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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Consultations: What purpose should they serve
- Romesh Khardori (17 August 2002)
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Consultations may have to be longer!
- Bruce Green, Daniela Sanders (17 August 2002)
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Need not want not?
- David M Lewis (20 August 2002)
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Time to end the five minute consultation
- Martin Roland (21 August 2002)
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Doctors benefit from longer consultations
- David F. Bird (22 August 2002)
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What is a good outcome to a consultation?
- Peter Davies (23 August 2002)
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Satisfactory consultations for who?
- Richard D G James (23 August 2002)
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The benefits of the electronic record
- Thomas M Davies (24 August 2002)
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He who pays the piper........and the chained dog
- Roger K.A. Allen (24 August 2002)
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Tabloid headline was misleading
- Andrew Wilson (30 August 2002)
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Longer consultations can improve patient satisfaction
- HARRY A LEE (4 September 2002)
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The benefits of longer consultations
- David J Heaney, John GR Howie, Margaret Maxwell (5 September 2002)
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Consultations can be short and meaningful
- Paul E Spicer (11 September 2002)
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The hare and the tortoise and speed kills
- Roger KA Allen (12 September 2002)
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Romesh Khardori, Professor-Director:Endocrinology, Metabolism & Molecular Medicine Southern Illinois University school of Medicine; Springfield, IL62794-9636;USA
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Sir, Patients come to physicians to seek answers to three basic questions a) Do they need to be worried about ailment b) Are there are potential immediate threats to their health, and if so how best to avoid them; c) What would be the most tested/evidence based treatment modality. Apart from these basic inquiries they seek reassurance and a forum to vent their concerns. All of the above can be accomplished by physicians in a relatively short order if physicians ask every patient what the purpose of their visit is in the very begining of their conversation with the patient. As for the details that are often recorded (family history, past medical history, Social history etc.,) these can be obtained from patients by mail ahead of time or during the time spent in waiting lounge at the time of their office appointment. Personally I find sometimes physicians have spent significant time (as reflected by the length of dictated notes)and yet very little is accomplished in terms of making specific recommendations. Some physicians provide very precise language in few sentences that sums up the issues patient is facing and how best these could be sorted in consultant's view. I see no correlation between the length of note and the quality of care. Thanks |
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Bruce Green, Lecturer School of Pharmacy, University of Queensland, Brisbane, Australia 4072, Daniela Sanders
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Dear Sir, this letter has provided some interesting data, although it seems the conclusions presented by Jenkins et al do not relate to the study undertaken. The authors suggest that patient outcomes are satisfactory based on their expectations from the consultation, and therefore consultation times are appropriate. It is important to recognise that the study presented in this letter sought to address patient’s perceptions and expectations of health care, and not their health care outcomes. Whilst accepted that a satisfactory consultation will incorporate patient ‘happiness’, one would assume that a successful consultation would also ensure an appropriate clinical pathway was chosen in consultation with the patient. Identification of such pathways are primarily the responsibility of the health care professional, and it is only possible for patients to be unhappy with a consultation if the practitioner fails to offer a pathway which the patient has prior knowledge of. If the patient has no such expectations, and inadequate consultation times prevent a thorough review of the patient’s history and current status, they may be happy with the consultation, whilst not receiving optimal clinical care. We suggest that Jenkins et al should confine the conclusions from their study to a confirmation that social skills of G.P.’s meet the expectation of patients, but not that consultations times are adequate to ensure an optimal clinical outcome. |
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David M Lewis, General Practitioner Watford WD24 7PH
