Impact on patients of expanded, general practice based, student teaching: observational and qualitative study.
ABSTRACT: OBJECTIVES: To compare patients' enablement and satisfaction after teaching and non-teaching consultations. To explore patients' views about the possible impact that increased community based teaching of student doctors in their practice may have on the delivery of service and their attitudes towards direct involvement with students. DESIGN: Observational study using validated survey instruments (patient enablement index--PEI, and consultation satisfaction questionnaire--CSQ) administered after teaching consultations and non-teaching consultations. Ten focus groups (two from each practice), comprising five with patients participating in prearranged teaching sessions and five with patients not participating in these. SETTING: Five general practices in west Suffolk and southern Norfolk, England, that teach student doctors on the Cambridge graduate medical course. PARTICIPANTS: 240 patients attending teaching consultations (response rate 82%, 196 patients) and 409 patients attending non-teaching consultations (response rate 72%, 294 patients) received survey instruments. Ten focus groups with a total of 34 patients participating in prearranged teaching sessions and 20 patients not participating in these. MAIN OUTCOME MEASURES: Scores on the patient enablement index and consultation satisfaction questionnaire, analysed at the level of all patients, allowing for age, sex, general practitioner, and practice, and at the level of the individual general practitioner teacher. Qualitative analysis of focus group data. RESULTS: Patients' enablement or satisfaction was not reduced after teaching consultations compared with non-teaching consultations (mean difference in scores on the patient enablement index and consultation satisfaction questionnaire with adjustment for confounders 2.24% and 1.70%, respectively). This held true for analysis by all patients and by general practitioner teacher. Qualitative data showed that patients generally supported the teaching of student doctors in their practice. However, this support was conditional on receiving sufficient information about reasons for doctors' absence, the characteristics of students, and the nature of teaching planned. Many patients viewed their general practice as different from hospital and expected greater control over students' presence during their consultations. CONCLUSIONS: Patients' enablement and satisfaction are not impaired by students' participation in consultations. Patients generally support the teaching of student doctors in their general practice but expect to be provided with sufficient information and to have a choice about participation, so they can give informed consent. Recognising this when organising general practice based teaching is important.
Project description:BACKGROUND:Research has not yet fully investigated links to consultation duration, patient expectations, satisfaction, and enablement in nurse practitioner consultations. This study was developed to address some of these research gaps in nurse practitioner consultations, particularly with a focus on expectations, satisfaction, and enablement.AimTo explore the influence of pre-consultation expectations, and consultation time length durations on patient satisfaction and enablement in nurse practitioner consultations in primary health care. DESIGN:Survey component of a larger convergent parallel mixed methods case study designed to conjointly investigate the communication processes, social interactions, and measured outcomes of nurse practitioner consultations. The survey element of the case study focusses on investigating patients' pre-consultation expectations and post-consultation patient satisfaction and enablement. METHODS:A questionnaire measuring pre-consultation expectations, and post-consultation satisfaction and enablement, completed by a convenience sample of 71 adults consulting with nurse practitioners at a general practice clinic. Initial fieldwork took place in September 2011 to November 2012, with subsequent follow-up fieldwork in October 2016. RESULTS:Respondents were highly satisfied with their consultations and expressed significantly higher levels of enablement than have been seen in previous studies of enablement with other types of clinicians (P=0.003). A significant, small to moderate, positive correlation of 0.427 (P=0.005) between general satisfaction and enablement was noted. No significant correlation was seen between consultation time lengths and satisfaction or enablement. CONCLUSION:Higher levels of patient enablement and satisfaction are not necessarily determined by the time lengths of consultations, and how consultations are conducted may be more important than their time lengths for optimising patient satisfaction and enablement.
Project description:<h4>Background</h4>Evidence of the beneficial effects of longer consultations in general practice is limited.<h4>Aim</h4>To evaluate the effect of increasing consultation length on patient enablement in general practice in an area of extreme socioeconomic deprivation.<h4>Design of study</h4>Longitudinal study using a 'before and after' design.<h4>Setting</h4>Keppoch Medical Centre in Glasgow, which serves the most deprived practice area in Scotland.<h4>Method</h4>Participants were 300 adult patients at baseline, before the introduction of longer consultations, and 324 at follow-up, more than 1 year after the introduction of longer consultations. The intervention studied was more time in complex consultations. Patient satisfaction, perceptions of the GPs' empathy, GP stress, and patient enablement were collected by face-to-face interview. Additional qualitative data were obtained by individual interviews with the GPs, relating to their perceptions of the impact of the longer consultations.<h4>Results</h4>Response rates of 70% were obtained. Overall, 53% of consultations were complex. GP stress was higher in complex consultations. Patient satisfaction and perception of the GPs' empathy were consistently high. Average consultation length in complex consultations was increased by 2.5 minutes by the intervention. GP stress in consultations was decreased after the introduction of longer consultations, and patient enablement was increased. GPs' views endorsed these findings, with more anticipatory and coordinated care being possible in the longer consultations.<h4>Conclusion</h4>More resource to provide more time in complex consultations in an area of extreme deprivation is associated with an increase in patient enablement.
