Time to talk? Patient experiences of waiting for clinical management of knee injuries.

BACKGROUND: People with knee problems face long waits for elective surgery in many parts of the world. However, there is little evidence about the impact of delays in such treatment, especially for patients with mechanical knee injuries. OBJECTIVE: To conduct a detailed exploration of patient experiences of waits for specialist diagnosis and surgery for knee injuries at one UK centre. RESEARCH DESIGN: In-depth qualitative paired interviews with a range of patients at baseline and 6 months later. SUBJECTS: Patients awaiting imminent therapeutic arthroscopy of the knee (n = 20) or recently referred from primary care for specialist opinion or imaging for a knee injury (n = 19). Sample stratified to maximise variation by gender and age. RESULTS: 36 patients completed both interviews. Four topic areas were identified. First, problems in the healthcare system were highlighted, including a lack of adequate information, which made it difficult for patients to make decisions about their lives. Second, patients experienced a social and psychological cost of waiting. Third, patients varied in their ability to cope and demonstrated both passive and proactive coping strategies. Fourth, patients described the management effectiveness of clinicians and their ability or otherwise to provide support. CONCLUSIONS: A detailed qualitative approach has identified broad physical and psycho-social consequences for patients with knee injuries experiencing delays in clinical management. An overarching theme was the important potential of both systemic and interpersonal communication to improve patient well-being. A managed care pathway which enhanced information provision may provide immediate opportunities for improving patient well-being.

The development of a new site-specific measure of quality of life for breast problems: the Cardiff breast scales.

The management of women presenting to primary care with symptoms of breast disease is of increasing interest given recent organisational changes aimed at improving accuracy and speed of referrals. As part of a randomised controlled trial, 1063 women were recruited following a primary care consultation for a variety of breast-related problems. In the absence of a suitable outcome measure for such women, a site-specific instrument was developed to complement a generic quality of life scale (SF-36). Items were generated using key informant interviews with health professionals. Draft scale items were piloted using a postal questionnaire and subsequent patient debrief interviews. A sample of respondents were also sent the same questionnaire I month later to assess test-retest reliability. Across the whole sample (n = 848), three factors were identified: 'general well-being', 'concerns' and 'relationships'. These factors accounted for 60% of total variance. Evidence of scale validity, reliability and responsiveness are reported for this new outcome measure for use in women presenting with breast problems.

Professional responses to innovation in clinical method: diabetes care and negotiating skills.

OBJECTIVE: To describe the responses of family doctors and nurses to applying an innovative clinical technique and technology in the context of a randomised controlled trial. DESIGN: Multi-faceted descriptive analysis of professional responses in the experimental arm of the trial. SUBJECTS AND SETTING: 29 family practices involving 30 doctors and 33 nurses over a 3-year time scale and 200 patients with type II diabetes. INTERVENTION: A new visual agenda-setting technology and other visual aids applied using the techniques of negotiation and motivational interviewing. OUTCOME MEASURES: Uptake of training, use of the method, group discussions, willingness to accept consultation recordings. RESULTS: 100% of clinicians welcomed two or more formal training sessions. The agenda-setting technology was used frequently by 71% of clinicians and occasionally by a further 22%. High levels of engagement with the method occurred among nurses but many doctors also reported benefits. CONCLUSIONS: Family doctors and nurses in Wales have found a new technology to facilitate negotiation in diabetes consultation acceptable and useful. Analysis of outcome is now awaited.

Innovation in clinical method: diabetes care and negotiating skills.

The development of a method to facilitate clinical negotiation with diabetic patients is described. The principles of the method incorporate patient centredness, an assessment of readiness to change and some elements of motivational interviewing. A simple low cost technology is part of the innovative method. Details of the method and its application are published before the results of a randomized controlled trial to ensure that the techniques are in the public domain before the outcome of the trial is known.

An unwelcome visitor? The opinions of mothers involved in a community-based undergraduate teaching project.

This paper describes the family case study, a community-based project for Cardiff medical students involving them in self-directed learning. A comparison is made (using self-administered questionnaires) between the opinions of mothers and students who participated in the 1990/91 project. The results indicate that mothers recruited to the study tended to come from the middle classes and be in stable relationships. The vast majority found participation in the study to be an enjoyable experience. This contrasts sharply with the opinions of students who often expressed concerns about imposing on their families. The study demonstrated that most students were able to pace their self-directed learning by visiting their families on a regular basis. The majority obtained 'hands-on' experience of the baby's development and, according to the mothers, improved in competence as a result. The high maternal response rate and the quality of the answers have prompted the authors to consider whether mothers could be more involved in teaching and assessment of medical students in the future.

'Advise yes, dictate no'. Patients' views on health promotion in the consultation.

Interviews with 130 mothers of lower social class provided the basis for studying their views on the desirability of general practitioner intervention in their lifestyle habits; the study used both quantitative (questionnaire) and qualitative (interview) techniques. The majority of women were in favour of counselling on specific topics by the general practitioner but the qualitative data also revealed that most respondents expected the issues to be relevant to their presenting problem. Moreover they were keen to assert their right to accept or reject the advice given. The same picture was obtained whether specific or general approaches were used. The results highlight the need for qualitative methods to amplify and clarify the results of quantitative techniques when views or attitudes are being explored. The practical implications of the conclusions touch on both the ethical and clinical dimensions of health promotion.

Opportunistic health promotion: quantity or quality?

A cohort of 130 working class mothers has been studied in depth over five years to quantify the extent of recording and counselling of lifestyle problems by general practitioners and their staff. Clinical records and mothers' personal accounts at two home interviews five years apart provide the data for this work. Fifty-nine per cent of women had one or more aspects of lifestyle recorded in their records, the commonest being smoking habits. Despite this evidence for good coverage of smokers in the population, alcohol and exercise problems were under-recorded. Clinical records only included details of advice given and follow-up plans for lifestyle problems in 40% of patients' records yet the women themselves remembered advice being given in 48% of cases. An analysis of the womens' accounts in conjunction with the clinical records revealed that over three quarters of those receiving advice remembered it several years later. The primary care team was most likely to target advice and plans on women who were heavy smokers and very obese. This study shows that clinical records underestimate the amount of lifestyle counselling which is conducted in general practice and that a surprising number of working class women remember and act on the advice from their doctors. The implications for clinical recording of lifestyle factors are discussed.

Health promotion and the human response to loss: clinical implications of a decade of primary health care research.

Ten years ago an academic group was established in Cardiff to determine why the public make life-style choices which are known to have an adverse impact on health and also to develop methods of measurement which describe trends in positive health motivation (salience) in the community. Three stages of this research are described in this paper and the results reveal a complex and fascinating set of human beliefs, attitudes and behaviours. Concern for health was not a consistent human characteristic and there was little evidence for the existence of a general preventive orientation in the cohorts studied. Discrepancies between expressed health beliefs/attitudes and behaviours are more explicable when the reality of ambiguity and paradox is recognized in human responses. Human responses to loss (grief) may have similarities to the respondents' experiences when facing a possible change of life-style for health reasons. The practical implications for primary care professionals are discussed.