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Dr Malcolm McLean recently carried out a study that concluded benefits of patient-centred consultations were small, but costs in time were significant ­ here he discusses his results

As a GP trainer I have found that eliciting patients' concerns is universally accepted as central to good modern patient-centred practice. Indeed, it remains an important part of the MRCGP exam. But in reality there is not a lot of patient-concern-eliciting about.

David Tuckett's2 huge study recorded 1,470 consultations between 1977 and 1983 but found less than 6 per cent involved doctors actively trying to elicit patient concerns. Much more recently, in 2002, MRCGP exam videos were studied and rarely found to contain the criteria demonstrating patient-centred consulting behaviour.

The literature of research into the outcomes of various forms of patient-centred medicine contains few studies that are in the form of randomised controlled trials and much of the evidence is conflicting.

So if it takes time and we are not sure it does

any good then why do we berate ourselves for not doing it?

What happens in a consultation?

Researchers over the last two decades have investigated GP consultations, looking at different types of doctor behaviour and patient outcomes.

Several, mainly qualitative, studies have shown that while the doctor may believe 'there is nothing to worry about', patients harbour concerns about their or their childrens' minor illness ­ often that they might die or remain permanently disabled.

Rarely are they able to express these fears to the doctor. In one study3 the researchers interviewed 30 mothers of children with cough (they had not expressed concerns to the doctor during the consultation): 22 feared they might die and 15 that they would develop a permanently weakened chest.

Finding out about such concerns is but one aspect of what has become known as 'patient-centred medicine'. Another way of putting this approach is to see it as 'entering into the patient's world'.

In the 1970s the consultation was examined by a number of workers who broke it down into its components.

It seems that since then more and more has been added in! In 1975 Byrne and Long identified six main functions:

·relating

·discovering the reason for attendance

·verbal +/- physical examination

·consolidation

·advising on treatment

·terminating the interview

Bain summarised these into two halves of the consultation: the first half ­ information 'pulled' from the patient and the second half advice 'pushed' back.

Three years later Stott and Davis added:

·dealing with health promotion

·continuing problems

In the 1980s Pendleton incorporated work from psychology, anthropology and sociology to develop his thoughts about patients' ideas, concerns and expectations, commonly abbreviated to 'ICE'. Roger Neighbour later reinterpreted all these components and added a further two:

·safety-netting

·housekeeping (the doctor looking after his/her own well-being)

Parallel to this evolution has been the advent of 'evidence-based medicine'. This too has been added to the workload to be undertaken during the consultation.

Finally we have the new GMS contract with the drive to check we have not only carried out

patient-care according to various quality markers but have recorded it all on our computer clinical systems.

What is the benefit to patients and GPs?

Much work has been done to examine the different qualities of doctor behaviour, the content and length of the consultation and various outcomes for the patient.

This sort of research, as you will see, is difficult and very time-consuming. The box on the left gives a selection of the evidence, much of which involved examination of tape-recorded consultations.

Is time on our side?

We can look at the time factor from two perspectives; if we increase the consulting interval we will do more and if we do more, we will take longer to consult.

Longer consultations lead to better outcomes on the whole and probably are more efficient in terms of less prescribing and reduced return consulting.

There is a drive from the RCGP, which has set up a working party on this subject, to push further the length of the consultation, probably beyond the 10-minute mark4.

Nevertheless it is clear that there will always be competing claims for the precious resource of consulting time.

The process of comparing these factors to define quality in primary care is a daunting task and, so far, we have only got to the point of understanding the complexity but not the resolution of this problem5.

My study has shown patients with acute self-limiting illness are slightly more satisfied when GPs ask about their concerns. But this increase was only for the 'professional care' score of the satisfaction section ­ with no discernible impact on the other scores which included general satisfaction, anxiety or the doctor-patient relationship. Perhaps a larger study would uncover changes in these measures.

On the other hand, a 10 per cent increase in consulting time adds up to a lot of GP resource.

If you have 25-30 consultations in a day, that's an extra 25-30 minutes.

Given that GPs' time is so precious and that the evidence only shows a slight increase in patient satisfaction, one has to wonder where this enthusiasm for longer consultations comes from. Quite possibly it comes from the satisfaction longer consultations give to GPs ­ rather than to the patients themselves.

Malcolm McLean is a GP trainer and GP tutor in Henfield, West Sussex

Dr McLean's study on the benefits of eliciting patients' concerns

The study1 was carried out in five semi-rural training practices.

In the middle of a consultation the participating GP, when it had become clear that this was a self-limiting problem, for which no referral or prescription was to be arranged, turned over the top sheet of a randomly arranged pile.

On the other side were written instructions: either 'control' ­ continue the consultation as normal; or 'intervention' ­ a written prompt of up to three questions to elicit the patient's concern. At the end of the consultation the doctor noted the time elapsed and the patient completed a questionnaire in the waiting room. Patient satisfaction was the main outcome measured.

Where the doctor had been prompted to elicit concerns, the patient did report slightly higher satisfaction than where the consultation occurred 'as normal'. But the intervention consultations took a whole minute longer than the control ones (11 vs 10 minutes). The paper published in the British Journal of General Practice concluded: 'The ideal may be desirable, but at a time when the fundamental problem of British general practice is a shortage of consultation resource, the best may be the enemy of the good.'

Evidence on the benefits of eliciting patients concerns

·Francis (1969) patients who received less explanation from the doctor were less satisfied and less 'compliant'.

·Verby (1979) doctors' peer review of their video-recorded consultations led to an improvement in patient-centredness but with an increase in consultation length.