Project description:BACKGROUND: The Consultation Quality Index (CQI) is a holistic quality marker for GPs based on patient enablement, continuity of the care and consultation length. AIM: To evaluate the CQI-2, a new version of the CQI incorporating a process measure of GP empathy (the Consultation and Relational Empathy Measure). DESIGN OF STUDY: Cross-sectional questionnaire study. SETTING: General practice in the west of Scotland. METHOD: Empathy, enablement, continuity, and consultation length were measured in 3044 consultations involving 26 GPs in 26 different practices in the west of Scotland. CQI-2 scores were calculated and correlated with additional data on GPs' and patients' attitudes. Comparisons were also made with the UK-wide data from which the original CQI had been calculated. RESULTS: CQI-2 scores were independent of deprivation, access, demographics, and case-mix. GPs with lower CQI-2 scores valued empathy and longer consultations less than these GPs with higher CQI-2 scores. 'Below average CQI-2' GPs (those in the bottom 25%) also felt less valued by patients and colleagues. Patients' showed less confidence in and gained less satisfaction from these doctors. Data ranges from the study were comparable with the UK data ranges used to construct the original CQI. CONCLUSIONS: The CQI-2 is a new measure of holistic interpersonal care. In a small but representative sample of GPs it appears to differentiate between below and above average doctors. CQI-2 scores may reflect important aspects of morale, core values and patient-centred care. There may be potential for its use as part of professional development and as a component of the general medical services contract.
Project description:BACKGROUND: Hong Kong (HK) has pluralistic primary care that is provided by a variety of doctors. The aim of our study was to assess patient-reported outcomes of primary care consultations in HK and whether having a family doctor (FD) made any difference. METHODS: We interviewed by telephone 3148 subjects from 5174 contacted households (response rate 60.8%) randomly selected from the general population of HK about the experience of their last primary care consultations in September 2007 and April 2008. We compared the patient-reported outcomes (PRO) and patient-centered process of care in those with a FD, those with other types of regular primary care doctors (ORD) and those without any regular primary care doctor (NRD). PRO included patient enablement, global improvement in health, overall satisfaction, and likelihood of recommending their doctors to family and friends. Patient-centered process of care indicators was explanations about the illness, and address of patient's concerns. RESULTS: One thousand one hundred fifty, 746, and 1157 reported to have FD, ORD, and NRD, respectively. Over 80% of those with FD consulted their usual primary care doctors in the last consultation compared with 27% of those with NRD. Compared with subjects having ORD or NRD, subjects with FD reported being more enabled after the consultation and were more likely to recommend their doctors to family and friends. Subjects with FD and ORD were more likely than those having NRD to report a global improvement in health and satisfaction. FD group was more likely than the other two groups to report receiving an explanation on the diagnosis, nature, and expected course of the illness, and having their concerns addressed. Patient enablement was associated with explanation of diagnosis, nature, and expected course of illness, and address of patient's concerns. CONCLUSION: People with a regular FD were more likely to feel being enabled and to experience patient-centered care in consultations.
Project description:Bedside teaching encounters (BTEs) involve doctor-patient-student interactions, providing opportunities for students to learn with, from and about patients. How the differing concerns of patient care and student education are balanced in situ remains largely unknown and undefined. This video ethnographic study explores patient involvement during a largely student-centric activity: 'feedback sequences' where students learn clinical and practical skills. Drawing on a data subset from a multi-site study, we used Conversation Analysis to investigate verbal and non-verbal interactional practices to examine patients' inclusion and exclusion from teaching activities across 25 BTEs in General Practice and General Surgery and Medicine with 50 participants. Through analysis, we identified two representations of the patient: the patient embodied (where patients are actively involved) and the patient as-a-body (when they are used primarily as a prop for learning). Overall, patients were excluded more during physical examination than talk-based activities. Exclusion occurred through physical positioning of doctor-patient-student, and through doctors and students talking about, rather than to, patients using medical jargon and online commentaries. Patients' exclusion was visibly noticeable through eye gaze: patients' middle-distance gaze coincided with medical terminology or complex wording. Inclusory activities maintained the patient embodied during teaching activities through doctors' skilful embedding of teaching within their care: including vocalising clinical reasoning processes through students, providing patients with a 'warrant to listen', allocating turns-at-talk for them and eye-contact. This study uniquely demonstrates the visible nature patient exclusion, providing firm evidence of how this affects patient empowerment and engagement within educational activities for tomorrow's doctors.
