Jan-Joost E Rethans

Quality of clinical aspects of call handling at Dutch out of hours centres : cross sectional national study

Objective To assess the quality of telephone triage by following the consecutive phases of its care process and the quality of the clinical questions asked about the patient’s clinical condition, of the triage outcome, of the content of the home management advice, and of the safety net advice given at out of hours centres. Design Cross sectional national study using telephone incognito standardised patients. Setting The Netherlands. Participants 17 out of hours centres. Main outcome measures Percentages of clinical obligatory questions asked and items within home management and safety net advice, both in relation to pre-agreed standards, and of care advice given in relation to the required care advice. Results The telephone incognito standardised patients presented seven clinical cases three times each over a period of 12 months, making a total of 357 calls. The mean percentage of obligatory questions asked compared with the standard was 21%. Answers to questions about the clinical condition were not always correctly evaluated from a clinical viewpoint, either by triagists or by general practitioners. The quality of information on home management and safety net advice varied, but it was consistently poor for all cases and for all out of hours centres. Triagists achieved the appropriate triage outcome in 58% of calls. Conclusion In determining the outcome of the care process, triagists often reached a conclusion after asking a minimal number of questions. By analysing the quality of different phases within the process of telephone triage, evaluation of whether an appropriate triage outcome has been arrived at by means of good clinical reasoning or by an educated guess is possible. In terms of enhancing the overall clinical safety of telephone triage, apart from obtaining an appropriate clinical history, adequate home management and safety net advice must also be given.

Do personal computers make doctors less personal

Ten months after the installation of a computer in a general practice surgery a postal survey (piloted questionnaire) was sent to 390 patients. The patients views of their relationship with their doctor after the computer was introduced were compared with their view of their relationship before the installation of the computer. More than 96% of the patients (n=263) stated that contact with their doctor was as easy and as personal as before. Most stated that the computer did not influence the duration of the consultation. Eighty one patients (30%) stated, however, that they thought that their privacy was reduced. Unlike studies of patients attitudes performed before any actual experience of use of a computer in general practice, this study found that patients have little difficulty in accepting the presence of a computer in the consultation room. Nevertheless, doctors should inform their patients about any connections between their computer and other, external computers to allay fears about a decrease in privacy.

Quality of communication during telephone triage at Dutch out-of-hours centres

OBJECTIVEnTo assess the quality of communication skills of triagists, working at out-of-hours (OOH) centres, and to determine the correlation between the communication score and the duration of the telephone consultation.nnnMETHODSnTelephone incognito standardised patients (TISPs) called 17 OOH centres presenting different clinical cases. The assessment of communication skills was carried out using the RICE-communication rating list. The duration of each telephone consultation was determined.nnnRESULTSnThe mean overall score for communication skills was 35% of the maximum feasible. Triagists usually asked questions about the clinical situation correctly and little about the patients personal situation, perception of the problem or expectation. Advice about the outcome of triage and self-care advice was usually given without checking for patients understanding and acceptance of the advice. Calls were often handled in an unstructured way, without summarizing or clarifying the different steps within the consultation. There was a positive correlation of 0.86 (p<0.01) between the overall communication score and the duration of the telephone consultation.nnnCONCLUSIONnAssessment of communication skills of triagists revealed specific shortcomings and learning points to improve the quality of communication skills during telephone triage.nnnPRACTICE IMPLICATIONSnTraining in telephone consultation should focus more on patient-centred communication with active listening, active advising and structuring the call. Apart from adequate communication skills, triagists need sufficient time for telephone consultation to enable high quality performance.

Do general practitioners act consistently in real practice when they meet the same patient twice? examination of intradoctor variation using standardised (simulated) patients

Abstract Objective: To assess the variation within individual general practitioners facing the same problem twice in actual practice under unbiased conditions. Design: General practitioners were consulted during normal surgery hours by a standardised patient portraying a patient with angina pectoris. Six weeks later the same general practitioners were consulted again by a similar standardised patient portraying a similar case. The patients reported on the consultations. Setting: Trondheim, Norway. Subjects: Of 87 general practitioners invited by letter, 28 (32%) agreed to participate without hesitation; nine others (10%) wanted more information before consenting. From these 24 were selected and visited. Main outcome measures: Number of actions undertaken from a guideline in both rounds of consultations. Duration of consultations. Results: The mean (range, interquartile range) guideline score, total score, and duration of consultation were not significantly different between the first and second patient encounters for the group as a whole. For individual doctors the mean (SD) difference was −0.09 (3.36) for the guideline score, 0.30 (8.1) for the total score, and −0.87 (9.01) for consultation time. Conclusions: The study shows that assessment of performance in real practice for a group of general practitioners is consistent from the first round of consultations to the second round. However, significant variation occurs in performance of individual physicians.

Controlled trial of effect of computer-based nutrition course on knowledge and practice of general practitioner trainees

BACKGROUNDnNutrition education is not an integral part of either undergraduate or postgraduate medical education. Computer-based instruction on nutrition might be an attractive and appropriate tool to fill this gap.nnnOBJECTIVEnThe study objective was to assess the degree to which computer-based instruction on nutrition improves factual knowledge and practice behavior of general practitioner (GP) trainees.nnnDESIGNnWe carried out a controlled experimental study, using a 79-item knowledge test and 3 incognito standardized patients visits in a pre- and posttest design with 49 first-year GP trainees. The experimental group (n = 25) received an average of 6 h of a newly developed computer-based instruction on nutrition. The control subjects (n = 24) took the standard vocational training program.nnnRESULTSnThe percentage of correct answers on the knowledge test increased from 30% at pretest to 42% at posttest in the experimental group, and from 36% to 37% in the control group. Analysis of covariance, with the pretest scores as covariate, showed a significant experimental versus control group difference at posttest: 9.2% (P = 0.002). The mean percentage of correctly performed items during the 3 standardized patients visits (assessed by checklists) showed an increase in the experimental group from 20% at pretest to 36% at posttest, whereas the control group changed from 20% to 22%. Analysis of covariance, with the pretest scores as covariate, revealed a significant group difference at posttest: 13.7% (P < 0.001).nnnCONCLUSIONnThe computer-based instruction proved its effectiveness, both by increasing factual knowledge and by substantially enhancing GP trainees practice behavior on the subject of nutrition.

Fielding incognito standardised patients as 'known' patients in a controlled trial in general practice.

Backgroundu2002 Incognito standardised patients (SPs) have only been used to represent new patients so far. The few trials with incognito SPs provide little detail on the method used for fielding them.