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BACKGROUND AND PURPOSE: Second opinion reports of neurologic head and neck imaging are requested with increased regularity, and they may contain a recommendation to the clinician. Our aim was to investigate the frequency and determinants of the presence of a recommendation and the adherence by the referring physician to the recommendation in a second opinion neurology head and neck imaging report and the diagnostic yield of these recommendations.MATERIALS AND METHODS: This retrospective study included 994 consecutive second opinion reports of neurology head and neck imaging examinations performed at a tertiary care center.RESULTS: Of the 994 second opinion reports, 12.2% (121/994) contained a recommendation. An oncologic imaging indication was significantly (P = .030) associated with a lower chance of a recommendation in the second opinion report (OR = .67; 95% CI, 0.46?0.96). Clinicians followed 65.7% (88/134) of the recommendations. None of the investigated variables (patient age, sex, hospitalization status, indication for the second opinion report, experience of the radiologist who signed the second opinion report, strength of the recommendation, and whether the recommendation was made due to apparent quality issues of the original examination) were significantly associated with the compliance of the referring physician to this recommendation. The 134 individual recommendations eventually led to the establishment of 52 (38.2%) benign diagnoses and 28 (20.6%) malignant diagnoses, while no definitive diagnosis could be established in 56 (41.2%) cases.CONCLUSIONS: Recommendations are relatively common in second opinion reports of neurology head and neck imaging examinations, though less for oncologic indications. They are mostly followed by requesting physicians, thus affecting patient management. In most cases, they also lead to the establishment of a diagnosis, hence adding value to patient care.

Background How to best support pregnant women in making truly autonomous decisions which accord with current consent law is poorly understood and problematic for them and their healthcare professionals. This observational study examined a range of ante-natal consultations where consent for an intervention took place to determine key themes during the encounter. Methods Qualitative research in a large urban teaching hospital in London. Sixteen consultations between pregnant women and their healthcare professionals (nine obstetricians and three midwives) where ante-natal interventions were discussed and consent was documented were directly observed. Data were collectively analysed to identify key themes characterising the consent process. Results Four themes were identified: 1) Clinical framing - by framing the consultation in terms of the clinical decision to be made HCPs miss the opportunity to assess what really matters to a pregnant woman. For many women the opportunity to feel that their previous experiences had been ‘heard’ was an important but sometimes neglected prelude to the ensuing consultation; 2) Clinical risk dominated narrative - all consultations were dominated by information related to risk; discussion of reasonable alternatives was not always observed and women’s understanding of information was seldom verified making compliance with current law questionable; 3) Parallel narrative - woman-centred experience – for pregnant women social factors such as the place of birth and partner influences were as or more important than considerations of clinical risk yet were often missed by HCPs; 4) Cross cutting narrative - genuine dialogue - we observed variably effective interaction between the clinical (2) and patient (3) narratives influenced by trust and empathy and explicit empowering language by HCPs. Conclusion We found that ante-natal consultations that include consent for interventions are dominated by clinical framing and risk, and explore the woman-centred narrative less well. Current UK law requires consent consultations to include explicit effort to gauge a woman’s preferences and values, yet consultations seem to fail to achieve such understanding. At the very least, consultations may be improved by the addition of opening questions along the lines of ‘what matters to you most?’

Background PROMs can help healthcare professionals gain an improved understanding of patients’ physical burdens, functional levels, and (health-related) quality of life throughout disease and medical treatment. The aim of this study was to investigate the barriers and potential opportunities PROMs may present in a haematological outpatient clinic from three different perspectives: patients, nurses and haematologists. Methods The present study synthesizes three previously published studies that separately explored the experiences of patients, nurses and haematologists when implementing PROMs. The studies were all guided by the qualitative methodology Interpretive Description, including a focused ethnographic approach, to develop implications for future practice. Results The overall themes that emerged from the analysis were “Structural similarities influence the adoption of PROMs” and “Different perspectives on the potential of PROMs.” Conclusion Across the different user groups in the haematological outpatient clinic, the use of PROMs was thwarted due to an unquestioned commitment to biomedical knowledge and the system’s rationality and norms: PROM data was not used in patient consultations. Nurses and haematologists expressed different preferences related to potential future PROMs and different objectives for PROMs in clinical practice. From the different perspectives of the patients, nurses and haematologists, PROMs were not compatible with clinical practice. Further research is recommended to develop PROMs validated for use in haematological outpatient clinics. Moreover, implementation strategies adjusted to the structural barriers of the system are crucial.

Introduction An increased risk of sexual health problems is seen among patients with chronic illnesses. The background is likely to be multifactorial, but it remains poorly understood. Aim To investigate the sexual health and functioning of patients with rheumatoid arthritis (RA) and to examine gender differences, general population comparisons, and possible somatic, psychological, and disease-specific determinants. Methods A cross-sectional study using a digital questionnaire distributed among 380 patients diagnosed with RA in a Danish university hospital outpatient setting. Main Outcome Measure A range of patient-reported outcomes were obtained, including scores from the validated rating scale Changes in Sexual Functioning Questionnaire. Furthermore, individual medical record information was collected. Results A total of 329 patients (250 women and 79 men) were included (age range: 25–73 years; mean age: 57.2 years). The Changes in Sexual Functioning Questionnaire scoring indicated an overall sexual dysfunction in 33.8% of men and 58.1% of women.More than one-third (37.6%) of patients felt that RA had made their sex life more complicated, and 32.4% feared that this might someday be the case. In total, 29.2% patients had experienced sexual problems due to their RA treatment. Of the respondents who experienced RA-related fatigue, 46.5% reported that this impacted negatively on their sexual activity. The risk of one or more sexual health adversities was significantly correlated with female gender, older age, moderate or severe depression, moderate to moderately high loneliness, more than 2 comorbidities, and a fatigue score above 75 out of 100 on a visual analogue scale. Compared to the general population, significantly fewer patients with RA considered their sex life important, and significantly fewer patients appraised their current sex life as good or very good. Moreover, significantly more women with RA (32.1%) than women from the general population (15.7%) had not had any sex life during the past year. A vast majority of patients with RA (93.5% of women and 85.5% of men) had not discussed sexual issues with a health-care professional during the last 5 years. Of all, 32.5% would like health-care professionals to address sexual topics in the consultation occasionally. Conclusion Sexual dysfunction is highly prevalent in patients with RA, but the problems are not regularly addressed in consultations provided by the rheumatology department.