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Sir, Jenkins et al seem content to reduce the doctor patient encounter to satisfying patient wants without giving thought to what patients need from health professionals. Sometimes patients do not leave my surgery happy, but they have been provided with what they need. For example, patients who regularly attend for minor ailments and unexplained medical symptoms may leave an appointment disgruntled for not being granted their wish for antibiotics (again) to treat a sore throat; such appointments may consume nearly 10 minutes! Green's rapid response refers to a doctor's social skills palying a large role in a patient's happiness with the consultation. Khardori is worried that Jenkins et al did not assess patient knowledge - ignorance may be bliss. Freeman et al (2002) studied consultation length and quality of general practice consultations. They concluded that the longer consultation was necessary for several reasons. (1) Longer consultations are associated with a range of better patient outcomes (2)Modern consultations in general practice deal with patients with more serious and chronic conditions Increasing patient participation means more complex interaction, which demands extra time (3)Difficulties with access and with loss of continuity add to perceived stress and poor performance and lead to further pressure on time (4)Longer consultations should be a professional priority, combined with increased use of technology and more flexible practice management to maximise interpersonal continuity. My role as a doctor is to elucidate why patients attend the surgery to see me, identify the suffering that underpins the attendance, assuage any fears, devise a management plan we can agree on and help the patient move on. I believe we should resist the temptation to always give patients what they want. Often the road to happiness and health can only be reached by giving patients what they need. Reference: Freeman et al (2002): Evolving general practice consultation in Britain: issues of length and context. BMJ 324: 880-882 [http://bmj.com/cgi/content/full/324/7342/880] |
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Martin Roland, Professor of General Practice University of Manchester
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Linda Jenkins and colleagues, letter 17th August, (1) found that patients vary widely in what they want from consultations with their GP – and whether they get it. There was a poor correlation between these and the length of the consultation. However, the BMJ’s catchy headline ‘Consultations don’t have to be longer to be better’ (front cover) seriously over-generalises these results. While some short consultations may be highly effective, a systematic review in the BMJ earlier this year summarised a range of patient outcomes which are improved when doctors have more time (2). In one large scale English survey, only twelve per cent of patients complained about insufficient time with their GP, but this figure rose to thirty percent when patients were seen for five minutes or less (3). Maybe it is the doctors who need additional time – perhaps more than their patients. Medical practice has become more complex, and more needs to be done during the course of consultations. This may explain why clinical care is inferior in practices with short consultations (4). Perhaps patients get most of what they want in short consultations – but don’t realise that it isn’t good medical care. It is 15 years since David Morrell and I published the first experimental study showing the limitations of short consultations (5, 6). It is well past time to consign surgeries booked at intervals as short as five minutes to history. The current payment system for GPs does nothing to discourage a “pack ‘em in and sell ‘em cheap” approach to general practice. This needs to be addressed in the contract currently being negotiated, so that all GPs have time to offer their patients first class care. Yours sincerely, Martin Roland 1. Jenkins L, Britten N, Barber N, Bradley C, Stevenson F. Consultations do not have to be longer. British Medical Journal 2002; 325: 388. 2. Freeman GK, Horder J, Howie JGR, Hungin P, Hill AP, Shah NC, Wilson A. Evolving general practice consultation in Britain: issues of length and context. British Medical Journal 2002; 324: 880-882. 3. Department of Health. The National Survey of NHS Patients General Practice: 1998. Available at: http://www.doh.gov.uk/public/nhssurvey.htm. 4. Campbell SM, Hann M, Hacker J, Burns C, Oliver D, Thapar A, Mead N, Gelb Safran D, Roland M. Identifying predictors of high quality care in English general practice: observational study British Medical Journal 2001;323:784-787 5. Morrell DC, Evans M, Morris RW, Roland MO The five minute consultation: effect of time constraint on clinical content and patient satisfaction. British Medical Journal 1986; 292: 870-873. 6. Roland MO, Bartholomew J, Courtenay MJF, Morris RW, Morrell DC The five minute consultation: effect of time constraint on verbal communication in the consultation. British Medical Journal 1986; 292: 874- 876 |
