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Biomedical subjects

F A Stevenson

Publications and source records attributed to F A Stevenson.

10 recordsLinked to original sources
PubMed2001

Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor-patient communication in general practice.

Mishler (The discourse of medicine. The dialectics of medical interviews. Norwood, NJ: Ablex), applying Habermas's theory of Communicative Action to medical encounters. showed how the struggle between the voice of medicine and the voice of the lifeworld fragmented and suppressed patients' multi-faceted, contextualised and meaningful accounts. This paper investigates and critiques Mishler's premise that this results in inhumane, ineffective medical care. Using a more complex data collection strategy, comprising patient interviews, doctor interviews and transcribed consultations we show more complex relations than emerged from Mishler's analysis. We found four communication patterns across 35 general practice case studies. When doctor and patient both used the voice of medicine exclusively (acute physical complaints) this worked for simple unitary problems (Strictly Medicine). When both doctor and patient engaged with the lifeworld, more of the agenda was voiced (Mutual Lifeworld) and patients were recognised as unique human beings (psychological plus physical problems). Poorest outcomes occurred where patients used the voice of the lifeworld but were ignored (Lifeworld Ignored) or blocked (Lifeworld Blocked) by doctors' use of voice of medicine (chronic physical complaints). The analysis supports the premise that increased use of the lifeworld makes for better outcomes and more humane treatment of patients as unique human beings. Some doctors switched communication strategies in different consultations, which suggests that their behaviour might be open to change. If doctors could be sensitised to the importance of dealing with the concerns of the lifeworld for patients with chronic physical conditions as well as psychological conditions, it might be possible to obtain better care for patients. This would require attention to structural aspects of the healthcare system to enable doctors to work fully within the patient-centred model.

Adult↗
PubMed2001

The strategies used by general practitioners when providing information about medicines.

Changes both inside and outside the consultation increase the chances that patients may gain information from sources other than their general practitioner (GP). Data from nine interviews and one focus group with British GPs were used to explore GPs' rationale for the information they provide when prescribing oral steroids and their perceptions of patients' expectations. GPs' communication strategies were associated with the type of relationship they sought to perpetuate with patients. Some GPs reported that decisions about the provision of information were based on their own judgements of what patients needed to know (paternalistic approach), while others reported attempts to take account of patients' existing knowledge and beliefs (mutualistic approach). All the GPs were aware of the availability of information about medical matters, and most believed that patients' expectations had increased. The communication strategies of some GPs may not be appropriate given the availability of medical information outside the consultation.

Attitude of Health Personnel↗
PubMed2001

Adherence to antibiotics prescribed in an accident and emergency department: the influence of consultation factors.

The objective of this study was to investigate the extent of non-adherence to prescribed antibiotics and the relationship of non-adherence to consultation and attitudinal factors. Self-completion postal questionnaires were sent to 202 consecutive adult attenders to an accident and emergency (A&E) department who had been given antibiotics to take home, within a week of the A&E attendance. The questionnaire included a detailed log of dosing, two sections of eight questions each on the patients' perceptions of the consultation and of their attitudes to medicines in general, which were marked on Likert scales; and questions inviting free text answers. Efforts were made to maximize the response rate, and to contact a random sample of 10 non-responders to assess any non-response bias. The response rate was 56%. The non-responders sampled reported similar non-adherence to that of the responders. Of the 113 responders, 10 (9%) indicated that they had taken none of their prescribed medicines, and 25 (22%) that they had taken less than 80%. The most common pattern of non-adherence was early cessation. Two aspects of the consultation (expectations about a prescription, and that there were too many tablets) were related to adherence. In conclusion, this study suggests that the effectiveness of some A&E consultations is reduced by inadequate exploration of patients' concerns and expectations.

Adolescent↗
PubMed2000

Patients' unvoiced agendas in general practice consultations: qualitative study.

OBJECTIVE: To investigate patients' agendas before consultation and to assess which aspects of agendas are voiced in the consultation and the effects of unvoiced agendas on outcomes. DESIGN: Qualitative study. SETTING: 20 general practices in south east England and the West Midlands. PARTICIPANTS: 35 patients consulting 20 general practitioners in appointment and emergency surgeries. RESULTS: Patients' agendas are complex and multifarious. Only four of 35 patients voiced all their agendas in consultation. Agenda items most commonly voiced were symptoms and requests for diagnoses and prescriptions. The most common unvoiced agenda items were: worries about possible diagnosis and what the future holds; patients' ideas about what is wrong; side effects; not wanting a prescription; and information relating to social context. Agenda items that were not raised in the consultation often led to specific problem outcomes (for example, major misunderstandings), unwanted prescriptions, non-use of prescriptions, and non-adherence to treatment. In all of the 14 consultations with problem outcomes at least one of the problems was related to an unvoiced agenda item. CONCLUSION: Patients have many needs and when these are not voiced they can not be addressed. Some of the poor outcomes in the case studies were related to unvoiced agenda items. This suggests that when patients and their needs are more fully articulated in the consultation better health care may be effected. Steps should be taken in both daily clinical practice and research to encourage the voicing of patients' agendas.