Introduction and objectives Although patient centred communication is associated with patients’ daily medication adherence, the exact communication phenomena promoting high treatment adherence remain elusive. Patients and methods We used conversation analysis of videotaped follow-up consultations of seven outpatients (4–13 years of age) with chronic asthma and their caregivers, consulting two paediatric respiratory physicians in a practice in which high treatment adherence has been documented, to explore the language paediatricians use to promote their patients’ adherence to daily controller medication. Results Starting the consultation with the patient’s (and caregivers’) agenda commonly resulted in presentation of issues new to the physician. Information was mostly provided in response to patient/caregiver questions, prompting the delivery of specific information tailored to the patient’s and caregivers’ needs. Although patients and caregivers showed resistance in response to unsolicited information and advice, they always accepted the doctor’s explicit request for agreement with proposed treatment. The doctor’s description of favourable treatment results in most patients prompted caregivers’ willingness to accept treatment proposals. Conclusions Paediatricians with a documented success in achieving adherence to controller medication in their patients with asthma tend to start consultations with the patient’s agenda, provide information in response to questions, offer reassurance on overall treatment effectiveness, and seek explicit agreement with a treatment proposal.

Using both statistical methods and conversation analysis, we examined how support workers in a mental health rehabilitation community encourage clients to participate in joint decision-making processes. Drawing on video-recordings of 29 community meetings as data, we considered support workers’ proposals (N = 449) and clients’ responsiveness to them. Support workers’ proposals were coded for their linguistic and other features and clients’ responsiveness was assessed by three independent raters. Multiple linear regression (MLR) analysis was carried out. A significant regression equation with seven predictor variables accounted for 24% of the variance in the data. Four variables predicted a higher level of client responsiveness: the use of explicit recipient address term, “quasi open” proposal form, support worker’s long work experience, and the average level of client participation during a session. Three variables predicted a lower level of client responsiveness: grammatical complexity of proposal form, modal declarative proposal form, and the presence of only one support worker in a session. The qualitative conversation-analytic investigation highlighted the advantages of the careful fine-tuning of openness vs. closedness of proposal form, the reflexive awareness of which, we argue, may help mental health professionals to encourage clients’ responsiveness in joint decision-making processes and thereby their participation in communal life. Using both statistical methods and conversation analysis, we examined how support workers in a mental health rehabilitation community encourage clients to participate in joint decision-making processes. Drawing on video-recordings of 29 community meetings as data, we considered support workers’ proposals (N = 449) and clients’ responsiveness to them. Support workers’ proposals were coded for their linguistic and other features and clients’ responsiveness was assessed by three independent raters. Multiple linear regression (MLR) analysis was carried out. A significant regression equation with seven predictor variables accounted for 24% of the variance in the data. Four variables predicted a higher level of client responsiveness: the use of explicit recipient address term, “quasi-open” proposal form, support worker’s long work experience, and the average level of client participation during a session. Three variables predicted a lower level of client responsiveness: grammatical complexity of proposal form, modal declarative proposal form, and the presence of only one support worker in a session. The qualitative conversation-analytic investigation highlighted the advantages of the careful fine-tuning of openness vs. closedness of proposal form, the reflexive awareness of which, we argue, may help mental health professionals to encourage clients’ responsiveness in joint decision-making processes and thereby their participation in communal life.

Contains fulltext : 251423.pdf (Publisher’s version ) (Open Access) BACKGROUND: General practice (GP) training in how to communicate with patients with medically unexplained symptoms (MUS) is limited. OBJECTIVE: Development, implementation and evaluation of an evidence-based communication training program for GP residents focused on patients with MUS in primary care. METHODS: We used the intervention mapping (IM) framework to systematically develop the MUS training program. We conducted a needs assessment to formulate change objectives and identified teaching methods for a MUS communication training program. Next, we developed, implemented and evaluated the training program with 46 residents by assessing their self-efficacy and by exploring their experiences with the training. RESULTS: The resulting program is a blended training with an online course and two training days. After attending the training program, GP residents reported significantly higher self-efficacy for communication with patients with MUS at four weeks follow up compared to baseline. Furthermore, GP residents experienced the training program as useful and valued the combination of the online course and training days. CONCLUSION AND PRACTICE IMPLICATIONS: We developed an evidence-based communication training program for the management of patients with MUS in primary care. Future research should examine the effect of the training on GP residents' communication skills in MUS consultations in daily practice.

Objective To assess trends in primary and specialist care consultation rates and average length of consultation by cardiovascular disease (CVD), type 2 diabetes mellitus (T2DM), or cardiometabolic multimorbidity exposure status. Methods Observational, retrospective cohort study used linked Clinical Practice Research Datalink primary care data from 01/01/2000 to 31/12/2018 to assess consultation rates in 141,328 adults with newly diagnosed T2DM, with or without CVD. Patients who entered the study with either a diagnosis of T2DM or CVD and later developed the second condition during the study are classified as the cardiometabolic multimorbidity group. Face to face primary and specialist care consultations, with either a nurse or general practitioner, were assessed over time in subjects with T2DM, CVD, or cardiometabolic multimorbidity. Changes in the average length of consultation in each group were investigated. Results 696,255 (mean 4.9 years [95% CI, 2.02–7.66]) person years of follow up time, there were 10,221,798 primary and specialist care consultations. The crude rate of primary and specialist care consultations in patients with cardiometabolic multimorbidity (N = 11,881) was 18.5 (95% CI, 18.47–18.55) per person years, 13.5 (13.50, 13.52) in patients with T2DM only (N = 83,094) and 13.2 (13.18, 13.21) in those with CVD (N = 57,974). Patients with cardiometabolic multimorbidity had 28% (IRR 1.28; 95% CI: 1.27, 1.31) more consultations than those with only T2DM. Patients with cardiometabolic multimorbidity had primary care consultation rates decrease by 50.1% compared to a 45.0% decrease in consultations for those with T2DM from 2000 to 2018. Specialist care consultation rates in both groups increased from 2003 to 2018 by 33.3% and 54.4% in patients with cardiometabolic multimorbidity and T2DM, respectively. For patients with T2DM the average consultation duration increased by 36.0%, in patients with CVD it increased by 74.3%, and in those with cardiometabolic multimorbidity it increased by 37.3%. Conclusions Annual primary care consultation rates for individuals with T2DM, CVD, or cardiometabolic multimorbidity have fallen since 2000, while specialist care consultations and average consultation length have both increased. Individuals with cardiometabolic multimorbidity have significantly more consultations than individuals with T2DM or CVD alone. Service redesign of health care delivery needs to be considered for people with cardiometabolic multimorbidity to reduce the burden and health care costs.