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David F. Bird, General practitioner French Weir Health Centre,Taunton TA2 6ET
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Patients may not seem to require longer consultations to fulfill their wants but its a lot more pleasant for the doctor.Nowadays we have so many extra aspects to a consultation apart from satisfying the immediate clinical need,whether its explaining possible drug side effects,reviewing an ongoing chronic problem,complying with the latest NSF or whatever.Cramming it all in to a 10 min appointment plus dealing with interruptions and squeezing phone calls between consultations puts a lot of pressure on the GP. For the last few months I have extended my afternoon surgeries to 15min appointments.To still see the same number of patients I start at 2.30 pm.This reduces the time for visits in the middle of the day but even with a very elderly list I find the demand for visits is less than even a few years ago. The effect on my afternoons has been excellent.I can look forward to relaxed surgeries with time to catch up if I do get a little behind and with a much reduced feeling of pressure.Its good for the doctor,regardless of what the patient feels ! David F.Bird |
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Peter Davies, GP Mixenden Stones Surgery,Halifax HX2 8RQ
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Sir, I am glad that Jenkins and colleagues have looked at what patients want from consultations, and whether these wants are achieved. In cases where the wants and medical needs are in alignment with each other patient satisfaction is probably a reasonable measure of a good outcome. However in many other cases patients wants should definitely not be met by a good doctor. For example if doctors gave out antibiotics to everyone who asked for them this might score highly on patient satisfaction. It might also be quick, and so appeal to a GP with a full waiting room! It would not however be good medicine showing inappropriate prescribing, disregard of side-effects, attempts to appease patient demand, and lack of acceptance of the public health necessity to maintain the power of antibiotics by using them only when necessary. Sometimes it is the duty of the doctor to demolish ill formed health beliefs and subsequent inappropriate wants as part of good medical practice. Such consultations require confidence, skill, tact and firmness on the part of the doctor within an overall frame of being willing to provide any appropriate treatment when needed. A patient whose beliefs are challenged in this way may leave a consultation confused and not entirely satisfied, but the outcome is good as the false beliefs have been challenged, and the patient has the possibility of new learning. Simply giving the patient what they want is the antithesis of good medicine. Longer consultations are necessary to give doctor and patient the opportunity to explore what is really needed in a situation and to reach a joint solution. When this is done both parties in the consultation can be satisfied. |
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Richard D G James, GP The Health Centre, Trevaylor Road, Falmouth, TR11 2LH
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Does this report just highlight the current trend for politicians and some doctors to assess GP performance in terms of patient satisfaction, or in this case patients getting what they want? Am I to be deemed a better doctor for providing inappropriate long term night sedation and other addictive drugs, antibiotics for trivial viral infections and sick notes to the fit? At the same time General Practitioners (rightly in my view) are being pressurised to deliver better quality therapeutic and preventative care which does lengthen consultations. Dealing solely with the patient’s agenda falls short of good practice, and may have negative health outcomes. Time in my view to stand up to the promised wave of assessment by patient satisfaction surveys. |
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Thomas M Davies, GP Principal Yaxley Group Practice PE7 3JL
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Dear Sir, It is timely to re-open this debate at a time when we are in danger of having the 10 minute consultation imposed upon us as a yardstick of ‘good practice’ All patients are different, and have different needs. I have been using only the computer to record all my clinical activity now for 5 years, and analyzing the consultations over this time have observed much better Patient interaction. Because the electronic record is now comprehensive, I can check (with the patient reading the screen) all relevant information instantly (macro’s call up pre designed pages of data items) and all letters having been scanned are there for us both to read. The time using the computer in the average consultation is less than 1 minute, yet 6 -7 Read Codes will have been recorded (real time) , and follow up plans made and recorded in a consultation that averages 8.1 minutes. The next patient is