Educational/counselling model health careSoliciting additional concerns in the primary care consultation and the utility of a brief communication intervention to aid solicitation: A qualitative study
Introduction
Primary care is generally patients’ first point of call [1]. Demand for general practice in countries like the United Kingdom is increasing, with 40 million more consultations in 2014 than in 2008/09 [2]. Although patients typically attend GP appointments with multiple concerns [3], [4], [5], British GP consultations are time-limited; often scheduled to last for approximately 10 minutes [6]. In this time-restricted context, patients do not raise all of their concerns at the outset of their appointment, instead presenting their further concerns towards the consultation’s close [4]. Where new concerns are raised late in the consultation, there may not be time to adequately address them.
Soliciting additional concerns (ACs) towards the beginning of the consultation has been recommended [7], [8]. Previous research, however, suggests such solicitations occur in only a minority of consultations [9], and where attempted, is usually towards the close of the consultation, once the presenting concern has been addressed [4], [10]. This may mean a number of patients leave with unvoiced ACs [10], [11], [12], although prevalence estimates range widely from 20–89% of consultations [10], [13].
Late-arising and unvoiced ACs can prevent GPs and patients prioritising important issues for discussion. This is particularly important since time restrictions may prevent the full management of multiple concerns [5]. Conversely, successfully soliciting ACs may facilitate early identification of serious problems, reduce patient anxiety, decrease the need for unnecessary intervention, and potentially increase patient satisfaction [14], [15], [16].
Linguistics research suggests the phrasing of AC solicitations may influence a patient’s response [17], [18], [19]. When incorporated into a solicitation, certain words appear more likely to occasion particular responses. Some words tend to occasion confirmation and others disconfirmation; these words are described as having positive or negative polarity, respectively. In a US study, Heritage et al [20]. tested the effect of using ‘some’, which has positive polarity, and ‘any’, which has negative polarity [21], on concern disclosure within primary care consultations for acute medical conditions. In one intervention arm GPs asked patients “Is there anything else you want to address in the visit today?”; in the other, GPs asked patients “Is there something else you want to address in the visit today?” [20. P1429]. In both arms, the GPs asked the question immediately after the patient had presented their initial concern(s).
Heritage et al [20]. found AC solicitations using ‘some’ reduced the number of patients leaving with unvoiced concerns by 78%. Although these results are promising, a similar study was needed to explore the utility of this communication intervention in a UK setting [20]; as consultation length and the types of issues discussed vary between countries and health care systems [6], [22], with some suggestion that psychosocial issues are more often solicited in fee-payer-provided systems in comparison to gate-keeper systems [22]. This study reports qualitative findings from a UK-based ‘Eliciting patient concerns’ (EPaC) study. This mixed-methods feasibility study was informed by the US study [20], but differed through inclusion of a third control arm and including patients attending for both acute and routine appointments. The qualitative study reported here explored GP perspectives on the practice of soliciting additional concerns (ACs) and the acceptability and utility of the brief communication interventions (prompts).
Section snippets
Study design and setting
Embedding qualitative research in trials is an established approach for understanding the intervention process and the scope for integrating interventions into routine practice [23]. Qualitative interviews provide access to GPs’ views on their study involvement [24], the soliciting ACs within the GP consultation and the utility of the communication interventions. The study was undertaken from a subtle realist position [25]. It sought a truthful account of the topic whilst recognising that the
Data organisation
Data were organised into four themes (Table 4). Themes 1 and 2, which relate to perspectives on AC and intervention utility are reported here; themes 3 and 4 (trial processes/experience) will be reported elsewhere.
Theme 1: perspectives on eliciting ACs
GPs described their views on the soliciting ACs within consultations, following participation in the trial. Data were organised into three subthemes: ‘the importance of ACs within consultations’, ‘approaches to eliciting ACs’ and ‘influences on the solicitation of ACs’.
Discussion
This paper reports novel findings exploring GP perspectives of soliciting ACs and the utility of an intervention to reduce unvoiced patient concerns. A number of studies have surveyed doctors’ views or explored solicitation practices observationally within GP-patient consultations [3], [4], [10], [15], [32], [33], but little research has explored doctors’ experiences of, and perspectives on, soliciting ACs. This study used semi-structured interviews to provide deeper insights into GP views on
Conflict of interests
None.
Acknowledgements
The authors would like to acknowledge: the EPaC project was part funded by the National Institute for Health Research (NIHR) School for Primary Care Research and part funded by the University of Southampton, Faculty of Medicine. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Our thanks to:
the NIHR Personal Fellowship Scheme for funding Dr Geraldine Leydon; the practice staff, GPs and patients for participating in the
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