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Objective: To gain insight into patient participation in general practice by examining if and how patients' question-asking behaviour has changed over the years (2007-2016)., Methods: A random set of real-life video-recorded consultations collected in 2015-2016 (n = 437) was observed and compared with that of a former study in 2007-2008 (n = 533). Patients' question-asking behaviour was coded using an adapted RIAS protocol containing six categories: medical condition/therapeutic regimen; psychosocial; social context; lifestyle; ask for opinion doctor; practical. GPs and patients completed questionnaires about their background characteristics. Data were analysed using multi-level analysis., Results: Patients asked fewer questions in 2016 than in 2007. The type of question-asking behaviour changed significantly: in particular medical questions decreased while practical questions increased. Less educated patients asked significantly more practical questions than higher educated patients., Conclusion: Contrary to our expectations, patients' question-asking has decreased in 2016 compared to 2007, while the average consultation length has increased. The type of questions shifted from medical to practical, especially in less educated patients. It seems that GPs' professional role has expanded over time, since patients nowadays ask their GP more non-medical questions., Practice Implications: GPs probably could continue facilitating patient involvement by more frequently using partnership-building and supportive communication., Competing Interests: Declaration of Competing Interest None, (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: It is currently not known when in the consultation GPs label symptoms as medically unexplained and what triggers this., Aim: To establish the moment in primary care consultations when a GP labels symptoms as medically unexplained and to explore what triggers them to do so., Design and Setting: This was a qualitative study. Data were collected in the Netherlands in 2015., Method: GPs' consultations were video-recorded. GPs stated whether the consultation was about medically unexplained symptoms (MUS). The GP was asked to reflect on the video-recorded consultation and to indicate the moment when they labelled symptoms as MUS. Qualitative interviewing and analysis were performed to explore the triggers GPs perceived that caused them to label the symptoms as MUS., Results: A total of 43 of the 393 video-recorded consultations (11%) were labelled as MUS. The mean time until GPs labelled symptoms as medically unexplained was about 4 minutes for newly presented symptoms and 2 minutes for symptoms for which the patients had already visited the GP before. GPs were triggered to label symptoms as MUS in the consultation by: the way patients presented their symptoms; the symptoms not fitting into a specific pattern; patients attributing the symptoms to a psychosocial context; and a discrepancy between symptom presentation and objective findings., Conclusion: Most GPs labelled the presented symptoms as medically unexplained soon after the start of the consultation. GPs are triggered to label symptoms as medically unexplained by patients' symptom presentation, symptom patterns, and symptom attribution. This suggests that non-analytical reasoning was a central component in their thought process., (© British Journal of General Practice 2020.)

Background: Shared decision-making (SDM) is, largely, espoused as the preferred model for making decisions in everyday health care. Studies exploring the application of SDM in primary care practice are still lacking., Objectives: This study explores how GPs involve their patients in decision-making, if application of SDM has increased over time (2007-15), and what factors are associated with it., Methods: We investigated the application of SDM by Dutch GPs by analysing a random set of real-life video-recorded consultations collected in 2007 (n = 50) and 2015 (n = 50). SDM was assessed by observing patient involvement in decision making (OPTION), a reliable and valid instrument measuring the extent to which clinicians involve patients in decision-making by coding 12 behavioural items. In addition, GPs and patients completed questionnaires about their background characteristics. The potential determinants for application of SDM by Dutch GPs (including year of measurement, sex and age of patients and GPs, the nature of complaints, consultation duration and the type of decision discussed) were analysed using multilevel analysis [with patients (Level 1) nested within GPs (Level 2)]., Results: In 2015, GPs applied SDM more often compared with 2007 according to OPTION. In consultations with older patients, there is less application of SDM by GPs., Conclusions: Although application of SDM by Dutch GPs has increased, low overall SDM scores still leave room for improvement. GPs should elicit the patient's preferred role in the decision-making process at any time, in particular in consultations with older patients., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Patients with overweight or obesity increasingly attend general practice, which is an ideal setting for weight-loss counselling. The present study is the first to investigate the quality of weight-loss counselling provided by practice nurses in general practice to patients with overweight or obesity, in order to identify points for improvement., Design: An observational checklist was developed to assess goal and implementation intentions and 'missed opportunities for lifestyle counselling'. Comparisons were made with overall consultation goals set by practice nurses, as measured in a post-visit questionnaire., Setting: Dutch general practice., Subjects: One hundred video-taped consultations (2010/2011) between practice nurses and patients with overweight or obesity., Results: Half of the consultations contained a goal intention, of which the majority aimed to change eating behaviour. Only part of these goal intentions could be considered implementation intentions. It appeared that actions (how elements) were not often included here. Lifestyle change was more often perceived as an overall consultation goal than weight change. Regarding patterns of overall consultation goals, the majority addressed only one lifestyle factor at a time. If practice nurses formulated weight change in their overall consultation goal, they also used goal or implementation intentions, especially for weight change. In a quarter of the consultations, practice nurses did not ask any further questions about weight, nutrition or physical activity to gain insight, which is an important 'missed opportunity for lifestyle counselling'., Conclusions: Matching implementation intentions to the broader overall consultation goals of practice nurses would be meaningful, leading to desired goal-directed behaviours and subsequent goal attainment.