Project description:BACKGROUND:The use of feedback has been integral to medical student learning, but rigorous evidence to evaluate its education effect is limited, especially in the role of patient feedback in clinical teaching and practice improvement. The aim of the Patient Teaching Associate (PTA) Feedback Study was to evaluate whether additional written consumer feedback on patient satisfaction improved consultation skills among medical students and whether multisource feedback (MSF) improved student performance. METHODS:In this single site, double-blinded randomised controlled trial, 71 eligible medical students from two universities in their first clinical year were allocated to intervention or control and followed up for one semester. They participated in five simulated student-led consultations in a teaching clinic with patient volunteers living with chronic illness. Students in the intervention group received additional written feedback on patient satisfaction combined with guided self-reflection. The control group received usual immediate formative multisource feedback from tutors, patients and peers. Student characteristics, baseline patient-rated satisfaction scores and tutor-rated consultation skills were measured. RESULTS:Follow-up assessments were complete in 70 students attending the MSF program. At the final consultation episodes, both groups improved patient-rated rapport (P =?0.002), tutor-rated patient-centeredness and tutor-rated overall consultation skills (P =?0.01). The intervention group showed significantly better tutor-rated patient-centeredness (P =?0.003) comparing with the control group. Distress relief, communication comfort, rapport reported by patients and tutor-rated clinical skills did not differ significantly between the two groups. CONCLUSIONS:The innovative multisource feedback program effectively improved consultation skills in medical students. Structured written consumer feedback combined with guided student reflection further improved patient-centred practice and effectively enhanced the benefit of an MSF model. This strategy might provide a valuable adjunct to communication skills education for medical students. TRIAL REGISTRATION:Australian New Zealand Clinical Trials Registry Number ACTRN12613001055796 .
Project description:OBJECTIVES:Patient-centred care is related to better health outcomes, greater patient satisfaction and reduced healthcare costs. One of the core components of patient-centred care, defined in the patient-centred clinical method, is enhancing the patient-doctor relationship. In this study, we aim to measure the therapeutic alliance in consultations between patients and family doctors in Belgium, and explore which patient, provider and practice characteristics are associated with the strength of the therapeutic alliance. DESIGN:Cross-sectional cohort study using the Working Alliance Inventory for General Practice (WAI-GP). The patients and family doctors completed a survey after the consultation. The survey consisted of the WAI-GP, demographics, consultation characteristics and variables related to the patient-doctor relationship. SETTING:Belgian primary care. PARTICIPANTS:Every third patient (both practice and house call visits) was invited to participate. 170 patient-doctor dyads from four practices were included. Total of 10 doctors (30% men, age range 24-63 years) and 170 patients (35.9% men, age range 18-92 years). PRIMARY AND SECONDARY OUTCOME MEASURES:Primary outcome was the WAI-GP score and its correlations with characteristics of the doctor (gender, age) and patients (gender, age, chronic disease, number of annual consultations). RESULTS:The median WAI-GP score reported after these consultations was 4.5±0.62. Higher WAI-GP scores were reported for consultations with male doctors and by older patients. In the subsample of patients with a chronic illness, higher WAI-GP scores were reported by patients who had more than 10 follow-up consultations per year. CONCLUSIONS:Consultation quality is an important aspect of healthcare, but attention is needed to understand how the WAI-GP performs in relation to variables that are beyond control, such as gender of the physician, age of the patient and variables related to building continuity of care. This has implications for the measurement of quality of healthcare.