·Hughes (1983) compared two practices in the same health centre. One (A) operated five- minute consultations and the other (B) 10 minutes. In B the referral rate and diagnoses were no different but there were fewer prescriptions and half the amount of return visits to the doctor within the next four weeks.

·Calnan (1988) compared older male GPs to younger female GPs. The latter had longer consultations and greater job satisfaction.

·Wilson (1991) likewise, consultations increased purposely by one minute led to less stress in the GP.

·Howie (1992) conversely, found longer consultations, which were more patient-centred and dealt with more psychological problems, led to more GP stress. More long-term problems were discussed. There was some reduction in prescribing, more patient satisfaction, but no difference in referral rates or return consulting.

·Wilson (1992) increasing consulting interval from 7.5 to 10 minutes led to more BP measurement and health promotion.

The politics of consultation time

References

1 McLean M, Armstrong D. Eliciting patients' concerns: a randomised controlled trial of different approaches by the doctor. British Journal of General Practice 2004;54 :663-6

2 David Tuckett et al. Meetings between Experts ­ An Approach to Sharing Ideas in Medical Consultations, Tavistock Publications (1985)

3 Cornford C et al. Why do mothers consult when their children cough? Family Practice 1993;10:193-6

4 Freeman G et al. Evolving general practice consultation in Britain:

issues of length and context.

BMJ 2002;324:880-2

5 Campbell S et al. Defining quality of care. Social Science and Medicine 2000;51:1611-25

Why I find longer consultations worthwhile

Dr Graham Archard has a 10-15-minute appointment system and feels putting time

into a consultation is a worthwhile investment

IIt takes at least 10 minutes just to take a history and examine a patient properly, be it for physical or emotional symptoms.

Of course there are some conditions where what-you-see-is-what-you-get, for example acute conjunctivitis, but a lot of people come in with much less structured problems. If it's a pain in the knee, you need to find out how that affects their job, what they're doing wrong and what management options there are.

Agreeing these management options can take a lot of time and if you're going to involve patients in these discussions the consultation is going to take more than 10 minutes.

I think as a result of offering longer consultations my job satisfaction is higher and so is patient satisfaction. I probably don't spend any more time with the patient in the long-run anyway as you're moving things so much further forward in the initial consultation that patients are less likely to return.

I usually end a consultation by asking patients if they're happy ­ unless it's something very straightforward like acute conjunctivitis, when I usually assume they are.

They almost invariably respond that they are happy, but if they say No then this poses a couple of difficulties.

The first is what have they got to add to the consultation that hasn't been covered,

and the second is that one of you has missed the whole point of the consultation and you've got to start all over again.....and that's when your surgery can start to get very behind.

Unsuccessful consultations where things don't go as well as you anticipated leave you feeling as if you've let the patient down and that you haven't achieved very much.

That doesn't necessarily come down to time, however. Sometimes it doesn't matter how much time you spend with the patient, you just can't get out of them what it really is that they want put on the agenda.

Obviously if you put more time into consultations I would have thought you get fewer unsuccessful consultations, though I couldn't quote you any evidence on that.

I'm surprised by the

David Tuckett figure of less than 6 per cent of GPs spending time eliciting patients' concerns.

I can believe only 6 per cent of GPs feel they spend enough time eliciting concerns, but I suspect they over-anticipate how much more would come out of that extra effort.

I could see GPs thinking they're not performing well when in fact they are. Most GPs do a fantastic job most of the time but always demand higher standards of themselves.

Graham Archard is a GP in Christchurch, Dorset, and national clinical governance lead at the NHS Alliance

Three-minute appointments give me a buzz

Dr Mark Feldman's practice has been running three-minute appointments in his practice for two years ­ he explains how it works

BBefore we introduced the three-minute appointments patients would sometimes have to wait weeks for an appointment or be forced to sit for hours in reception until the end of surgery to be seen. Now they arrive and are given a three-minute appointment for later that day and are delighted to be seen so quickly.

I do an hour of three-minute appointments and see about 20 patients in that time, and then after a short break do 90 minutes of normal 10-minute consultations.

The nurse starts the consultation by taking a history, taking blood pressure or doing peak flows. We have two nurses or nurse assistants doing this and I flit between the two rooms.

The nurse briefs me about the patient and, while I am speaking to the patient and making notes on the computer, the nurse writes out any forms needed.

Using the nurses in this way makes it a very cost-effective system. For this to work your staff must possess good social and computer skills ­ although clinical knowledge is an asset, these skills are more important.

I really buzz when I'm doing the three-minute session, though it couldn't be any longer than 90 minutes as you are really having to use your brain so much during that time. The three-minute consultation isn't suitable for psychological problems or for those that are not easily diagnosable, but for common complaints such as back pain, contraception advice, ear infections and UTI it works very well.

My partner and I have decided to use this system to achieve the 50 access points in the quality contract, but the trade-off has been that we have had to forefeit the 30 points for having an average consultation time of nine minutes. It's worth it though as the patients are so much more satisfied with the access we have now.

We still run a 10-minute consultation that patients can book in for if they prefer.

This puts the patients in control. We have had a lot of positive feedback from the patients and I am sure it has also reduced the number of home visits as appointments are always available.

One great plus is the flexibility ­ we can easily offer additional sessions to satisfy demand if required or drop them when things are quiet. This is the first time in 25 years that patients can be seen on the day both for 10- and three-minute appointments.

I feel this system could also be used to run new contract clinics such as lipid management, asthma and COPD ­ the nurses could do the initial checks and the doctor reviews the management. We already have clear protocols to enable nurses to manage hyperlipidaemia without direct medical supervison, although they have much more time for these clinics.

Mark Feldman is a GP in Harold Hill near

Romford in Essex

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