Communication assessment in real-life consultations is a complex task. Generic assessment instruments help but may also have disadvantages. The generic nature of the skills being assessed does not provide indications for context-specific behaviour required in practice situations; context influences are mostly taken into account implicitly. Our research questions are: 1. What factors do trained raters observe when rating workplace communication? 2. How do they take context factors into account when rating communication performance with a generic rating instrument? Nineteen general practitioners (GPs), trained in communication assessment with a generic rating instrument (the MAAS-Global), participated in a think-aloud protocol reflecting concurrent thought processes while assessing videotaped real-life consultations. They were subsequently interviewed to answer questions explicitly asking them to comment on the influence of predefined contextual factors on the assessment process. Results from both data sources were analysed. We used a grounded theory approach to untangle the influence of context factors on GP communication and on communication assessment. Both from the think-aloud procedure and from the interviews we identified various context factors influencing communication, which were categorised into doctor-related (17), patient-related (13), consultation-related (18), and education-related factors (18). Participants had different views and practices on how to incorporate context factors into the GP(-trainee) communication assessment. Raters acknowledge that context factors may affect communication in GP consultations, but struggle with how to take contextual influences into account when assessing communication performance in an educational context. To assess practice situations, raters need extra guidance on how to handle specific contextual factors.

Background: Today, in several north-western European countries, patients are encouraged to choose, actively, a healthcare provider. However, patients often visit the provider that is recommended by their general practitioner (GP). The introduction of patient choice requires GPs to support patients to be involved, actively, in the choice of a healthcare provider. We aim to investigate whether policy on patient choice is reflected in practice, i.e. what the role of the patient is in their choices of healthcare providers at the point of referral and to what extent GPs' and patients' healthcare paths influence the role that patients play in the referral decision., Methods: In 2007-2008, we videotaped Dutch GP-patient consultations. For this study, we selected, at random, 72 videotaped consultations between 72 patients and 39 GPs in which the patient was referred to a healthcare provider. These were analysed using an observation protocol developed by the researchers., Results: The majority of the patients had little or no input into the choice of a healthcare provider at the point of referral by their GP. Their GPs did not support them in actively choosing a provider and the patients often agreed with the provider that the GP proposed. Patients who were referred for diagnostic purposes seem to have had even less input into their choice of a provider than patients who were referred for treatment., Conclusions: We found that the GP chooses a healthcare provider on behalf of the patient in most consultations, even though policy on patient choice expects from patients that they choose, actively, a provider. On the one hand, this could indicate that the policy needs adjustments. On the other hand, adjustments may be needed to practice. For instance, GPs could help patients to make an active choice of provider. However, certain patients prefer to let their GP decide as their agent. Even then, GPs need to know patients' preferences, because in a principal-agent relationship, it is necessary that the agent is fully informed about the principal's preferences.