called in immediately the previous consultation ends. It is time to assess consultations not by their length, nor even content but by the question ‘at the end of the consultation the clinician must have up to date information with regard to Current therapy, Relevant Family History, Recent Hospital attendances, Recent Investigations, Social and Occupational factors. Much of this is added piecemeal over the years, and with the full Primary care team contributing to the record, communication is as effective as it could be. We are an ‘advanced access’ practice, and up to one third of my consultations are done by phone. All these are recorded, and various plans jointly negotiated. In the event of the patient subsequently being seen, there is often already a clear plan of action and the ‘short’ consultation suitably focused and hopefully effective. The phrase I use is ‘one hits the ground running. The fully designable Summary screen within seconds brings the clinician up to date and therefore gives him/for more time to engage with the patient. The best comment arose from a patient on looking up and seeing all that was on the screen, “I didn’t see you write that, my last doctor spent all the time looking in the notes and never listening!!” Dr Tom Davies Chairman National Vision User Group Yaxley, Peterborough PE7 3TB |
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Roger K.A. Allen, Consultant Thoracic and Sleep Physician, Private Practice Suite 299,St Andrew's Place,33 North St, Spring Hill, Brisbane,Qld 4000, Australia
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Until recently many Australian GP's and a few specialists for that matter, had been running like rats on a rotating wheel, turning faster and faster, and governed not by common sense, but by outmoded community expectations and government-dictated fee structures related to duration of consultation.The Medicare reimbursement has lagged further and further behind the CPI and practice costs since first established about 25 years ago. The GP's are now finally rebelling and abandoning what we call 'Bulk Billing'; a system where the patient just signs a magic piece of paper and makes no personal financial contribution; not even one dollar. The insurance crisis, no doubt assisted by Sept 11, has caused them to revolt and to charge patients directly just like my plumber and baker and most specialists and my GP father did for years. Consequently, the doctor and patient now have a more effective consultation/interchange, the duration of which is dictated by need, not by our masters in Canberra, the land- locked federal capital in the Land of Oz. For the American BMJ readers this should not be confused with the West Witch,Kansas, Dorothy or yellow brick roads. Patients pay for the service and can that day lodge a reimbursement form at the local Medicare Office for most but not all of the fee. The fee may be dictated by the M.O. If he is a softy, he may charge at or below the Medicare fee or even nothing for some poor patients. They will be reimbursed that day. That is a personal decision. The doctor does better medicine, the patient is more satisfied in general and the community now realises that the previous system was untenable. We may end up needing more Pommmy M.O.'s to come out here (wearing a white Panama, dressed in short longs or long shorts, brown sandals and beige long or white short socks) to help as the need for medical officers must increase (market forces). On the other hand for our former colonial master,the medicus britannicus seems to be lean dog chained to a cold, leaking flea-infested kennel,perhaps of its own making. To paraphrase Aesop, I'd rather be an independent wolf roaming free, than a dog chained to a dog house...or to use another analogy...he who pays the piper, calls the tune...and you blokes are dancing to your political masters' hornpipe. You poor buggers.The doctor and the patient have a unique relationship and the current folie ŕ trois with your demanding mistress, Madame Le Gouvernement is bound to to be your undoing and give you a terminal case of the French disease or is it the English disease? You have been living this way for so long you can't see what damned fools you are. You are going insane and don't realise it (viz. some of your former politicians). Many have already jumped your sinking, rat infested ship to go to other shores to seek the freedom to exercise their medical professionalism just like what you blokes did during the Californian and Australian gold rushes in the 1850's. Sadly you don't seem to realise that the medical officer really has the upper hand over government if enough of you stand together.After all,politicians, reproduce, get sick and fortunately die too. Once upon a time, we medical sons and daughters from Oz used to come to specialist finishing school in Great Britain (?UK) but due to your generally crummy system now, most of us stay at home or go to that other dreadful 'united' kingdom, the USA. I had better call my plumber now for that leaking tap and a few other matters. I had better ask him if that will be an HIC Item 00119, a 'subsequent