
They worked with 146 general practices. In half of them the guidelines were actively promoted. The remaining were regarded as a control group; they were given the guidelines but no special efforts were made to encourage their use. It was decided at random which practices would be in which group; this approach is called a randomized controlled trial. The methods used to actively promote use of the guidelines included personal visits to the practices by pharmacists and use of a computerized reminder system. Information was then collected on the number of patients who, when first treated for hypertension, were prescribed a thiazide. Other information collected included whether patients had been properly assessed for their level of risk (for strokes and heart attacks) before antihypertensive or cholesterol-lowering drugs were given. In addition, the researchers recorded whether the recommended targets for improvement in blood pressure and cholesterol level had been reached.
Only 11% of those patients visiting the control group of practices who should have been prescribed thiazides, according to the guidelines, actually received them. Of those seen by doctors in the practices where the guidelines were actively promoted, 17% received thiazides. According to statistical analysis, the increase achieved by active promotion is significant. Little or no differences were found for risk assessment prior to prescribing and for achievement of treatment goals.
What Do These Findings Mean?
Even in the active promotion group, the great majority of patients (83%) were still not receiving treatment according to the guidelines. However, active promotion of guidelines is more effective than simply issuing the guidelines by themselves. The study also demonstrates that it is very hard to change prescribing practices. The efforts made here to encourage the doctors to change were considerable, and although the results were significant, they were still disappointing. Also disappointing is the fact that achievement of treatment goals was no better in the active-promotion group. These issues are discussed further in a Perspective about this study (DOI: 10.1371/journal.pmed.0030229).
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030134.
• The Web site of the American Academy of Family Physicians has a page on heart disease
• The MedlinePlus Medical Encyclopedia's pages on heart diseases and vascular diseases
• Information from NHS Direct (UK National Health Service) about heart attack and stroke
• Another PLoS Medicine article has also addressed trends in thiazide prescribing
Passive dissemination of management guidelines for hypertension and hypercholesterolaemia was compared with active promotion. Active promotion led to significant improvement in antihypertensive prescribing but not other aspects of management.
doi:10.1371/journal.pmed.0030134
PMCID: PMC1472695  PMID: 16737346
23.  “Doctor, please tell me it’s nothing serious”: an exploration of patients’ worrying and reassuring cognitions using stimulated recall interviews 
BMC Family Practice  2014;15:73.
Background
Many patients who consult their GP are worried about their health, but there is little empirical data on strategies for effective reassurance. To gain a better understanding of mechanisms for effective patient reassurance, we explored cognitions underlying patients’ worries, cognitions underlying reassurance and factors supporting patients’ reassuring cognitions.
Methods
In a qualitative study, we conducted stimulated recall interviews with 21 patients of 12 different GPs shortly after their consultation. We selected consultations in which the GPs aimed to reassure worried patients and used their videotaped consultation as a stimulus for the interview. The interviews were analysed with thematic coding and by writing interpretive summaries.
Results
Patients expressed four different core cognitions underlying their concerns: ‘I have a serious illness’, ‘my health problem will have adverse physical effects’, ‘my treatment will have adverse effects’ and ‘my health problem will negatively impact my life’. Patients mentioned a range of person-specific and context-specific cognitions as reasons for these core cognitions. Patients described five core reassuring cognitions: ‘I trust my doctor’s expertise’, ‘I have a trusting and supporting relationship with my doctor’, ‘I do not have a serious disease’, ‘my health problem is harmless’ and ‘my health problem will disappear.’ Factors expressed as reasons for these reassuring cognitions were GPs’ actions during the consultation as well as patients’ pre-existing cognitions about their GP, the doctor-patient relationship and previous events. Patients’ worrying cognitions were counterbalanced by specific reassuring cognitions, i.e. worrying and reassuring cognitions seemed to be interrelated.
Conclusions
Patients described a wide range of worrying cognitions, some of which were not expressed during the consultation. Gaining a thorough understanding of the specific cognitions and tailoring reassuring strategies to them should be an effective way of achieving reassurance. The identified reassuring cognitions can guide doctors in applying these strategies in their daily practice.
doi:10.1186/1471-2296-15-73
PMCID: PMC4008437  PMID: 24762333
24.  Longing for ground in a ground(less) world: a qualitative inquiry of existential suffering 
BMC Nursing  2011;10:2.