Background: It is generally acknowledged that GPs and practice nurses (PNs) may significantly contribute to a patient's healthy lifestyle behaviour. Two counselling techniques are known to strengthen this process: tailoring information and advice about lifestyle behaviour to a patient and motivational interviewing (MI). It is not clear to what extent GPs and PNs actually apply these techniques during routine consultations., Objectives: To examine how GPs and PNs discuss patients' lifestyle behaviour, in terms of the level of tailoring of information and advice and their application of MI., Methods: We randomly videotaped GP-patient and PN-patient consultations within Dutch general practices and selected 124 and 141 consultations, respectively, that included any discussion about the patient's lifestyle. These were analysed, using the 'Behaviour Change Counselling Index', level of tailoring and content of lifestyle counselling., Results: Information about lifestyle is mainly given in generic terms by GPs and PNs. In contrast, advice about smoking behaviour more often seems to be tailored to the patient. GPs hardly ever applied MI in their consultations about patient's lifestyle behaviour. PNs trained in MI did apply this technique, but to some extent only., Conclusion: Both GPs and PNs somehow perform lifestyle counselling according to generally acknowledged criteria. However, for both, there is room for improvement in the application of MI skills and in tailoring of information and advice about lifestyle behaviour. Effort needs to be put into integrating such techniques into busy daily practice while simultaneously complying with the many other clinical demands.

Background: Communication is a key competence for health care professionals. Analysis of registrar and GP communication performance in daily practice, however, suggests a suboptimal application of communication skills. The influence of context factors could reveal why communication performance levels, on average, do not appear adequate. The context of daily practice may require different skills or specific ways of handling these skills, whereas communication skills are mostly treated as generic. So far no empirical analysis of the context has been made. Our aim was to identify context factors that could be related to GP communication., Methods: A purposive sample of real-life videotaped GP consultations was analyzed (N = 17). As a frame of reference we chose the MAAS-Global, a widely used assessment instrument for medical communication. By inductive reasoning, we analyzed the GP behaviour in the consultation leading to poor item scores on the MAAS-Global. In these cases we looked for the presence of an intervening context factor, and how this might explain the actual GP communication behaviour., Results: We reached saturation after having viewed 17 consultations. We identified 19 context factors that could potentially explain the deviation from generic recommendations on communication skills. These context factors can be categorized into doctor-related, patient-related, and consultation-related factors., Conclusions: Several context factors seem to influence doctor-patient communication, requiring the GP to apply communication skills differently from recommendations on communication. From this study we conclude that there is a need to explicitly account for context factors in the assessment of GP (and GP registrar) communication performance. The next step is to validate our findings.

Background: General practice is the centre of care for patients with medically unexplained symptoms (MUS). Providing explanations for MUS, i.e. making sense of symptoms, is considered to be an important part of care for MUS patients. However, little is known how general practitioners (GPs) do this in daily practice.Objective: This study aimed to explore how GPs explain MUS to their patients during daily general practice consultations.Methods: A thematic content analysis was performed of how GPs explained MUS to their patients based on 39 general practice consultations involving patients with MUS.Results: GP provided explanations in nearly all consultations with MUS patients. Seven categories of explanation components emerged from the data: defining symptoms, stating causality, mentioning contributing factors, describing mechanisms, excluding explanations, discussing the severity of symptoms and normalizing symptoms. No pattern of how GPs constructed explanations with the various categories was observed. In general, explanations were communicated as a possibility and in a patient-specific way; however, they were not very detailed.Conclusion: Although explanations for MUS are provided in most MUS consultations, there seems room for improving the explanations given in these consultations. Further studies on the effectiveness of explanations and on the interaction between patients and GP in constructing these explanations are required in order to make MUS explanations more suitable in daily primary care practice. [ABSTRACT FROM AUTHOR]

