Intended for healthcare professionals


Interventions before consultations to help patients address their information needs by encouraging question asking: systematic review

BMJ 2008; 337 doi: (Published 16 July 2008) Cite this as: BMJ 2008;337:a485
  1. Paul Kinnersley, reader1,
  2. Adrian Edwards, professor of primary care1,
  3. Kerry Hood, reader1,
  4. Rebecca Ryan, research fellow2,
  5. Hayley Prout, research officer1,
  6. Naomi Cadbury, academic fellow1,
  7. Fergus MacBeth, director3,
  8. Phyllis Butow, professor of pyschology4,
  9. Christopher Butler, professor of primary care1
  1. 1Neuadd Meirionydd, School of Medicine, Cardiff University, Cardiff CF14 4XN
  2. 2Cochrane Consumers and Communication Review Group, Australian Institute of Primary Care, LaTrobe University, Victoria, Australia
  3. 3Clinical Effectiveness Support Unit (Wales) Roseway, Llandough Hospital, Penarth
  4. 4School of Psychology, University of Sydney, Australia
  1. Correspondence to: P Kinnersley kinnersley{at}
  • Accepted 9 May 2008


Objective To assess the effects on patients, clinicians, and the healthcare system of interventions before consultations to help patients or their representatives gather information in consultations by question asking.

Design Systematic review with meta-analysis.

Data sources Electronic literature searches of seven databases and hand searching of one journal and bibliographies of relevant articles.

Review methods Inclusion criteria included randomised controlled trials.

Main outcome measures Primary outcomes were question asking; patients’ anxiety, knowledge, and satisfaction; and length of consultation.

Results 33 randomised trials of variable quality involving 8244 patients were identified. A few studies showed positive effects. Meta-analyses showed small and statistically significantly increases in question asking (standardised mean difference 0.27, 95% confidence interval 0.19 to 0.36) and patients’ satisfaction (0.09, 0.03 to 0.16). Non-statistically significant changes occurred in patients’ anxiety before consultations (weighted mean difference −1.56, −7.10 to 3.97), patients’ anxiety after consultations (standardised mean difference −0.08, −0.22 to 0.06), patients’ knowledge (−0.34, −0.94 to 0.25), and length of consultation (0.10, −0.05 to 0.25). Interventions comprising written materials had similar effects on question asking, consultation length, and patients’ satisfaction as those comprising the coaching of patients. Interventions with additional training of clinicians had little further effect than those targeted at patients alone for patients’ satisfaction and consultation length.

Conclusions Interventions for patients before consultations produce small benefits for patients. This may be because patients and clinicians have established behaviours in consultations that are difficult to change. Alternatively small increases in question asking may not be sufficient to make notable changes to other outcomes.


  • We thank the staff and editors of the Cochrane Consumers and Communication Review Group, particularly Megan Prictor for her overall advice; Sophie Hill (coordinating editor of the review group); Dell Horey (contact editor for the review); Dominique Broclain (contact editor for the protocol); Judy Stoelwinder (former search coordinator for the trials) for her help with the search strategy; Damien Jolley and Kelly Allen for their statistical feedback; Diane Owen for her help with data extraction; other editors and external peer reviewers for their comments; and the following consumers for their helpful feedback: Janine Cooper-Marshall, Pat Oliver, Iris Mackenzie, Peter Palmer, and Richard Berry (University of Wales College of Medicine Simulated Patients); from Amy Zelmer, Nete Villebro, Rosemary Humphreys, Amy Arkle, and Judi Strid (consumer representatives of the Cochrane Consumer and Communication Group). The initial idea for this work came when Paul Kinnersley was working in Australia funded by a grant from the PPP Foundation (now the Health Foundation).

  • Contributors: PK conceived the study and is guarantor. PK, RR, HP, and NC did the literature searches and reviewed the abstracts. KH directed the meta-analyses. All authors interpreted the results and were involved in the production of the manuscript.

  • Funding: This research received no specific grant from any funding agency in the public, commercial, or not for profit sectors.

  • Competing interests: PK directs a university unit that generates income by delivering training in communication skills to clinicians.

  • Ethical approval: Not required.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

View Full Text