Background
Existential and spiritual concerns are fundamental issues in palliative care and patients frequently articulate these concerns. The purpose of this study was to understand the process of engaging with existential suffering at the end of life.
Methods
A grounded theory approach was used to explore processes in the context of situated interaction and to explore the process of existential suffering. We began with in vivo codes of participants' words, and clustered these codes at increasingly higher levels of abstractions until we were able to theorize.
Results
Findings suggest the process of existential suffering begins with an experience of groundlessness that results in an overarching process of Longing for Ground in a Ground(less) World, a wish to minimize the uncomfortable or anxiety-provoking instability of groundlessness. Longing for ground is enacted in three overlapping ways: by turning toward one's discomfort and learning to let go (engaging groundlessness), turning away from the discomfort, attempting to keep it out of consciousness by clinging to familiar thoughts and ideas (taking refuge in the habitual), and learning to live within the flux of instability and unknowing (living in-between).
Conclusions
Existential concerns are inherent in being human. This has implications for clinicians when considering how patients and colleagues may experience existential concerns in varying degrees, in their own fashion, either consciously or unconsciously. Findings emphasize a fluid and dynamic understanding of existential suffering and compel health providers to acknowledge the complexity of fear and anxiety while allowing space for the uniquely fluid nature of these processes for each person. Findings also have implications for health providers who may gravitate towards the transformational possibilities of encounters with mortality without inviting space for less optimistic possibilities of resistance, anger, and despondency that may concurrently arise.
doi:10.1186/1472-6955-10-2
PMCID: PMC3045972  PMID: 21272349
25.  Duties of a doctor: UK doctors and Good Medical Practice 
Quality in Health Care : QHC  2000;9(1):14-22.
Objective—To assess the responses of UK doctors to the General Medical Council's (GMC) Good Medical Practice and the Duties of a Doctor, and to the GMC's performance procedures for which they provide the professional underpinning.
Design—Questionnaire study of a representative sample of UK doctors.
Subjects—794 UK doctors, stratified by year of qualification, sex, place of qualification (UK v non-UK), and type of practice (hospital v general practice) of whom 591/759 (78%) replied to the questionnaire (35 undelivered).
Main outcome measures—A specially written questionnaire asking about awareness of Good Medical Practice, agreement with Duties of a Doctor, amount heard about the performance procedures, changes in own practice, awareness of cases perhaps requiring performance procedures, and attitudes to the performance procedures. Background measures of stress (General Health Questionnaire, GHQ-12), burnout, responses to uncertainty, and social desirability.
Results—Most doctors were aware of Good Medical Practice, had heard the performance procedures being discussed or had received information about them, and agreed with the stated duties of a doctor, although some items to do with doctor-patient communication and attitudes were more controversial. Nearly half of the doctors had made or were contemplating some change in their practice because of the performance procedures; a third of doctors had come across a case in the previous two years in their own professional practice that they thought might merit the performance procedures. Attitudes towards the performance procedures were variable. On the positive side, 60% or more of doctors saw them as reassuring the general public, making it necessary for doctors to report deficient performance in their colleagues, did not think they would impair morale, were not principally window dressing, and were not only appropriate for problems of technical competence. On the negative side, 60% or more of doctors thought the performance procedures were not well understood by most doctors, were a reason for more defensive practice, and could not be used for problems of attitude. Few differences were found among older and younger doctors, hospital doctors, or general practitioners, or UK and non-UK graduates, although some differences were present.
Conclusions—Most doctors working in the UK are aware of Good Medical Practice and the performance procedures, and are in broad sympathy with Duties of a Doctor. Many attitudes expressed by doctors are not positive, however, and provide areas where the GMC in particular may wish to encourage further discussion and awareness. The present results provide a good baseline for assessing change as the performance procedures become active and cases come before the GMC over the next few years.
(Quality in Health Care 2000;9:14–22)
Key Words: performance procedures; good medical practice; duties; attitudes; knowledge
doi:10.1136/qhc.9.1.14
PMCID: PMC1743494  PMID: 10848365

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