consultation, short, for one problem only lasting 5 minutes or will it be an Item 00116, the slightly longer one with two problems to deal with. I hope he still 'Bulk Bill's' as I believe it is my God-given right to have a dry tap. I await the howls of self-righteous indignation from our socialist colonial masters in Great Britain, the only country on the planet to be pompous enough to call itself 'Great'. No wonder you get up the noses of the Frogs. Incidentally I am a frogophile/phone. Yours sincerely, Roger ALLEN from Great Australia. Incidentally for the geographically minded and for the American readers we do have a Great Australian Bight(no not McDonalds) and the Great Barrier Reef but that doesn't count.They were both named by Poms. Great, eh? Oz is in the Southern Hemisphere near the South Pole. You know; the place where the kangaroos come from. Footnote: Bulk Billing is so-called because the M.O. would submit a pile of signed Medicare forms periodically and eventually get paid by the governmment about 6 weeks later or when ever they feel ilke it. You may note I have not used the word 'doctor' once. |
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Andrew Wilson, Reader Department of General Practice and Primary Health Care, University of Leicester. LE5 4PW
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While Jenkins et al’s (1) final sentence that “from the patient’s perspective satisfactory consultations do not have to be long ones” is supported by their data, I find it extraordinary that the letter was entitled “Consultations do not have to be longer” and still worse your front page headline “Consultations do not have to be longer to be better”. The reported study justifies neither of these assertions. Clearly the amount of consultation time required relates to the complexity of the reason for consulting, which may well be different from the number of things the patient wants from their visit, as counted by Jenkins. To establish whether ‘longer’ consultations are ‘better’ we need to examine not individual consultations of differing lengths but the performance and outcomes of doctors who consult quickly with those who consult more slowly. Studies have shown that doctors who take more time prescribe less(2), achieve higher levels of enablement(3) and some elements of patient satisfaction (4), and better manage chronic disease.(5) Results from a systematic review on this topic are soon to be published.(6) Your new cover style does well in attracting attention but need not stoop to the levels of tabloid journalism. 1. Jenkins L, Britten N, Barber N, Bradley CP, Stevenson FA. Consultations do not have to be longer. BMJ 2002;325:388. 2. Howie JG, Porter AM, Heaney DJ, Hopton JL. Long to short consultation ratio: a proxy measure of quality of care for general practice. Br.J.Gen.Pract. 1991;41:48-54. 3. Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK, Rai H. Quality at general practice consultations: cross sectional survey. BMJ 1999;319:738-43. 4. Baker R. Characteristics of practices, general practitioners and patients related to levels of patients' satisfaction with consultations. British Journal of General Practice 1996;46:601-5. 5.Campbell SM, Hann M, Roland MO, Hacker J, Burns C, Oliver D et al. Identifying predictors of high quality care in English general practice: observational study. BMJ 2001;323:784-7. 6.Wilson A, Childs S. The relationship between consultation length process and outcomes in general practice: a systematic review. British Journal of General Practice (in press). |
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HARRY A LEE, Professor and Head of Gulf Veterans' Medical Assessment Programme Baird Health Centre, Gassiot House, St Thomas' Hospital London SE1 7EH
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Jenkins et al indicate from a general practice perspective that consultations do not have to be longer to get benefit. What they do not address is the nature of the consultation. Clearly, if it is about a wart, an attack of acute bronchitis or urinary tract infection, about a rash or whether or not to smoke, the consultation can be succinct and short-lived. However, what about when a patient comes with a problem that has been beset with publicity arising from politicians, the public in general, and often sensational and one-sided media coverage? In such circumstances, when the problem is multi-factorial, time is of the essence. In this department, we see patients referred both from military and civilian doctors. The common complaint has always been we have never had enough time to talk about the issues involved. Here, because we need the time, and indeed have the time, average consultations are one and a half hours per patient. As a result of this approach, we have a 95% patient satisfaction rate based on a questionnaire filled in after they leave the department. Such data has been collected on an anonymised aggregated basis. We do not believe that generalisations can be made. Our experience has been that longer consultations have resulted in higher patient satisfaction rates. Our perspective is that the ptient would agree that longer consultations do result in more satisfactory outcomes. |