Background: Many general practitioners (GPs) struggle with the communication with patients with medically unexplained symptoms (MUS). This study aims to identify GPs' difficulties in communication during MUS consultations. Methods: We video-recorded consultations and asked GPs immediately after the consultation whether MUS were presented. GPs and patients were then asked to reflect separately on the consultation in a semi-structured interview while watching the consultation. We selected the comments where GPs experienced difficulties or indicated they should have done something else and analysed these qualitatively according to the principles of constant comparative analysis. Next, we selected those video-recorded transcripts in which the patient also experienced difficulties; we analysed these to identify problems in the physician-patient communication. Results: Twenty GPs participated, of whom two did not identify any MUS consultations. Eighteen GPs commented on 39 MUS consultations. In 11 consultations, GPs did not experience any difficulties. In the remaining 28 consultations, GPs provided 84 comments on 60 fragments where they experienced difficulties. We identified three issues for improvement in the GPs' communication: psychosocial exploration, structure of the consultation (more attention to summaries, shared agenda setting) and person-centredness (more attention to the reason for the appointment, the patient's story, the quality of the contact and sharing decisions). Analysis of the patients' views on the fragments where the GP experienced difficulties showed that in the majority of these fragments (n = 42) the patients' comments were positive. The video-recorded transcripts (n = 9) where the patient experienced problems too were characterised by the absence of a dialogue (the GP being engaged in exploring his/her own concepts, asking closed questions and interrupting the patient). Conclusion: GPs were aware of the importance of good communication. According to them, they could improve their communication further by paying more attention to psychosocial exploration, the structure of the consultation and communicating in a more person-centred way. The transcripts where the patient experienced problems too, were characterised by an absence of dialogue (focussing on his/her own concept, asking closed questions and frequently interrupting the patient). [ABSTRACT FROM AUTHOR]

Background: Many GPs find the care of patients with medically unexplained symptoms (MUS) challenging. Patients themselves are often not satisfied with the care they receive.Aim: To explore the problems patients with MUS experience in communication during consultations, with the aim of improving such consultations DESIGN AND SETTING: A qualitative analysis of semi-structured interviews.Method: GP consultations were videorecorded and the GPs were asked immediately afterwards whether MUS were presented. Patients in these MUS consultations were asked to reflect on the consultation in a semi-structured interview while watching a recording of their own consultation.Results: Of the 393 videorecorded consultations, 43 contained MUS. Patients who did identified six categories of problems. First, they reported a mismatch between the GP's and their own agenda. Second, patients indicated that the GP evoked an uncomfortable feeling in them during the consultation. Third, they found that GPs did not provide a specific management plan for their symptoms. Fourth, patients indicated that the GP was not well prepared for the consultation. Fifth, they perceived prejudices in the GP during the consultation. Finally, one patient found that the GP did not acknowledge a limited understanding of the origin of the symptoms.Conclusion: According to patients, GPs can improve their consultations on MUS by making genuine contact with their patients, by paying more attention to the patient's agenda, and by avoiding evoking uncomfortable feelings and displaying prejudices. They should prepare their consultations and focus on the issues that matter to patients, for example, symptom management. GPs should be honest to patients when they do not understand the origin of symptoms. [ABSTRACT FROM AUTHOR]

Background: Many general practitioners (GPs) find the care for patients with medically unexplained symptoms (MUS) challenging. The patients themselves are often not satisfied with the care they receive.Objectives: The aim of this study is to explore what patients with MUS expect from their GP by looking at relevant communication elements in consultations as identified by patients.Methods: We video-recorded everyday consultations with GPs and asked the GPs immediately after the consultation whether MUS were presented. The patients in these MUS consultations were asked to reflect on the consultation during a semi-structured interview while watching a recording of their own MUS consultation. The interviews were analysed qualitatively according to the principles of constant comparative analysis.Results: Of the 393 video-recorded consultations, 43 concerned MUS. All MUS patients said that they wanted to be taken seriously. According to the patients, their feeling of being taken seriously is enhanced when the GP: (i) pays empathic attention to them as individuals, meaning that the GP knows their personal circumstances and has an open and empathic approach, (ii) ensures a good conversation by treating the patient as an equal partner and (iii) is attentive to their symptoms by exploring these symptoms in depth and by acting on them.Conclusion: Like chronic patients, patients with MUS value a personalised approach in which GPs pay attention to patients' personal circumstances, to proper somatic management of their symptoms and to a proper conversation in which they are treated as equal partners. Use of these basic consultation skills may greatly improve care of MUS patients. [ABSTRACT FROM AUTHOR]