Background Measures taking aim at minimizing the risk of coronavirus transmission and fear of infection may affect decisions to seek care for other medical emergency conditions. The purpose of this analysis was to analyze intermediate-term effects of the COVID-19 pandemic on neuroradiological emergency consultations (NECs). Methods We conducted an ambispective study on NEC requests to a university hospital from a teleradiological network covering 13 hospitals in Germany. Weekly NEC rates for prepandemic calendar weeks (CW) 01/2019–09/2020 were compared with rates during first COVID-19 wave (CW 10–20/2020), first loosening of restrictions (CW 21–29/2020), intensified COVID-19 testing (CW 30–39/2020) and second COVID-19 wave (CW 40–53/2020), and contrasted with COVID-19 incidence in Germany. Results A total of n = 10 810 NECs were analyzed. Prepandemic NEC rates were stable over time (median: 103, IQR: 97–115). Upon the first COVID-19 wave in Germany, NEC rates declined sharply (median: 86, IQR: 69–92; p p = 0. 188), a phase of intensified testing (median: 111, IQR: 101–114; p = 0.434) and as of a second COVID-19 wave (median: 102, IQR: 94–112; p = 0. 462) were not significant. Likewise, patient age and gender distribution remained constant. Conclusion Upon the first pandemic COVID-19 wave in Germany, NEC rates declined but recovered within weeks. It is unknown whether this recovery reflects improved medical care and test capabilities or an adjustment of the patients’ behaviour.

Objective: In March-April 2020, during the coronavirus disease 2019 (COVID-19) pandemic lockdown in Denmark, the Danish Health Authorities recommended that, where possible, face-to-face patient-physician consultations be replaced by telephone consultations. The aim of this study was to obtain patients’ evaluation of their telemedicine experience. Methods: Patients who were candidates for telemedicine consultations were recruited based on their urological ailment, necessity for follow-up and comorbidity. New referrals including patients with suspicion of cancer were not candidates for telemedicine. In total, 548 patients had their appointment altered during the period from 13 March to 30 April 2020. Postal questionnaires were sent to 548 patients and 300 (54.7%) replied. Results: In total, 280 patient answered, 224 (80%) men and 56 (20%) women, mean age 69 years (range 18–91) of whom 180 (64.3%) had a benign and 100 (35.7%) a malignant diagnosis. Twenty (6.7%) respondents did not remember their telephone consultation and were therefore excluded. Telephone consultation satisfaction was reported by 230 (85.0%) patients, but they would not prefer video consultations over telephone consultations, and only 102 (36.4%) would prefer telephone consultations in the future. Patients’ age, sex and distance to the hospital did not seem to be associated with telephone consultation satisfaction (age p = 0.17; sex p = 0.99; distance p = 0.27, respectively). In total, 226 (80.7%) were medically assessed as being at risk for COVID, but 74 (26.4%) subjectively evaluated themselves as being at risk. Conclusions: In general (85.0%), urological patients were satisfied with telephone consultations.

The COVID-19 pandemic has been a major burden for healthcare systems worldwide and has caused multiple changes and problems in outpatient care. The aim of this study was to investigate the impact of the COVID-19 pandemic on consultations and diagnoses in gastroenterology practices in Germany. To this end, we retrospectively analyzed data from the Disease Analyzer database (IQVIA) using the International Classification of Diseases, 10th revision (ICD-10). We included all patients aged ≥18 years with at least one visit to one of 48 gastroenterology practices in Germany between April and September 2019 and April and September 2020. A total of 63,914 patients in the 2nd quarter of 2019, 63,701 in the 3rd quarter of 2019, 55,769 in the 2nd quarter of 2020, and 60,446 in the 3rd quarter of 2020 were included. Overall, a clear downward trend in the number of visits to gastroenterologists was observed in the 2nd quarter of 2020 compared to 2019 (−13%, p = 0.228). The decrease in consultations was particularly pronounced in patients >70 years of age (−17%, p = 0.096). This trend was evident for all gastrointestinal diagnoses except for tumors. Most notably, rates of gastrointestinal infections (−19%) or ulcers (−43%) were significantly lower in this period than in the same quarter of 2019. Reflecting the course of the pandemic, the differences between the 3rd quarter of 2020 and that of 2019 were less pronounced (−5%, p = 0.560). Our data show that the pandemic changed patients' behavior with respect to the health care system. Using the example of German gastroenterology practices, we show that the number of consultations as well as the number and range of diagnoses have changed compared to the same period in 2019.

Background Telemedicine has become an integral part of health care delivery in recent years. One of the leading applications for this use is WhatsApp — a free smartphone application that allows instant messaging with pictures and videos. This study analyzed the emerging role of WhatsApp on reducing the need for referrals to medical specialists and to compare the views of physicians regarding WhatsApp consultations. Methods A cross-sectional study based on an anonymous web-survey was conducted among PCPs and medical specialists working in the Israel Defense Forces Medical-Corps during September and October, 2019. Results Of 201 participants, 153 were PCPs and 48 were medical specialists. 86.9 % of PCPs and 86.5 % of specialists used WhatsApp every day in professional settings. Added workload, potential breaching of patient confidentiality and lack of full documentation of consultations were the main concerns among physicians using the application. 60.7 % of PCPs and 95.7 % of specialists stated that these consultations have reduced the need for in-person appointments at least once a week. Conclusions In times of COVID-19 that require social distancing, WhatsApp provides a simple, readily available platform for consultations between healthcare providers, even to the extent of rendering some in-person appointments unnecessary. Healthcare organizations should address the matters troubling healthcare providers, mainly patient confidentiality and lack of documentation in patients’ medical records, while providing adequate compensation for those providing the service during and after work hours.