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David J Heaney, Research Fellow,Department of Community Health Sciences - General Practice, Edinburgh University, 20 West Richmond Street, Edinburgh EH8 9DX, John GR Howie, Margaret Maxwell
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Dear Sir Consultations are infinitely variable, and are difficult to research quantitatively. After the better part of twenty years attempting to do this, we think the following conclusions can be safely drawn. At longer as against shorter consultations, as well as the presenting complaint, it is more likely that long-term co-morbidity and psychosocial problems will be recognised, and that having been recognised, they will be addressed. It is likely that more health education will be offered. And patients and doctors are more likely to be satisfied.(1) We have identified a sub-set of satisfaction-like questions (which include important outcomes such as patients understanding their problems better and feeling more able to cope) as ‘enablement’. We have consistently found that those doctors who enable more people, and who enable people more, are those whose average consultation time is longer. They are also the doctors whose patients know them better (a proxy for continuity). There is thus an association between longer consultations and better processes and outcomes; we cannot say to what extent the relationship is a causal one, although it is reasonable to suggest that it will be at least in part. Almost certainly further important variables (for example, empathy) are also important correlates, but these too are difficult to research.(2) No-one has ever suggested that all long consultations are good ones, or that short ones cannot be effective, and indeed Jenkins and her colleagues did not imply that.(3) We would argue that while an individual consultation does not have to be long, doctors who on the whole provide shorter consultations are likely to be providing less good care. Similarly, patients who have never had the opportunity for longer consultation are unlikely to have their wants met. At a time when sensitive general practitioner contract negotiations are in progress, scientifically simplistic headlines such as you have used serve neither doctors nor patients well. The message should be that consultations do have to be longer. We still believe that there should also be a contractual reward/incentive for providing such a service.(2) Yours etc John Howie, David Heaney, Margaret Maxwell
1 Howie JGR, Porter AMD, Heaney DJ, Hopton JL. Long to short consultation ratio: a proxy measure of quality of care for general practice.BJGP1991; 41:48-54. 2 Howie JGR, Heaney DJ, Maxwell M, Walker JJ, Freeman GK. Developing a ‘consultation quality index’ (CQI) for use in general practice. Family Practice 2000; 17:455-61. 3 Jenkins L, Britten N, Barber N, Bradley CP, Stevenson FA. Consultations do not have to be longer BMJ 2002;325:388. |
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Paul E Spicer, Semi-retired - consulting/research Cairns, Far N. QLD. Australia 4870
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Editor In response to the research into communication between doctors and patients by Jenkins et al may I re-iterate an old adage, "If one has not made up one's mind regarding a diagnosis in 30 seconds one never will"! The secondary questions and physical examination usually confirms the diagnosis. Very rarely is one surprised. By taking some time to converse with the patient and to perform perhaps a limited examination the patient should receive most of the "wanted" aspects of the consultation. Paul E. Spicer Retired - formally GP Newark, Notts and Murwillumbah, NSW, Australia and CMO for Ok Tedi Mines in Papua New Guinea and Freeport Mcmoran/Moffat Mine Irian Jaya, Indonesia. |
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Roger KA Allen, Consultant Thoracic and Sleep Physician, Private Practice Suite 299,St Andrew's Place,33 North St, Spring Hill, Brisbane,Qld 4000, Australia
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Dear Editor, As a consultant physician I spend most of my life undiagnosing diagnoses made by such quick-draw diagnostic genius(genii for those pompous Pommy doctors reading this in their smoking jackets at the club). Such is the lamentable state of the modern diagnostic approach. The art of diagnosis rests in a thorough history-taking, a sixth sense (probably unacceptable) i.e. non-verbal "vibes", attention to detail, and ferretting into some hidden nooks and crannies others have not even thought of (apologies for ending the sentence in such a sloppy fashion). The examination should confirm or refute the postulates already evolving in your head. Remind me not to get sick in Cairns on my next Barrier Reef holiday. The consultation is not quizz show where the first to hit the buzzer wins. If you regard it as such you will make some tragic errors. Speed kills. Slow and steady wins the race. Yours sincerely,
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