Consultations do not have to be longer
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7360.388 (Published 17 August 2002) Cite this as: BMJ 2002;325:388
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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.
Competing interests: No competing interests
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
University of Edinburgh
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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).
Competing interests: No competing interests
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 à 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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
The hare and the tortoise and speed kills
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,
Roger Allen,
Tortoise
Queensland.
Competing interests: No competing interests