Background The healthcare system is faced by an ageing population, increase in chronic conditions and multimorbidity. Multimorbid patients are faced with multiple parallel care processes leading to a risk of fragmented care. These problems relate to the disease-oriented paradigm. In this paradigm the treatment goals can be in contrast with what patients value. The concept of goal-oriented care is proposed as an alternative way of providing care as meeting patients’ goals could have potential benefits. Though, there is a need to translate this concept into tangible knowledge so providers can better understand and use the concept in clinical practice. The aim of this study is to address this need by means of a concept analysis. Method This concept analysis using the method of Walker and Avant is based on a literature search in PubMed, Embase, Cochrane Library, PsychInfo, CINAHL, OTSeeker and Web of Science. The method provides eight iterative steps: select a concept, determine purpose, determine defining attributes, identify model case, identify additional case, identify antecedents and consequences and define empirical referents. Results The analysis of 37 articles revealed that goal-oriented care is a dynamic and iterative process of three stages: goal-elicitation, goal-setting, and goal-evaluation. The process is underpinned by the patient’s context and values. Provider and patient preparedness are required to provide goal-oriented care. Goal-oriented care has the potential to improve patients’ experiences and providers’ well-being, to reduce costs, and improve the overall population health. The challenge is to identify empirical referents to evaluate the process of goal-oriented care. Conclusion A common understanding of goal-oriented care is presented. Further research should focus on how and what goals are set by the patient, how this knowledge could be translated into a tangible workflow and should support the development of a strategy to evaluate the goal-oriented process of care.

Background: Infectious diseases (IDs) dominate the disease profile in South Africa (SA) and the ID department is increasingly valuable. There has been little evaluation of the IDs consultation services in SA hospitals. Methods: A qualitative review of ID inpatient consultations was performed over 6 months at a SA tertiary hospital. Prospectively entered data from each consultation were recorded on a computerised database and retrospectively analysed. Results: 749 ID consultations were analysed, 4.8% of hospital admissions. Most consultations included initiation of antiretroviral therapy (ART) (27.8%), lipoarabinomannan antigen testing (24.8%) and change of ART (21.6%). Of patients reviewed, 93.3% were human immunodeficiency virus (HIV) positive and the median CD4 count was 52 cells/mm 3 . The infectious diagnoses (excluding HIV) most frequently encountered were pulmonary and abdominal tuberculosis (TB) and acute gastroenteritis. When all subcategories of TB infection were combined, 42.9% were found to have TB. Patients had predominantly one (45.4%) or two (30.2%) infectious diagnoses in addition to HIV. Some (12%) had three infectious diagnoses during their admission. The number of diagnoses, both infectious (odds ratio [OR] 2.00; 95% confidence interval [CI] 1.11–3.60) and non-infectious (OR 2.27; 95% CI 1.25–4.11), was associated with increased odds of death. Conclusion: The IDs department sees a high volume of patients compared to most developed countries. HIV, TB and their management dominate the workload. This study shows that HIV patients still have significant morbidity and mortality. The complexity of these patients indicates that specific expertise is required beyond that of the general physician.

Introduction:l´objectif de cette étude est d´évaluer l´impact du COVID-19 sur les activités de soins et les recettes au Centre Hospitalier National d´Enfant Albert Royer de Dakar au Sénégal. Méthodes:il s´agissait d´une étude rétrospective, descriptive et analytique comparant les activités de consultations externes, d´hospitalisation et les recettes du premier trimestre des années 2019 et 2020. Résultats:une baisse moyenne de 33% des consultations externes a été notée au premier trimestre de l´année 2020 correspondant à la période de la pandémie comparée au premier trimestre de 2019. Une augmentation des hospitalisations était observée surtout pour les mois de janvier et février. Cependant, au mois de mars, une baisse de 11% était notée. Il en est de même pour les recettes où une baisse n´est observée qu´au mois de mars; elle était de 10%. Conclusion:l´épidémie actuelle au COVID-19 impacte fortement sur les activités de consultations externes, de soins et les recettes du centre hospitalier national d´Enfants Albert Royer. Des mesures efficaces doivent être prises pour éviter les conséquences sur la mortalité et le fonctionnement de la structure.

A recent systematic review of randomised trials suggested that empathic communication improves patient health outcomes. However, the methods for training healthcare practitioners (medical professionals; HCPs) in empathy and the empathic behaviours demonstrated within the trials were heterogeneous, making the evidence difficult to implement in routine clinical practice. In this secondary analysis of seven trials in the review, we aimed to identify (1) the methods used to train HCPs, (2) the empathy behaviours they were trained to perform and (3) behaviour change techniques (BCTs) used to encourage the adoption of those behaviours. This detailed understanding of interventions is necessary to inform implementation in clinical practice. We conducted a content analysis of intervention descriptions, using an inductive approach to identify training methods and empathy behaviours and a deductive approach to describe the BCTs used. The most commonly used methods to train HCPs to enhance empathy were face-to-face training (n = 5), role-playing (n = 3) and videos (self or model; n = 3). Duration of training was varied, with both long and short training having high effect sizes. The most frequently targeted empathy behaviours were providing explanations of treatment (n = 5), providing non-specific empathic responses (e.g. expressing understanding) and displaying a friendly manner and using non-verbal behaviours (e.g. nodding, leaning forward, n = 4). The BCT most used to encourage HCPs to adopt empathy behaviours was “Instruction on how to perform behaviour” (e.g. a video demonstration, n = 5), followed by “Credible source” (e.g. delivered by a psychologist, n = 4) and “Behavioural practice” (n = 3 e.g. role-playing). We compared the effect sizes of studies but could not extrapolate meaningful conclusions due to high levels of variation in training methods, empathy skills and BCTs. Moreover, the methods used to train HCPs were often poorly described which limits study replication and clinical implementation. This analysis of empathy training can inform future research, intervention reporting standards and clinical practice.

BackgroundBecause of practice variation and new developments in palliative pediatric care, the Dutch Association of Pediatrics decided to develop the clinical practice guideline (CPG) palliative care for children. With this guideline, the association also wanted to precipitate an attitude shift towards shared decision-making (SDM) and therefore integrated SDM in the CPG Palliative care for children. The aim was to gain insight if integrating SDM in CPGs can potentially encourage pediatricians to practice SDM. Its objectives were to explore pediatricians’ attitudes and thoughts regarding (1) recommendations on SDM in CPGs in general and the guideline Palliative care for children specifically; (2) other SDM enhancing strategies or tools linked to CPGs.MethodsSemi-structured face-to-face interviews. Pediatricians (15) were recruited through purposive sampling in three university-based pediatric centers in the Netherlands. The interviews were audio-recorded and transcribed verbatim, coded by at least two authors and analyzed with NVivo.ResultsSome pediatricians considered SDM a skill or attitude that cannot be addressed by clinical practice guidelines. According to others, however, clinical practice guidelines could enhance SDM. In case of the guideline Palliative care for children, the recommendations needed to focus more on how to practice SDM, and offer more detailed recommendations, preferring a recommendation stating multiple options. Most interviewed pediatricians felt that patient decisions aids were beneficial to patients, and could ensure that all topics relevant to the patient are covered, even topics the pediatrician might not consider him or herself, or deems less important. Regardless of the perceived benefit, some pediatricians preferred providing the information themselves instead of using a patient decision aid.ConclusionsFor clinical practice guidelines to potentially enhance SDM, guideline developers should avoid blanket recommendations in the case of preference sensitive choices, and SDM should not be limited to recommendations on non-treatment decisions. Furthermore, preference sensitive recommendations are preferably linked with patient decision aids.

