Family Practice Vol. 16, No. 6, 562-565
© Oxford University Press 1999
How should patients consult? A study of the differences in viewpoint between doctors and patients
St Thomas Medical Group, Cowick Street, Exeter EX4 1HJ, UK.
Kernick DP, Reinhold DM and Mitchell A. How should patients consult? A study of the differences in viewpoint between doctors and patients. Family Practice 1999; 16: 562–565.
Received 16 November 1998; Revised 7 June 1999; Accepted 25 June 1999.
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Abstract |
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Background. Increasing pressure on limited NHS resources has led to the introduction in primary care of a skill mix which seeks to match clinical presentation to an intervention based on skills and training. There has also been increasing emphasis on the use of telephone consultations. However, outcomes on the benefits of these different approaches may be difficult to obtain and process variables such as the views of patients may be important.
Objective. The objective of the study was to answer the following questions (i) how many existing GP consultations do doctors and patients assess as being suitable for consultation with a specially trained nurse or for telephone advice from a doctor?; (ii) do doctors and patients share similar views on the suitability of individual cases?; and (iii) do these assessments differ between acute, chronic and urgent cases?
Method. A sample of 750 patients comprising of 150 patients attending for booked consultation with each of five doctors were interviewed prior to the consultation and asked whether they would be happy to see a specially trained practice nurse or if their problem could be dealt with by a doctor on the telephone. For each case the GP gave his response. A similar study was undertaken with 150 ‘extras' patients who needed to be seen urgently and who could not wait for an appointment the following day. The viewpoint of the GP was compared with that of the patient.
Results. GPs felt that 20% of all booked cases could be seen by a nurse compared with the patients' assessment of 29%. These figures were higher for acute booked cases (30 and 34%) and for urgent extras (44 and 58%). There was a poor agreement between the viewpoints of doctor and patient especially for chronic booked cases although this agreement increased with the more acute presentations. The number of cases that could be dealt with on the telephone ranged from 5 to 9% with poor agreement between doctor and patient.
Conclusion. This study extends the findings of a number of others which indicate that patients can be seen satisfactorily by nurses, and that both doctors and patients see scope for increasing the number of consultations dealt with by nurses. Booked patients with chronic presentations and urgent extras are more likely than their doctors to think that they could be dealt with by the nurse. This may be due to a difference in perspective between doctors and patients about the outcome they hope to achieve in the consultation. Further qualitative work is needed to explore these differences and to clarify the best approach to this expanding area.
Keywords. Consultation, general practice, nurse, patients' views, telephone..
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Introduction |
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A commitment to a primary care-led NHS based on teamwork between health professionals1 has resulted in a move towards the delivery of care by a multi-disciplinary team in which the nurse is seen as a core member. Since the introduction of the 1990 contract there has been a rapid expansion in the number of nurses in general practice who provide a wide range of services. The concept of skill mix seeks to match clinical presentation to an intervention based on skill and training2 and it has been suggested that 30–70% of all tasks performed by doctors could be carried out satisfactorily by nurses with significant implications for medical manpower.3
A second changing pattern highlighted by the development of out-of-hours co-operatives has been the increasing use of telephone access to practitioners. In a review of 67 co-operatives, Jessupp4 found that 38% of all consultations were managed by telephone advice. Although patients approve of telephone access to GPs5 and there is no evidence that additional workload is generated,6 this area of access remains underutilized.
In this study we explore the differences between the viewpoints of doctors and patients with the aim of answering the following questions:
- How many existing GP consultations do doctors and patients assess as being suitable for consultation with a specially trained nurse or for telephone advice?
- Do doctors and patients share similar views on the suitability of individual cases?
- Do these assessments differ between acute, chronic and urgent cases?