Background: In a recent study comparing psychosocial consultations prior to and after the implementation of national clinical guidelines in the Netherlands, we found that general practitioners (GPs) showed less empathy in the more recent consultations. As a consequence, patients possibly have less scope to express their worries. The objective is to investigate whether patients have become more reluctant to open up about their concerns during psychosocial consultations and how GPs respond. Methods: Consultations from previous study samples videotaped between 1977 and 2008 and categorized by GPs as ‘completely psychosocial’ were selected for the present study. These consultations were observed using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to capture cues and concerns expressed by patients and GPs’ immediate responses. We compared consultations prior to (N = 121) and after (N = 391) introduction of national clinical guidelines in the 1990s. Results: In 92% of the consultations, patients presented at least one worry. These were most often expressed implicitly. However, the proportion of consultations containing at least one explicit concern changed from 24% to 37% over time. The increased number of expressed cues and concerns was partly explained by a change in GP characteristics; the latter sample contained more female and more experienced GPs. Furthermore, cues and concerns were more often expressed during later phases of consultations in recent years. Conclusions: Our study shows that patients have become somewhat more explicit in expressing their worries. However, GPs need to be aware that, still, most worries are expressed implicitly and that new concerns may appear towards the end of consultations. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Acquiring adequate communication skills is an essential part of general practice (GP) specialty training. In assessing trainee proficiency, the context in which trainees communicate is usually not taken into account. The present paper aims to explore what context factors can be found in regular GP trainee consultations and how these influence their communication performance. Methods: In a randomly selected sample of 44 videotaped, real-life GP trainee consultations, we searched for context factors previously identified in GP consultations and explored how trainee ratings change if context factors are taken into account. Trainee performance was rated twice using the MAAS-Global, first without and then with incorporating context factors. Item score differences were calculated using a paired samples t-test and effect sizes were computed. Results: All previously identified context factors were again observed in GP trainee consultations. In communication assessment scores, we found a significant difference in 5 out of 13 MAAS-Global items, mostly in a positive direction. The effect size was moderate (0.57). Conclusions: GP trainee communication is influenced by contextual factors; they seem to adapt to context in a professional way. Practice implications: GP specialty training needs to focus on a context-specific application of communication skills. Communication raters need to be taught how to incorporate context factors into their assessments. [Copyright &y& Elsevier]

Abstract: Objective: Active listening is a prerequisite for a successful healthcare encounter, bearing potential therapeutic value especially in clinical situations that require no specific medical intervention. Although generally acknowledged as such, active listening has not been studied in depth. This paper describes the development of the Active Listening Observation Scale (ALOS-global), an observation instrument measuring active listening and its validation in a sample of general practice consultations for minor ailments. Methods: Five hundred and twenty-four videotaped general practice consultations involving minor ailments were observed with the ALOS-global. Hypotheses were tested to determine validity, incorporating patients’ perception of GPs’ affective performance, GPs’ verbal attention, patients’ self-reported anxiety level and gender differences. Results: The final 7-item ALOS-global had acceptable inter- and intra-observer agreement. Factor analysis revealed one homogeneous dimension. The scalescore was positively related to verbal attention measured by RIAS, to patients’ perception of GPs’ performance and to their pre-visit anxiety level. Female GPs received higher active listening scores. Conclusion: The results of this study are promising concerning the psychometric properties of the ALOS-global. More research is needed to confirm these preliminary findings. Practice implications: After establishing how active listening differentiates between health professionals, the ALOS-global may become a valuable tool in feedback and training aimed at increasing listening skills. [Copyright &y& Elsevier]