A twice-weekly galactomannan (gm) screening protocol was implemented in high-risk hematology inpatients. Study objectives were to determine adherence to the protocol, use of selected resources, and patient outcomes. This retrospective cohort study compared outcomes of interest before and after implementation of gm screening. Adults undergoing matched related allogeneic hematopoietic stem-cell transplantation or induction chemotherapy for acute leukemia were eligible. Patients could be enrolled more than once and were evaluated as episodes. Adherence to the gm protocol was assessed in post-implementation episodes. Use of broad-spectrum antifungals (bsafs), consultations (infectious diseases, respirology), and diagnostic procedures (computed tomography imaging, bronchoalveolar lavage) were compared between phases, as were the patient outcomes of all-cause mortality and clinical success (alive and not taking a bsaf). Of 182 episodes consecutively screened, 70 per phase were enrolled. Clinical characteristics and duration of assessment were similar for the phases. Full or partial adherence to the protocol was observed in 61 post-implementation episodes (87%), with full adherence in 40 episodes (57%). More episodes in the pre-implementation phase than in the post-implementation phase involved receipt of bsafs, consultations, and diagnostics (27% vs. 7%, p = 0.02, 46% vs. 26%, p = 0.014, and 46% vs. 31%, p = 0.083 respectively). Although mortality was similar in the two phases, clinical success at the final assessment was observed in fewer pre-implementation than post-implementation episodes (79% vs. 98%, p < 0.001). Implementation of a gm screening protocol was feasible and associated with significantly fewer episodes involving receipt of bsafs and consultations, and with significantly more episodes showing clinical success.

Background Professionally-focussed behaviour change intervention (BCI) workshops were utilised in the Management of OsteoArthritis in Consultations (MOSAICS) trial investigating the feasibility of implementing the National Institute for Health and Care Excellence (NICE) Osteoarthritis (OA) Guideline in general practice. The workshops aimed to implement the general practitioner (GP) component of the trial intervention: an enhanced consultation for patients presenting with possible OA. This study presents an evaluation of the BCI workshops on GP competency in conducting these enhanced consultations. Methods A before-and-after evaluation of the workshops, delivered to GPs participating in the intervention arm of the MOSAICS trial, using video-recorded GP consultations with simulated OA patients. GPs attended four workshops, which had been developed using an implementation framework. Videos were undertaken at three time-points (before workshops and at one- and five-months after) and were assessed by independent observers, blinded to time points, for GP competency in undertaking 14 predetermined consultation tasks. Results Videos of 15 GPs were assessed. GP competency increased from a median of seven consultation tasks undertaken by each GP at baseline to 11 at both time-points after the workshops. Specific tasks which were undertaken more frequently after the workshops related to explaining that OA is treatable and not inevitably progressive, eliciting and addressing patient expectations of the consultation, and providing written OA information. However, the use of the word “osteoarthritis” in giving the diagnosis of OA was not enhanced by the workshops. Conclusions BCI workshops can enhance GP competency in undertaking consultations for OA. Further initiatives to implement the NICE OA Guideline and enhance the care of people with OA in primary care can be informed by the content and delivery of the workshops evaluated in this study. Electronic supplementary material The online version of this article (10.1186/s12875-018-0715-8) contains supplementary material, which is available to authorized users.

Background Despite evidence of the benefits of physical activity in the management of type 2 diabetes, it is poorly addressed in diabetes care. This study aimed to identify the prevalence and correlates of meeting ≥600MET-min/wk. (150 min/wk) of physical activity and sitting time in adults with type 2 diabetes in Oman. Approaches to encourage physical activity in diabetes care were explored. Methods A cross-sectional study using the Global Physical Activity Questionnaire was conducted in 17 randomly selected primary health centres in Muscat. Clinical data including co-morbidities were extracted from the health information system. Questions on physical activity preferences and approaches were included. Patients were approached if they were ≥18 years, and had been registered in the diabetes clinic for >2 years. Results The questionnaire was completed by 305 people (females 57% and males 43%). Mean age (SD) was 57 (10.8) years and mean BMI (SD) was 31.0 (6.0) kg/m2. Duration of diabetes ranged from 2 to 25 (mean 7.6) years. Hypertension (71%) and dyslipidaemia (62%) were common comorbidities. Most (58.4%) had an HbA1c ≥7% indicating poor glycaemic control (55% in males vs 61% in females). Physical activity recommendations were met by 21.6% of the participants, mainly through leisure activities. Odds of meeting the recommendations were significantly higher in males (OR 4.8, 95% CI 2.5–9.1), individuals ≤57 years (OR 3.0, 95% CI 1.6–5.9), those at active self-reported stages of change for physical activity (OR 2.2, 95% CI 1.2–4.1) and those reporting no barriers to performing physical activity (OR 2.7, 95% CI 1.4–4.9). Median (25th, 75th percentiles) sitting time was 705 (600, 780) min/d. Older age (>57 years) was associated with longer sitting time (>705 min/d) (OR 2.8, 95% CI 1.7–4.6). Preferred methods to support physical activity in routine diabetes care were consultations (38%), structured physical activity sessions (13.4%) and referrals to physical activity facilities (5.6%) delivered by a variety of health care providers. Conclusions The results suggest that intervention strategies should take account of gender, age, opportunities within daily life to promote active behaviour and readiness to change. Offering physical activity consultations is of interest to this study population, thus development and evaluation of interventions are warranted. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4643-7) contains supplementary material, which is available to authorized users.