Adult↗
PubMed2000

Misunderstandings in prescribing decisions in general practice: qualitative study.

OBJECTIVES: To identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice. DESIGN: Qualitative study. SETTING: 20 general practices in the West Midlands and south east England. PARTICIPANTS: 20 general practitioners and 35 consulting patients. MAIN OUTCOME MEASURES: Misunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicine. RESULTS: 14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor's decision, and relationship factors. All the misunderstandings were associated with lack of patients' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients' ideas about medicines for successful prescribing. CONCLUSIONS: Patients' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings.

Adult↗
PubMed2000

Doctor-patient communication about drugs: the evidence for shared decision making.

The traditional paternalistic model of medical decision-making, in which doctors make decisions on behalf of their patients, has increasingly come to be seen as outdated. Moreover, the role of the patient in the consultation has been emphasised, notably through the adoption of 'patient-centred' strategies. Models that promote patients' active involvement in the decision-making process about treatment have been developed. We examine one particular model of shared decision making [Charles, C., Gafni, A., Whelan, T, 1997. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Social Science & Medicine 44, 681-692.]. The model has four main characteristics. These are that (1) both the patient and the doctor are involved, (2) both parties share information, (3) both parties take steps to build a consensus about the preferred treatment and (4) an agreement is reached on the treatment to implement. Focusing on the first two of the four characteristics of the model, we use the findings from a study of 62 consultations, together with interviews conducted with patients and general practitioners, to consider participation in the consultation in terms of sharing information about, and views of, medicines. We found little evidence that doctors and patients both participate in the consultation in this way. As a consequence there was no basis upon which to build a consensus about the preferred treatment and reach an agreement on which treatment to implement. Thus even the first two of the four conditions said to be necessary for shared decision making were not generally present in the consultations we studied. These findings were presented in feedback sessions with participating GPs, who identified a number of barriers to shared decision making, as well as expressing an interest in developing strategies to overcome these barriers.

Decision Making↗
PubMed2000

GPs' recognition of, and response to, influences on patients' medicine taking: the implications for communication.

BACKGROUND: Research evidence suggests that patients' beliefs about medicines influence medicine taking. Therefore, it is important that GPs are able to both identify and take account of such beliefs in the consultation. OBJECTIVES: The purpose of this study was to explore GPs' awareness of asthma patients' beliefs about medicine, and of the ways in which friends and family, television programmes and the Campaign for Asthma may influence these beliefs. We also wanted to consider how GPs believe they would feel, and their likely behaviour, when a patient refers to these influences in the consultation. METHOD: Four events, drawn from 17 semi-structured interviews previously conducted with patients recently prescribed oral steroids (prednisolone), were used to compose a narrative account of a hypothetical patient's behaviour. The narrative described a series of scenarios to which GPs were asked to respond. It was sent to all GPs in Derbyshire (n = 476). RESULTS: The response rate was 69%. Half judged that the scenarios which presented the patients' beliefs about medicine, the influence of friends and family and the television were not 'realistic'. GPs also reported feeling more 'supportive' and 'sympathetic' towards the Campaign for Asthma as a source of patient information than they were towards opinions based on advice given by patients' family and friends. CONCLUSION: Developing 'common ground' in the consultation will be problematic if GPs are not aware of, and sympathetic towards, the ways in which patients use information from a range of sources to formulate beliefs that then affect their medicine-taking behaviour. GPs should be encouraged to open up their discussions with patients so as to encourage the development of a partnership in which each party is aware of, and respects, the other's point of view.

Administration, Oral↗
PubMed1999

GPs' perceptions of patient influence on prescribing.

BACKGROUND: Controlling prescribing costs is an issue of concern to many GPs. OBJECTIVE AND METHODS: This paper is based on interviews with 21 GPs in which they were asked about influences on prescribing budgets. RESULTS: The results presented relate specifically to GPs' perceptions of the influence of patients on prescribing. Perceptions of patient demand were described both in terms of a general demand and demand by patients with specific health beliefs or particular social characteristics. Generally, GPs reported that decisions to prescribe were informed by a concern to maintain a good relationship with their patients, and not to risk the relationship by not prescribing when they believed a prescription was expected. CONCLUSIONS: Although information was available about whether practices had a 'high' or 'low' budget, and whether they were under- or overspent, there did not appear to be any relationship between GPs' beliefs that patient expectations affected their prescribing and whether they were under or over budget. This paper suggests that patient demand for prescriptions may not only be overestimated but also perpetuated by GPs' belief in its existence and a wish to maintain a good doctor-patient relationship.

Attitude of Health Personnel↗