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Method |
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Five GPs from a single practice took part in the study. For each GP, 150 patients attending for booked consultation were interviewed in the waiting room by a research assistant prior to seeing the doctor. No patients refused to answer the questionnaire. The interviews were spread across the working day to avoid any time bias. For each presentation, patients were asked whether they would be happy to see a specially trained nurse who could issue a limited number of prescriptions such as antibiotics, painkillers and anti-inflammatory drugs, would have been happy to speak to the doctor on the telephone or felt that they needed to see the doctor. For each case, the GP gave their views on a similar questionnaire completed after each consultation. In addition, the GP described the consultation as acute (a new presentation of 5 or less days duration) or chronic. A similar study was undertaken on 150 ‘extras’—patients seen at the end of evening surgery who felt that their condition could not wait until the next day.
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Analysis |
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The distribution of variables across the five samples are given as means ± one standard deviation. As each doctor saw a different proportion of acute and chronic cases, distributions are given as percentages of total patients seen and not number of cases. Differences between and within groups were tested using a Student's two-tailed t- or chi-square test.
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Results |
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For all cases, the doctor felt that 5.1 (±3.2) % of cases could be dealt with over the telephone compared with 5.8 (±4.2) % of the patients. There was little agreement as to which cases were most suitable, but as these numbers were small, further analysis was not undertaken.
Table 1
shows the doctors' and patients' views of the cases that could be seen by the nurse. For all GP-booked cases, the doctor felt that 20.3 (±8.8) % were suitable compared with the patients' view of 29.3 (±7.6) %.
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When booked cases were broken down into chronic and acute presentation, analysis between groups showed a significant difference between doctors' and patients' views of suitability to be seen by the nurse for chronic but not acute cases. 27.7 (±9.5) % of patients with chronic presentations felt that they could have been seen by the nurse compared with only 10.2 (±6.0) % of the doctors' assessments (P < 0.05).
Analysis within groups showed that doctors felt that more acute than chronic cases could be seen by the nurse. Doctors felt that 29.8 (±10.9) % of acute cases could be seen by the nurse compared with 10.2 (±6.0) % of chronic booked cases (P < 0.002). There was no significant difference in the proportion of acute and chronic cases patients felt could be seen by the nurse.
Presentations thought most suitable for nurse consultation by both parties were urgent extras, but the patients thought that significantly more urgent cases were relevant for nurse consultation (P < 0.002), 58% from the patients' and 44% from the doctors' perspective.
Table 2 shows that there is poor agreement between the opinions of doctor and patient as to the suitability of each case. For all booked appointments, the doctor agreed with the patients' assessment in 40.0 (±10.9) % of cases and the patient with the doctor in 28.2 (±10.2).
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The differences were most striking for chronic booked cases where only 14.3 (±10.3) % of patients were in agreement with the doctor.
For urgent extras there was a much higher agreement of 71 and 59% from the doctors' and patients' perspectives, respectively.
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Discussion |
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We sought to identify possible differences between the perspectives of doctors and patients when offered theoretical alternative forms of consultation. We found that 20% of all consultations were felt suitable by the doctor for delegation. This compares with 42% in a study of 836 consultations by Jenkins Clark.7 The reasons for this difference are not clear but may include differences in case mix and doctors' viewpoints based on their previous experience.
We found wide divergence of opinion between both parties, but the number of cases thought to be suitable for nurse consultation and agreement between parties was greater for more urgent cases. As case mix across the practice is equal, the variation between doctors (the number of all booked cases judged to be suitable for nurse consultation ranged between 7 and 29%) probably reflects the particular style and approach of individual doctors.
The problems inherent in a study of this nature are well recognized. How questions are framed can affect the response obtained and often represent the compilers' opinions and perceptions and not those of the patients.8 When prompted by researchers, GPs identify more delegation than when compiling diaries themselves.9 A further limitation of the current study is that for practical reasons, the patients' views were sought before the consultation and the doctors' views afterwards. Their experience of the consultation may have led the patients to have answered differently.
Local precedent and the context of patients' previous experience may also influence results. For example, the low uptake of the telephone advice option does not concur with other studies from settings where the use of the telephone is more prevalent. Brown6 found that in his practice 53% of patients used the telephone as an alternative to making an appointment, while Gallagher10 showed that 26% of urgent requests to see the doctor could be dealt with satisfactorily by the nurse on the telephone. Despite these reservations, our findings reflect those of other studies which suggest that doctors and patients differ over the aspects of care that they consider important.11 Why should this be?