The practice of dermatology remains to be one that mainly deals with outpatients, but the role dermatologic consultations also play in the care of inpatients should not be undermined. A few studies examined the significance of dermatologic consultations/referrals. Methods 25 cases, randomly chosen from recent referrals to the dermatology service at King Fahd Hospital of the University, a tertiary health facility, were studied to determine whether the referral was necessary. Results The primary reasons for referral were for reevaluation of diagnosis and therapy (44%), therapy (52%) and diagnosis only in 4% ( Table 2 ). Most frequent requesting services were primary care (32%), general practitioners (28%) and nonspecialist dermatologists (25%). The details of the 25 cases are discussed. The differences between dermatologists vs. non-dermatologists, non-specialists in the evaluation of the individual cases are discussed ( Table 1 ). In 88% of cases, additional testing and tissue confirmation were needed in the evaluation and confirmation of the referrals ( Table 3 ). Conclusion Complicated cases and those not responding to therapies given by non-dermatologist practitioners or non-specialists need to have access to tertiary care specialists. Such referrals are of value; however our findings are not informative about quality of care of patients who were not referred.

Currently, shared decision making (SDM) is on the agenda among target patient representative groups, policy makers and professional bodies. Although the International Conference for Shared Decision Making (ISDM) 2011 generated a positive boost, hesitation was also felt among Dutch clinicians, who are challenged by many new tasks. No hesitation is seen among the majority of patients, opting mostly for the SDM model. We haven't reached these patients' needs fully yet, given disappointing research data on patients' experiences and professional behaviour.There is plenty of room for improvement in daily practice, for which many best practices are being designed and increasingly implemented, such as national campaigns to empower patients, central governance of patient decision aids that are developed along clinical practice guidelines, postgraduate training, collaborative learning and system changes, and merging goal setting and SDM in complex care. This is explicitly supported by the Dutch government, the Ministry of Health, patient groups, professional bodies and health insurers. The culture shift in the minds and hearts of patients and clinicians has started but is still ongoing. Enthusiasm for this way of working could be undermined if SDM is defined and implemented in a simplistic, dogmatic manner leading to irresponsible transferring of the professionals' uncertainty, responsibility, and decisional stress to patients.

The quality of interaction between hearing health professionals and patients is one prominent, yet under-studied explanation for the low adherence in acquiring and using a hearing aid. This study describes two different ways of introducing hearing aid to the patients at their first visits at the hearing clinic: an inquiry asking patients opinion followed by offer, and an expert evaluation of the necessity of a hearing aid; and shows two different trajectories ensuing from these introductions. The trajectories represent two extreme ends of a continuum of practices of starting a discussion about hearing aid rehabilitation, in terms of how these practices affect patient participation in decision-making. The analysis shows how granting different degrees of deontic and epistemic rights to professionals and patients has different consequences with regard to the activity of reaching shared understanding on the treatment. The data consist of 17 video-recorded encounters at the hearing clinic. The method used is conversation analysis.

Purpose: Diagnostic delay is a major problem concerning common variable immunodeficiency (CVID). We aimed to determine the pattern of general practitioner (GP) consultations in individuals diagnosed with CVID within 3 years before the diagnosis and whether the risk of diagnosis was associated with the frequency of consultations or character of examinations. Methods: We conducted a nested case-control study, identifying 132 adult CVID patients and 5940 age- and gender-matched controls from national registers during 1997–2013. We used conditional logistic regression to calculate the odds ratios (OR) and 95% confidence intervals (95%CI). Results: The median number of consultations among individuals with CVID was more than twice that of the controls in all 3 years (3rd, 10; 2nd, 11.5; and 1st, 15.4 vs. 4). We found a statistically significant association between the number of consultations and the risk of a subsequent CVID diagnosis, independent of age and gender, but strongest in the individuals < 40 years. In the 3rd year before diagnosis, having 9–15 consultations compared with 1–4 was associated with an OR (95%CI) of 5.0 (2.3–10.9), 2.4 (1.1–5.4), and 1.3 (0.3–5.3) for those aged 18–40, 41–60, and > 60, respectively. Several examinations (i.e., blood tests for inflammation/infection and pulmonary function test) were associated with increased odds of a subsequent CVID diagnosis. Conclusion: The risk of a CVID diagnosis was highly related to both the number of consultations and the character of examinations performed by the GP. CVID should be a differential diagnosis among patients with multiple consultations, especially in patients < 40 years old.

BackgroundGPs have a central position in the care of patients with medically unexplained symptoms (MUS), but GPs find their care challenging. Currently, little is known about symptom management by GPs in daily practice for patients with MUS.AimThis study aimed to describe management strategies used by GPs when confronted with patients with MUS in daily practice.Design and settingQualitative study in which videos and transcripts of 39 general practice consultations involving patients with MUS in the region of Nijmegen in the Netherlands in 2015 were analysed.MethodA thematic analysis of management strategies for MUS used by GPs in real-life consultations was performed.ResultsThe study revealed 105 management strategies in 39 consultations. Nearly half concerned symptom management; the remainder included medication, referrals, additional tests, follow-up consultations, and watchful waiting. Six themes of symptom management strategies emerged from the data: cognitions and emotions, interaction with health professionals, body focus, symptom knowledge, activity level, and external conditions. Advice on symptom management was often non-specific in terms of content, and ambiguous in terms of communication.ConclusionSymptom management is a considerable part of the care of MUS in general practice. GPs might benefit from support in how to promote symptom management to patients with MUS in specific and unambiguous terms.

Background: The need for the use of telemedicine is expected to increase in the coming years. There is, furthermore, a lack ofevidence about the use of video consultations for hematological patients, and how the use of video consultations is experiencedfrom the patients’ perspective.Objective: This study aimed to identify patients’ experiences with the use of video consultations in place of face-to-faceconsultations, what it means to the patient to save the travel time, and how the roles between patients and health care professionalsare experienced when using video consultation. This study concerns stable, not acutely ill, patients with hematological disease.Methods:The study was designed as an exploratory and qualitative study. Data were collected through participant observationsand semistructured interviews and analyzed in a postphenomenological framework.Results: The data analysis revealed three categories: “Intimacy is not about physical presence,” “Handling technology,” and“Technology increases the freedom that the patients desire.”Conclusions: This study demonstrates what is important for patients with regards to telemedicine and how they felt about seeinghealth care professionals through a screen. It was found that intimacy can be mediated through a screen and physical presence isnot as important to the patient as other things. The study further pointed out how patients valued being involved in the planningof their treatment. The patients also valued the freedom associated with telemedicine and actively took responsibility for theirown course of treatment. Patients felt that video consultations allowed them to be free and active, despite their illness.