Project description:OBJECTIVE: To assess the effect of patient completed agenda forms for the consultation and doctors' education on identifying patients' agendas on the outcome of consultations. DESIGN: Randomised controlled trial. SETTING: General practices in Leicestershire and Nottinghamshire, United Kingdom. PARTICIPANTS: 46 general practitioners and 976 patients. INTERVENTIONS: Education for general practitioners, with an embedded clustered randomised controlled trial of a patient agenda form. MAIN OUTCOME MEASURES: Number of problems identified, time required to manage each problem, duration of consultations, number of problems raised after the doctor considered the consultation finished ("by the way" questions), and patient satisfaction. RESULTS: Data were available from 45 doctors (98%) and 857 patients (88%). The number of problems identified in each consultation increased by 0.2 (95% confidence interval 0.1 to 0.4) with the agenda form, by 0.3 (0.1 to 0.6) with education, and by 0.5 (0.3 to 0.7) with both interventions. The time required to manage each problem was not affected. The duration of consultations with the agenda form was increased by 0.9 minutes (0.3 to 1.5 minutes) and with the combined intervention by 1.9 minutes (1.0 to 2.8 minutes). Patient satisfaction with the depth of the doctor-patient relationship was increased with the agenda form. The occurrence of "by the way" presentations did not change. CONCLUSION: A patient completed agenda form before the consultation or general practitioner education about the agenda form, or both, enabled the identification of more problems in consultations even though consultations were longer.
Project description:OBJECTIVE: To explore whether responses to questions in surveys of patients that purport to assess the performance of general practices or doctors reflect differences between practices, doctors, or the patients themselves. DESIGN: Secondary analysis of data from a study of access to general practice, combining data from a survey of patients with information about practice organisation and doctors consulted, and using multilevel modelling at practice, doctor, and patient level. SETTING: Nine primary care trusts in England. PARTICIPANTS: 4573 patients who consulted 150 different doctors in 27 practices. MAIN OUTCOME MEASURES: Overall satisfaction; experience of wait for an appointment; reported access to care; satisfaction with communication skills. RESULTS: The experience based measure of wait for an appointment was more discriminating between practices (practice level accounted for 20.2% (95% confidence interval 9.1% to 31.3%) of variance) than was the overall satisfaction measure (practice level accounted for 4.6% (1.6% to 7.6%) of variance). Only 6.3% (3.8% to 8.9%) of the variance in the doctors' communication skills measure was due to differences between doctors; 92.4% (88.5% to 96.4%) of the variance occurred at the level of the patient (including differences between patients' perceptions and random variation). At least 79% of the variance on all measures occurred at the level of the patient, and patients' age, sex, ethnicity, and housing and employment status explained some of this variation. However, adjustment for patients' characteristics made very little difference to practices' scores or the ranking of individual practices. CONCLUSIONS: Analyses of surveys of patients should take account of the hierarchical nature of the data by using multilevel models. Measures related to patients' experience discriminate more effectively between practices than do measures of general satisfaction. Surveys of patients' satisfaction fail to distinguish effectively between individual doctors because most of the variation in doctors' reported performance is due to differences between patients and random error rather than differences between doctors. Although patients' reports of satisfaction and experience are systematically related to patients' characteristics such as age and sex, the effect of adjusting practices' scores for the characteristics of their patients is small.
Project description:The objectives of this study were to assess burnout in a sample of general practitioners (GPs), to determine factors associated with depersonalisation and to investigate its impact on doctors' consultations with patients.Cross-sectional, postal survey of GPs using the Maslach Burnout Inventory (MBI). Patient survey and tape-recording of consultations for a subsample of respondents stratified by their MBI scores, gender and duration of General Medical Council registration.UK general practice.GPs within NHS Essex.Scores on MBI subscales (depersonalisation, emotional exhaustion, personal accomplishment); scores on Doctors' Interpersonal Skills Questionnaire and patient-centredness scores attributed to tape-recorded consultations by independent observers.In the postal survey, 564/789 (71%) GPs completed the MBI. High levels of emotional exhaustion (261/564 doctors, 46%) and depersonalisation (237 doctors, 42%) and low levels of personal accomplishment (190 doctors, 34%) were reported. Depersonalisation scores were related to characteristics of the doctor and the practice. Male doctors reported significantly higher (p<0.001) depersonalisation than female doctors. Doctors registered with the General Medical Council under 20 years had significantly higher (p=0.005) depersonalisation scores than those registered for longer. Doctors in group practices had significantly higher (p=0.001) depersonalisation scores than single-handed practitioners. Thirty-eight doctors agreed to complete the patient survey (n=1876 patients) and audio-record consultations (n=760 consultations). Depersonalised doctors were significantly more likely (p=0.03) to consult with patients who reported seeing their 'usual doctor'. There were no significant associations between doctors' depersonalisation and their patient-rated interpersonal skills or observed patient-centredness.This is the largest number of doctors completing the MBI with the highest levels of depersonalisation reported. Despite experiencing substantial depersonalisation, doctors' feelings of burnout were not detected by patients or independent observers. Such levels of burnout are, however, worrying and imply a need for action by doctors themselves, their medical colleagues, professional bodies, healthcare organisations and the Department of Health.