John Holden

International variations in primary care physician consultation time: a systematic review of 67 countries

Objective To describe the average primary care physician consultation length in economically developed and low-income/middle-income countries, and to examine the relationship between consultation length and organisational-level economic, and health outcomes. Design and outcome measures This is a systematic review of published and grey literature in English, Chinese, Japanese, Spanish, Portuguese and Russian languages from 1946 to 2016, for articles reporting on primary care physician consultation lengths. Data were extracted and analysed for quality, and linear regression models were constructed to examine the relationship between consultation length and health service outcomes. Results One hundred and seventy nine studies were identified from 111 publications covering 28 570 712 consultations in 67 countries. Average consultation length differed across the world, ranging from 48 s in Bangladesh to 22.5 min in Sweden. We found that 18 countries representing about 50% of the global population spend 5 min or less with their primary care physicians. We also found significant associations between consultation length and healthcare spending per capita, admissions to hospital with ambulatory sensitive conditions such as diabetes, primary care physician density, physician efficiency and physician satisfaction. Conclusion There are international variations in consultation length, and it is concerning that a large proportion of the global population have only a few minutes with their primary care physicians. Such a short consultation length is likely to adversely affect patient healthcare and physician workload and stress.

Diagnostic uncertainty in general practice: A unique opportunity for research?

General practice encounters often involve vague symptoms, potentially representing illness in its early stage. Managing such undifferentiated symptoms is difficult, but one of the key tasks of the general practitioner is to discover serious disease at an appropriate stage whilst also minimising over-investigation. Although the diagnostic process and methods of coping with uncertainty in general practice have been described, the early course of disease, especially undifferentiated presentations, is poorly understood. There is still much to learn about diagnosis in general practice, and important contributions could be made by researchers in any primary care setting.

Which cuff should I use? Indirect blood pressure measurement for the diagnosis of hypertension in patients with obesity: a diagnostic accuracy review

Objective To determine the diagnostic accuracy of different methods of blood pressure (BP) measurement compared with reference standards for the diagnosis of hypertension in patients with obesity with a large arm circumference. Design Systematic review with meta-analysis with hierarchical summary receiver operating characteristic models. Bland-Altman analyses where individual patient data were available. Methodological quality appraised using Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS2) criteria. Data sources MEDLINE, EMBASE, Cochrane, DARE, Medion and Trip databases were searched. Eligibility criteria Cross-sectional, randomised and cohort studies of diagnostic test accuracy that compared any non-invasive BP tests (upper arm, forearm, wrist, finger) with an appropriate reference standard (invasive BP, correctly fitting upper arm cuff, ambulatory BP monitoring) in primary care were included. Results 4037 potentially relevant papers were identified. 20 studies involving 26 different comparisons met the inclusion criteria. Individual patient data were available from 4 studies. No studies satisfied all QUADAS2 criteria. Compared with the reference test of invasive BP, a correctly fitting upper arm BP cuff had a sensitivity of 0.87 (0.79 to 0.93) and a specificity of 0.85 (0.64 to 0.95); insufficient evidence was available for other comparisons to invasive BP. Compared with the reference test of a correctly fitting upper arm cuff, BP measurement at the wrist had a sensitivity of 0.92 (0.64 to 0.99) and a specificity of 0.92 (0.85 to 0.87). Measurement with an incorrectly fitting standard cuff had a sensitivity of 0.73 (0.67 to 0.78) and a specificity of 0.76 (0.69 to 0.82). Measurement at the forearm had a sensitivity of 0.84 (0.71 to 0.92) and a specificity 0.75 of (0.66 to 0.83). Bland-Altman analysis of individual patient data from 3 studies comparing wrist and upper arm BP showed a mean difference of 0.46 mm Hg for systolic BP measurement and 2.2 mm Hg for diastolic BP measurement. Conclusions BP measurement with a correctly fitting upper arm cuff is sufficiently sensitive and specific to diagnose hypertension in patients with obesity with a large upper arm circumference. If a correctly fitting upper arm cuff cannot be applied, an incorrectly fitting standard size cuff should not be used and BP measurement at the wrist should be considered.

The time-efficiency principle: time as the key diagnostic strategy in primary care

The test and retest opportunity afforded by reviewing a patient over time substantially increases the total gain in certainty when making a diagnosis in low-prevalence settings (the time-efficiency principle). This approach safely and efficiently reduces the number of patients who need to be formally tested in order to make a correct diagnosis for a person. Time, in terms of observed disease trajectory, provides a vital mechanism for achieving this task. It remains the best strategy for delivering near-optimal diagnoses in low-prevalence settings and should be used to its full advantage.

Writing therapy: a new tool for general practice?