Purpose: To assess the perceptions of physicians about diabetic retinopathy (DR) screening, barriers to DR screening, and change in management protocol of Diabetes Mellitus (DM) patients with DR. Methods: A cross-sectional descriptive study was conducted using a standard predesigned and pretested structured questionnaire through online mode in the month of April 2021 to assess the criteria used for referral of diabetic patients for DR screening, barriers to DR screening, and the management plan among physicians after the patient has been diagnosed with DR. Results: In total, 100 physicians participated in the study. Physicians responded that criteria used for referral for DR screening according to duration was 10 years (n = 10), and irrespective of the duration (n = 30). According to severity, well-controlled DM without (n = 30) and with other system involvement (n = 50) and uncontrolled DM without (20) and with other system involvement (n = 50) and irrespective of the severity of disease (n = 30) was reported. Physicians (n = 40) responded that patients who were diagnosed with DR belonged to the Type 1 DM category rather than Type 2 DM (P < 0.05). With regard to the barriers and challenges faced in ensuring DR screening, the following themes emerged: no ocular symptoms, lack of compliance, time constraint for the patient, and lack of motivation. Conclusion: We found that the preferred practice pattern of physicians regarding referral for DR screening was dependent on the duration of the disease (mostly 5–10 years of the disease) and severity (when other systems were involved). Noncompliance with advice was the major barrier to DR screening.

Background: Preventive dental visits help in the prior detection and treatment of oral diseases; therefore, to improve oral health outcomes, an opposite knowledge of the way the individuals use health services and the factors apocalyptic of this behavior is essential. Aim: To quantify oral health-care-seeking behavior and influencing factors in the field practice area. Materials and Methods: A cross-sectional study was done in the field practice area among WHO indexed age groups using a pretested and validated questionnaire in August 2017. A stratified random sampling technique was used resulting in a sample size of 200 to assess oral health-care-seeking behavior and influencing factors in this population. Obtained data were analyzed using SPSS version 20. Descriptive statistics, Chi-square test, and binomial logistic regression analysis were used to summarize the results, whereP ≤ 0.05 was considered as statistically significant. Results: The results of this study evinced a female preponderance of 64% with less proportionate (26%) of the study population seeking oral health services, out of which private dental clinic occupied the first choice in using dental services (17%). A carious tooth without pain was the most common dental problem irrespective of age (47.5%). Females were 0.392 times more likely to attend dental visits when compared to males (P = 0.003), while considering social class, people belonging to the upper-middle class were 0.24 times more likely to avail dental services when compared to lower social class (P = 0.015). Conclusion: This study revealed lower rates of dental services sought among the field practice area where most of them availed private clinics compared to government clinics.

Antimicrobial resistance represents a growing threat to global health, yet antibiotics are frequently prescribed in primary care for acute childhood illness, where there is evidence of very limited clinical effectiveness. Moral philosophy supports the need for doctors to consider wider society, including future patients, when treating present individuals, and it is clearly wrong to waste antibiotics in situations where they are largely clinically ineffective at the expense of future generations. Doctors should feel confident in applying principles of antibiotic stewardship when treating children in primary care, but they must explain these to parents. Provision of accurate, accessible information about the benefits and harms of antibiotics is key to an ethical approach to antimicrobial stewardship and to supporting shared decision making. Openness and honesty about drivers for antibiotic requests and prescribing may further allow parents to have their concerns heard and help clinicians to develop with them an understanding of shared goals.

Innledning: Kvaliteten på henvisninger innen konvensjonell røntgen er avgjørende for å kunne gjennomføre og rapportere resultater av undersøkelsen. Likevel tyder mye på at suboptimale henvisninger er et problem som bildediagnostiske avdelinger må forholde seg til. Det er lite kunnskap om hvordan henvisninger vurderes og håndteres i radiologisk avdeling, særlig er radiografens rolle i dette udokumentert. Målet med denne studien er å undersøke hvordan radiografer forstår, erfarer og forholder seg til suboptimale henvisninger og hvordan dette kan påvirke deres arbeid. Metode: Kvalitativ forskningsmetode ble anvendt. En semistrukturert intervjuguide ble utarbeidet og individuelle intervjuer med 5 radiografer fra et sykehus i Østlandsregionen ble utført. Datamaterialet ble analysert ved bruk av tematisk analyse metode. Resultat: Fem kategorier ble identifisert utfra intervjuene. 1) Henvisningskvalitet hvor omfanget av suboptimale henvisninger oppfattes som stort, hvor kliniske opplysninger ofte mangler, særlig ved kontrollundersøkelser. 2) Kommunikasjon, hvor erfaring med innhenting av supplerende informasjon fra pasient, kolleger og leger beskrives som avhengig av erfaringsnivå. 3) Konsekvenser av suboptimale henvisninger, hvor informantene vektla tidsbruk, unødvendige undersøkelser og egen arbeidsopplevelse. 4) Radiografens ansvar for optimalisering og berettigelse av røntgenundersøkelser. 5) Forbedring av henvisningskvalitet ses som en ledelsesoppgave, men også et felles ansvar, noe som tilsier at det er behov for økt samarbeid mellom radiografer, radiologer og henvisere. Konklusjon: Suboptimal henvisningskvalitet erfares som hyppig forekommende. Det påvirker radiografenes yrkesutøvelse, kan gi helsemessige konsekvenser for pasienten og økonomiske konsekvenser for samfunnet. Økt tverrfaglig samarbeid vil kunne bidra til å heve kvaliteten på henvisninger til røntgenundersøkelser. Introduction: Adequately filled in radiology requests forms are crucial for the quality of conducting and reporting examinations. Still suboptimal referrals occur. The knowledge of how the referrals are assessed handled in the radiological department is limited, in particular the role of the radiographers. The purpose of this study was to investigate how radiographers understand, experience and act upon suboptimal referrals and how this influence their work. Methods and Materials: A semi-structured interview guide was developed and applied in individual interviews with five radiographers in south-east Norway. The radiographers had different length of employment and experience in performing plain radiographs. The interviews were transcribed and analyzed using a thematic analysis method. Results: Five main categories were identified from the interviews. 1) Scope and type of referral quality problems, where the problem is recognised, mainly due to missing clinical information, which is reported to occur frequently, particularly in referrals for control examinations. 2) Communication experiences and approaches towards patients, experienced colleges or radiologists, when seeking to substitute missing/wrong referral information. 3)Consequences of inappropriate referrals, in shape of unwarranted examinations, waste of time, and reduced job satisfaction. 4) Perceived responsibility for optimisation and justification of examinations. 5) Strategies to overcome the problem, through leadership and co-operation between radiographers, radiologists and referring physicians. Conclusion: Suboptimal referral quality influence the radiographers work. They recognize it as a commonplace problem with implication for quality patient care, own work-situation and -satisfaction and economically for health society. Increased interdisciplinary co-operation may improve the quality of the referrals.

