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PRIMARY CARE: Paul Little, Martina Dorward, Greg Warner, Michael Moore, Katharine Stephens, Jane Senior, and Tony Kendrick Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care BMJ 2004; 328: 441 [Abstract] [Full text]

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Clinical effects of depression

Justine M H Carr-Brion   (24 February 2004)

Were doctors "activated" or could patients have been better "activated"?

Robbie C Foy, Kirstie Vickers, GP pre-registration house officer, St Albans Medical Group, Gateshead NE10 9QG   (27 February 2004)

Show doctors what patients have written down

Thomas P E Wells, Stephen J Falk, Paul A Dieppe   (28 February 2004)

Clinical effects of depression 24 February 2004
Justine M H Carr-Brion, former GP none Send response to journal: Re: Clinical effects of depression	I am not suprised that your 80 patients with possible major depression were not helped by being given a leaflet. I wonder how many of them actually read the leaflet. I personally know too well the poor concentration and total lack of motivation to do anything which goes with that condition. Competing interests: None declared
Were doctors "activated" or could patients have been better "activated"? 27 February 2004
Robbie C Foy, Clinical senior lecturer in primary care Centre for Health Services Research, University of Newcastle upon Tyne, NE2 4AA, Kirstie Vickers, GP pre-registration house officer, St Albans Medical Group, Gateshead NE10 9QG Send response to journal: Re: Were doctors "activated" or could patients have been better "activated"?	Editor We welcome the trial by Little and colleagues and appreciate some of the methodological difficulties they overcame to test the effect of patient empowerment leaflets.(1) We wondered whether the lack of effect for most outcomes could be related to two factors in the design of the study and the intervention respectively. First, is it possible that the doctors themselves rather than the patients were “activated” either by the intervention or by Hawthorne effects? Hence, doctors seeing control patients may have become habituated or altered their performance to explore patient expectations in more depth than before the trial, thereby reducing any difference between the study arms. Perhaps a cluster randomised trial would have provided reassurance that contamination did not occur.(2) Second, as reported in the long version of the paper, patients were recruited just prior to consultations. Many patients may mentally “rehearse” their consultations well before entering the waiting room. Therefore a leaflet provided at the point of (say) booking an appointment might have had greater scope for effect. Robbie Foy Clinical senior lecturer in primary care Centre for Health Services Research, University of Newcastle upon Tyne NE2 4AA Kirstie Vickers GP house officer St Albans Medical Group, Gateshead NE10 9QG 1. Little P, Dorward M, Warner G, Moore M, Stephens K, Senior J et al. Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care. BMJ 2004; 328:441-444. 2. Wood J, Freemantle N. Choosing an appropriate unit of analysis in trials of interventions that attempt to influence practice. J Health Serv Res Policy 1999; 4:44-48. Competing interests: None declared
Show doctors what patients have written down 28 February 2004
Thomas P E Wells, specialist registrar clinical oncology Bristol Haematology and Oncology Centre, Bristol BS1 5QH, Stephen J Falk, Paul A Dieppe Send response to journal: Re: Show doctors what patients have written down	EDITOR – Little et al highlight in their two papers that patients have ideas, concerns and expectations at consultation, which are not always identified by their general practitioner [1,2]. The use of leaflets is an intervention that appears to improve patients’ satisfaction and perception of communication in the primary care consultation. It was interesting to note that doctors do not always elicit patients’ expectations and that investigations were requested when not always medically indicated. Surely a good way to improve consultation outcome would be for doctors to be shown the listings that patients have made regarding their ideas, concerns and expectations of the consultation. This might help doctor and patient work together in the consultation by having a clear agenda, rather than having to negotiate which issues each party considers important, whether this is simple reassurance, being examined, writing a prescription, requesting an investigation or anything else. The use of question prompt sheets [3], in which patients identified questions from a choice of questions already listed for them, has been previously investigated and consultation duration decreased if the question prompt sheet was endorsed by the doctor. We regarded a prepared list of questions for patients to choose from to be patronising, and so we conducted a study in which patients were asked to list questions or topics on a participation form without any obvious influence [4,5]. Eighty-eight of 100 patients attending for new and follow up outpatient appointments at a regional oncology centre agreed to participate in our study, and 65 of these 88 participants listed one or more items for discussion with the doctor. On our study participation form was the statement, "Please list below any questions or topics that you would like the doctor to discuss when you see him or her in your clinic consultation". This form only addressed concerns and did not address patients’ expectations. Perhaps we should have included three statements on the form, these statements being: (1) please list any concerns that you would like to discuss with the doctor; (2) please list any questions that you would like to ask the doctor; (3) please list what you would like the doctor to do for you and what expectations you have of the consultation. The potential advantages of showing the doctor what patients have written on such a form are that patients can set the agenda without any obvious influence and that the listing is in the patients’ own language, giving the doctor important insights into the patients’ understanding. This would be a simple intervention to implement; the established need to improve doctor-patient consultation dynamics warrants further investigation of its use in both primary and secondary care. Studies, such as those by Little et al, that investigate aspects of patients’ ideas, concerns and expectations should be encouraged. Thomas Wells specialist registrar clinical oncology Stephen Falk consultant clinical oncology Bristol Haematology and Oncology Centre, Bristol BS1 8ED Paul Dieppe director MRC Health Services Research Collaboration, Department of Social Medicine, Bristol BS8 2PR The Department of Social Medicine of the University of Bristol is the lead centre of the MRC Health Services Research Collaboration. Competing interests: None declared. [1] Little P, Dorward M, Warner G, Moore M, Stephens K, Senior J, Kendrick T. Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care. BMJ 2004;328:441-3. [2] Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral and prescribing in primary care: nested observational study. BMJ 2004;328:444-6. [3] Butow PN, Dunn S, Tattersall M, Jones Q. Patient participation in the cancer consultation: evaluation of a question prompt sheet. Ann Oncol 1994;5:199-204. [4] Wells TPE, Falk SJ, Dieppe PA. The patients' written word: a simple communication aid. Forthcoming: Patient Educ Counsel (accepted for publication on 7 July 2003). [5] Wells TPE, Falk SJ, Dieppe PA. Let patients have their say: reducing miscommunication. Clinical Oncology 2003;15:298. Competing interests: None declared