Intended for healthcare professionals

Primary Care

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 doi: (Published 19 February 2004) Cite this as: BMJ 2004;328:444
  1. Paul Little, professor of primary care research (psl3{at},
  2. Martina Dorward, research nurse1,
  3. Greg Warner, general practitioner2,
  4. Katharine Stephens, medical student1,
  5. Jane Senior, medical student1,
  6. Michael Moore, general practitioner3
  1. 1Primary Medical Care, Community Clinical Sciences Division, Southampton University, Aldermoor Health Centre, Southampton SO16 5ST
  2. 2Nightingale Surgery, Romsey SO51 7QN
  3. 3Three Swans Surgery, Salisbury SP1 1DX
  1. Correspondence to: P Little
  • Accepted 10 December 2003


Objective To assess how pressures from patients on doctors in the consultation contribute to referral and investigation.

Design Observational study nested within a randomised controlled trial.

Setting Five general practices in three settings in the United Kingdom.

Participants 847 consecutive patients, aged 16-80 years.

Main outcomes measures Patient preferences and doctors' perception of patient pressure and medical need.

Results Perceived medical need was the strongest independent predictor of all behaviours and confounded all other predictors. The doctors thought, however, there was no or only a slight indication for medical need among a significant minority of those who were examined (89/580, 15%), received a prescription (74/394, 19%), or were referred (27/125, 22%) and almost half of those investigated (99/216, 46%). After controlling for patient preference, medical need, and clustering by doctor, doctors' perceptions of patient pressure were strongly associated with prescribing (adjusted odds ratio 2.87, 95% confidence interval 1.16 to 7.08) and even more strongly associated with examination (4.38, 1.24 to 15.5), referral (10.72, 2.08 to 55.3), and investigation (3.18, 1.31 to 7.70). In all cases, doctors' perception of patient pressure was a stronger predictor than patients' preferences. Controlling for randomisation group, mean consultation time, or patient variables did not alter estimates or inferences.

Conclusions Doctors' behaviour in the consultation is most strongly associated with perceived medical need of the patient, which strongly confounds other predictors. However, a significant minority of examining, prescribing, and referral, and almost half of investigations, are still thought by the doctor to be slightly needed or not needed at all, and perceived patient pressure is a strong independent predictor of all doctor behaviours. To limit unnecessary resource use and iatrogenesis, when management decisions are not thought to be medically needed, doctors need to directly ask patients about their expectations.


  • Contributors PL had the original idea for the study, which was developed by all authors. MD, JS, and KS ran the study on a day to day basis, and analysed the results with PL. All authors contributed to writing the paper. PL will act as guarantor for the paper. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding Southampton University

  • Competing interests None declared. JS can no longer be contacted but PL states she has no competing interests.

  • Ethical approval This study was approved by the Salisbury and Southampton and South West Hants ethics committees

  • Graphic Effect of consultation time and interventions on generalisability are on

  • Accepted 10 December 2003
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