BackgroundGPs are crucial in adequately diagnosing and initiating appropriate management for patients with psychological problems, but face many challenges and require support.AimTo determine the effects of the e-tool PsyScan.Design and settingA randomised controlled trial with a 1-year follow-up, comparing care using PsyScan with usual care for psychological problems, was undertaken in 10 multidisciplinary primary healthcare centres in Eindhoven, the Netherlands.MethodBetween consultations with their GP, participants in the intervention group could complete PsyScan. The e-tool consists of a distress screener and Four-Dimensional Symptom Questionnaire to differentiate between stress, depression, anxiety, and somatisation symptoms, and to explore symptom severity. PsyScan generated diagnostic and therapeutic advice for GPs and participants that was automatically transferred to each patient’s electronic medical record. The primary outcome was the proportion of participants that achieved a successful treatment result; namely, a decrease of ≥50% on the Symptom Checklist-90-Revised, after 1 year.ResultsThere were 176 participants in the intervention group and 160 in the control group. After multiple imputation, the participants in the intervention group had higher chances of achieving a successful treatment result compared with those in the control group (odds ratio [OR] 2.7, 95% confidence interval [CI] = 1.5 to 4.8, P = 0.002). Quality of life was higher in the intervention group at 12 months (mean difference in EuroQol 5 Dimensions 5 Levels index values was 0.076, 95% CI = 0.015 to 0.136, P = 0.01). The mean 1-year costs per participant were similar (€13 622 in intervention group, €12 487 in control group [β = −0.03, P = 0.71, R2 = 0.05]).ConclusionPsyScan generated clinically relevant and statistically significant effects, and could be useful in offering effective individualised care to patients.

Contains fulltext : 182286.pdf (Publisher’s version ) (Open Access) To inform the development of recommendations to facilitate learning of skilled doctor-patient communication in the workplace, this qualitative study explores experiences of trainees and supervisors regarding how trainees learn communication and how supervisors support trainees' learning in the workplace. We conducted a qualitative study in a general practice training setting, triangulating various sources of data to obtain a rich understanding of trainees and supervisors' experiences: three focus group discussions, five discussions during training sessions and five individual interviews. Thematic network analysis was performed during an iterative process of data collection and analysis. We identified a communication learning cycle consisting of six phases: impactful experience, change in frame of reference, identification of communication strategies, experimentation with strategies, evaluation of strategies and incorporation into personal repertoire. Supervisors supported trainees throughout this process by creating challenges, confronting trainees with their behaviour and helping them reflect on its underlying mechanisms, exploring and demonstrating communication strategies, giving concrete practice assignments, creating safety, exploring the effect of strategies and facilitating repeated practice and reflection. Based on the experiences of trainees and supervisors, we conclude that skilled communication involves the development of a personal communication repertoire from which learners are able to apply strategies that fit the context and their personal style. After further validation of our findings, it may be recommended to give learners concrete examples, opportunities for repeated practise and reflection on personal frames of reference and the effect of strategies, as well as space for authenticity and flexibility. In the workplace, the clinical supervisor is able to facilitate all these essential conditions to support his/her trainee in becoming a skilled communicator.

Funding: British Association of Head and Neck Oncologists Fear of cancer recurrence (FCR) is common among individuals treated for cancer. Explorations of how this fear is expressed within an oncology setting and responded to are currently lacking. The aim was to investigate how head and neck cancer survivors in follow-up consultations express FCR, investigate how a healthcare professional addresses recurrence fears, and examine how survivors experience this interaction. We recorded the follow-up consultations of those participants who have reported FCR as a concern on the Patient Concerns Inventory. We also conducted a follow-up phone interview with the participants. We analysed the transcripts using thematic analysis. Five men and six women were recruited, aged 55–87 (mean age = 64). Follow-up consultation analyses revealed that the consultant used “normalising FCR,” “reassurance,” and “offer of referral to a counsellor.” Interviews revealed themes around how they coped with FCR, relevance of personal history on FCR, and the impact of feeling gratitude towards the consultant on expression of FCR. Analyses indicate that patients may feel reluctant to raise their FCR with their clinician for fear of appearing “ungrateful” or of damaging a relationship that is held in high esteem. Findings indicate the initiation of FCR with patients can be beneficial for patient support. Postprint

Background Chart-stimulated recall (CSR) is a case-based interviewing technique, which is used in the assessment of clinical decision-making in medical education and professional certification. Increasingly, clinical decision-making is a concern for clinical research in primary care. In this study, we review the prior application and utility of CSR as a technique for research interviews in primary care. Methods Following Arksey & O’Malley’s method for scoping reviews, we searched seven databases, grey literature, reference lists, and contacted experts in the field. We excluded studies on medical education or competence assessment. Retrieved citations were screened by one reviewer and full texts were ordered for all potentially relevant abstracts. Two researchers independently reviewed full texts and performed data extraction and quality appraisal if inclusion criteria were met. Data were collated and summarised using a published framework on the reporting of qualitative interview techniques, which was chosen a priori. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines informed the review report. Results From an initial list of 789 citations, eight studies using CSR in research interviews were included in the review: six from North America, one from the Netherlands, and one from Ireland. The most common purpose of included studies was to examine the influence of guidelines on physicians’ decisions. The number of interviewees ranged from seven to twenty nine, while the number of charts discussed per interview ranged from one to twelve. CSR gave insights into physicians’ reasoning for actions taken or not taken; the unrecorded social and clinical influences on decisions; and discrepancies between physicians’ real and perceived practice. Ethical concerns and the training and influence of the researcher were poorly discussed in most of the studies. Potential pitfalls included the risk of recall, selection and observation biases. Conclusions Despite the proven validity, reliability and acceptability of CSR in assessment interviews in medical education, its use in clinical research is limited. Application of CSR in qualitative research brings interview data closer to the reality of practice. Although further development of the approach is required, we recommend a role for CSR in research interviews on decision-making in clinical practice. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2539-y) contains supplementary material, which is available to authorized users.