> ‘I hear and I forget, I see and I remember, I write and I understand.’ Chinese Proverb Disclosure in the form of the spoken word has long been considered beneficial and widely used in counselling and other therapies. Self-inhibition of negative emotions is thought to lead to continuous autonomic arousal and poorer health.1 Writing therapy, otherwise described in the literature as ‘expressive (emotional) disclosure’, ‘expressive writing’, or ’written disclosure therapy’ may have the potential to heal mentally and physically. In early experiments, participants wrote about their most traumatic thoughts and feelings related to a stressful event for up to 20 minutes over three or four writing sessions. To isolate any non-specific beneficial effect from participating in studies, control groups wrote about superficial non-emotive topics. The experimental group observed better physical health, improved immune system functioning, and fewer days off due to illness. This formed the basis of subsequent studies into writing therapy. How writing potentially brings about health benefits is unknown and the underlying mechanism is likely to be complex and multifactorial. One theory is that of emotional catharsis whereby the mere act of disclosure, essentially ‘getting it off your chest’ is a powerful therapeutic agent in itself.2 Writing may facilitate cognitive processing of traumatic memories, resulting in more adaptive, integrated representations about the writer themselves, their world, and others.3 It is also possible that development of a coherent narrative over time results in ongoing processing and finding meaning in the traumatic experience.4 Writing therapy could potentially be a cheap and easily accessible option that would require minimal input from healthcare professionals. We wondered whether it could be an effective alternative form of therapy in general practice, since access to psychological therapies in primary care can often be slow or limited, much to the frustration of …

Presentation and outcome of clinical poor performance in one health district over a 5-year period: 2002–2007

BACKGROUND The detection, assessment, and management of primary care poor performance raise difficult issues for all those involved. Guidance has largely focused on managing the most serious cases where patient safety is severely compromised. The management of primary care poor performance has become an increasingly important part of primary care trust (PCT) work, but its modes of presentation and prevalence are not well known. AIM To report the prevalence, presentation modes, and management of primary care poor performance cases presenting to one PCT over a 5-year period. DESIGN OF STUDY A retrospective review of primary care poor performance cases in one district. SETTING St Helens PCT administered 35 practices with 130 GPs on the performers list, caring for 190 110 patients in North West England, UK. METHOD Cases presenting during 2002-2007 were initially reviewed by the chair of the PCT clinical executive committee. Anonymised data were then jointly reviewed by the assessor and another experienced GP advisor. RESULTS There were 102 individual presentations (20 per year or one every 2-3 weeks) where clinician performance raised significant cause for concern occurred over the 5-year period. These concerns related to 37 individual clinicians, a range of 1-14 per clinician (mean 2.7). Whistleblowing by professional colleagues on 43 occasions was the most common presentation, of which 26 were from GPs about GPs. Patient complaints (18) were the second most common presentation. Twenty-seven clinicians were GPs, of whom the General Medical Council (GMC) were notified or involved in 13 cases. Clinicians were supported locally, and remedying was exclusively locally managed in 14 cases, and shared with an external organisation (such as the GMC or deanery) in another 12. CONCLUSION Professional whistleblowing and patient complaints were the most common sources of presentation. Effective PCT teams are needed to manage clinicians whose performance gives cause for concern. Sufficient resources and both formal and informal ways of reporting concerns are essential.

Isolation and insight: practical pillars of revalidation?

The imminent introduction of revalidation, ‘the process by which doctors will, in future, demonstrate to the General Medical Council (GMC) on a regular basis that they remain up to date and fit to practise’,1 obliges us to ask what guiding principles should be addressed as we implement revalidation? Seven years ago Good Medical Practice (GMP) for GPs stated, ‘the unacceptable GP has little knowledge of developments in clinical practice; has limited insight into the current state of his or her knowledge or performance; selects educational opportunities which do not reflect his or her learning needs; does not audit care in his or her practice, or does not feed it back into practice,’ and ‘is hostile to external audit or advice.’2,3 The five characteristics of the acceptable GP are the converse of the unacceptable one, but in our experience are not applicable to the complete breadth of a doctors work. As we have assessed GPs whose performance has raised serious concerns4 we have found repeatedly that basic failures in diagnosis, poor management and haphazard follow-up are clear to assessors. It is clear that such doctors lack insight into their deficiencies and …

Calling time on the 10-minute consultation

In their editorial, Silverman and Kinnersley present a strong case for moving on from the 10-minute consultation.1 In 2011 an electronic ‘consultation length’ survey of all UK GP trainees (ST1–ST4) was undertaken by the RCGP Associates in Training committee. One of the key questions within the electronic survey was, ‘what consultation length does your trainer offer for routine booked appointments?’ …

Saying sorry is not the same as admitting legal liability

According to Minerva,1 the Canadian Medical Protective Association advises: “an admission of error made during an apology could be admissible during subsequent legal proceedings.” But doctors apologising after mistakes in the United Kingdom can rest assured that saying sorry is …

Don't shoot the messenger: the problem of whistleblowing in general practice.

We agree that there are unique problems for GPs in whistleblowing.1 However, over 5 years we found whistleblowing on 43 occasions …