It is not surprising that the viewpoints of doctors and patients vary widely when over 50% of patients' problems are not elicited and in 50% of consultations, patient and doctor do not agree on the main problem.12 St Claire13 concluded that doctors and patients construe health differently and consequently have different objectives for health care behaviour. These differences help explain why patients adopt patterns which diverge from the professional's perspective.
Overall, doctors tend to focus on the technical aspects of care while patients are more concerned with broad psychosocial issues.14,15 Patients, especially those with chronic conditions, place greater emphasis than doctors on the quality of the therapeutic relationship (empathy, respect and understanding), communication (especially information and explanation), and provision of self-help advice.16 Doctors may misunderstand what patients want which may only partly overlap with that which doctors aim to achieve. If patients perceive that these outcomes are more likely to be achieved through nurse rather than doctor consultations, then this may go some way towards explaining the differences in views found in this study.
Greenhaugh has highlighted the gap between patients' and doctors' narratives about health and illness.17 Doctors' narratives centre around disease and its cure through the application of scientific medicine. Studies suggest that for lay people, health is seen as independent of disease and illness and has meaning in terms of feelings and capacities involving activities and other people.18 Psychological and epidemiological research indicates that health is largely determined by social support and social power.19 Patients may be seeking support and empowerment through medical consultations more than their doctors realize, and nurses place a higher value than do doctors on the ‘caring’ perspective which involves responsiveness to patients' wishes.20
Further studies could investigate the extent to which different practitioners achieve the outcomes which patients with acute and chronic presentations wish to achieve. Such studies may help to bridge the gap between doctors' disease-category narratives and patients' complex narratives about illness and health.
Difficulties with the measurement of outcomes—towards a patient-centred approach?
Traditionally, health outcomes have concentrated on morbidity and mortality but with the development of a broader concept of health, there has been an emphasis on other domains such as quality of life and from the perspectives of not only the patient but also carers and family, and different problems may have different outcomes.21 The identification and attribution of outcomes will be a major difficulty when comparing the effectiveness of the nurse specialist with the doctor.
McWhinney22 has outlined an approach to the consultation in which the central issue is the involvement of the patient in the process of care and the integration of perspectives of both doctor and patient towards a common goal. Brooks23 has emphasized the importance of delivering primary care from a system based on personal responsibility, patient participation and co-active teamwork.
Patients' views correlate well with other independent measures of doctors' personal skills, communication style and technical proficiency.24 In a recent study of consultations with nurse practitioners it was found that patients could safely and effectively ‘self triage’ themselves between GP and nurse with no difference in the outcomes that were measured.25 Prescribing studies have also indicated that patients have more insight into their needs than their doctors give them credit for.26
Patients' beliefs of the causes of their symptoms and their doctor's ability to alleviate them are the major determinants of consultation satisfaction, compliance with treatment and ultimately outcome.9 Patients themselves may be in a position to make adequate and valid judgements about the way their care is delivered.
Qualitative research may help to explore the different perspectives and clarify the best approach to doctor/nurse skill mix. But until the picture is clearer rather than chasing the end of the outcomes rainbow with experimental studies of doubtful relevance which themselves have significant resource implications, the best option when considering skill mix in primary care may be to give our patients the choice and let them vote with their feet.
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Acknowledgments |
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The study was funded with a grant from Bristol Myers Squibb College. St Thomas Medical Group is a research practice and receives funding from the South & West NHS Research & Development Executive. The views expressed are those of the authors and not necessarily the NHS Research and Development Executive.
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References |
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1 NHS Executive. Priorities and Planning—Guidance for the NHS. 1997/8. NHS Executive, 1996.
2 Rashid A, Watts A, Leneham C. Skill mix in primary care: sharing clinical workload and understanding professional roles. Br J Gen Pract 1996; 6: 639–640.
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Jessupp L, Beck I, Hollins L et al. Changing the pattern out of hours: a survey of general practice co-operatives. Br Med J 1997; 314: 199–200.
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