Objective To get insight into the changes over time of patients’ involvement in the decision-making process, and into the factors contributing to patients’ involvement and general practitioners’ (GPs) communication related to the Medical Treatment Act (MTA) issues: information about treatment, other available treatments and side-effects; informed decision making; asking consent for treatment. Background Societal developments have changed the doctor–patient relationship recently. Informed decision making has become a central topic. Patients’ informed consent was legalized by the MTA (1995). Design Data of two cross-sectional studies, the First (1987) and Second (2001) Dutch National Survey of General Practice, were compared. Setting and participants General practice consultations; 16 GPs and 442 patients in 1987; 142 GPs and 2784 patients in 2001. Methods Consultations were videotaped and rated using Roter's Interaction Analysis System and observer questionnaires; pre- and post-consultation patient questionnaires; and GP questionnaires. Descriptive analyses and multivariate, multilevel analysis were applied. Main results Most patients reported to have received the information they had considered as important prior to the consultation. There were discrepancies in involvement in treatment decisions and in giving information about other available treatments, side-effects and risks. GPs who were more affective and gave more information, more often involved their patients, especially younger patients, in decision making. In 2001, more informed decision making was observed and the GPs asked consent for a treatment more often, but they less often asked for the patients’ understanding. Conclusion Patients’ involvement in decision making has increased over time, but not in every respect. However, this does not apply for all patients, especially the older ones. It should be questioned whether they are willing or capable to be involved and if so, how they could be encouraged. [ABSTRACT FROM AUTHOR]

Objective Positive communication is advocated for physicians during consultations with patients presenting medically unexplained symptoms (MUS), but studies generally focus on what is said rather than how it is said. This study quantified language use differences of general practitioners (GPs), and assessed their relation to patient anxiety. Methods Language use of 18 Dutch GPs during 82 consultations was compared for patients with MUS versus medically explained symptoms (MES). Message content (positive or negative) was differentiated from its directness (direct or indirect), and related to changes in patient’s state anxiety (abbreviated State Trait Anxiety Inventory; STAI). Results In total, 2590 clauses were identified. GPs approached patients with MES with relatively more direct (vs. indirect) positive and indirect (vs. direct) negative messages (OR 1.91, 95% CI 1.42–2.59). Anxiety of both patient groups increased when GPs used more direct (vs. indirect) negative messages ( b  = 0.67, 95% CI 0.07–1.27) Conclusions GPs use different language depending on the content of messages for patients with MES, but not MUS. Direct negative messages relate to an increase in patient anxiety. Practice implications GPs could manage patient’s state anxiety by expressing negative messages in an indirect rather than direct manner. [ABSTRACT FROM AUTHOR]

Objective: Patients with medically unexplained symptoms (MUS) are believed to have a deviant way of talking about complaints. This study systematically compared linguistic markers in symptom presentations of patients with MUS and medically explained symptoms (MES).Methods: This content analysis (cross-sectional study) conceptualized relevant linguistic markers based on previous research about MUS communication. Linguistic markers included negations ("not"), intensifiers ("very"), diminishers ("a little"), first or third person subject ("I" vs. "my body"), subjectivity markers ("I think") and abstraction ("I'm gasping for breath" vs. "I'm short of breath"). We also coded valence, reference to physical or mental states, and consultation phase. We compared 41 MUS and 41 MES transcribed video-recorded general practice consultations. Data were analyzed with binary random intercepts models.Results: We selected and coded 2752 relevant utterances. Patients with MUS used less diminishers compared to patients with MES, but this main effect disappeared when consultation phase was included as predictor. For all other linguistic variables, the analyses did not reveal any variation in language use based on whether patients had MUS or MES. Importantly, utterances' valence and reference to physical or mental state did predict the use of linguistic markers.Conclusion: We observed no systematic variations in linguistic markers for patients who suffered from MUS compared to MES. Patients varied their language use based on utterances' valence and reference to physical or mental states. Current ideas about deviant patient communication may be based on stigmatized perceptions of how patients with MUS communicate, rather than actual differences in their talk. [ABSTRACT FROM AUTHOR]