We apologise for any lack of clarity in our implication that the extra minute, on average, taken to elicit patients' concerns was statistically significant. For reasons that we described, the study did not recruit sufficient patients to provide clear answers to all our questions. Even so, the regression analysis showed that the extra time contributed almost as much as elicitation to the already small effect on satisfaction with professional care. We then conflated these observations into the claim that elicitation takes time — for which we have, admittedly, only suggestive results.
We still, however, think it feels intuitively right that enquiring after patients' views in a consultation for a self-limiting condition will add to consultation length. If elicitation does not take extra time, then we concede that the small gain in satisfaction with professional care could be worthwhile; if it does lengthen consultation, however, then that cost must be set against the limited gains. We were unable to explore this trade-off further given the problems with statistical power, but these are surely important questions, namely: does eliciting the patient's concerns lengthen the consultation and, if so, is this cost worth the benefit in terms of patient satisfaction?
The use of the prompt as the intervention in this study was not an invitation to switch from one style to another. In consultations designated as controls, the doctors were instructed to ‘continue as usual’ in whichever style he/she chose. In those randomised to the intervention, it is true that it is possible that the doctor may have been behaving in a very doctor-centred way other than when using the prompt, and this would have seemed incongruous. Our validation process was not designed to examine this possibility and it would have required a much more complex study design to explore properly.
Despite these weaknesses, we still think that a debate about elicitation activity (which, in fact, we both practice and teach) would not go amiss. There is conflicting evidence of the benefits of a patient-centred approach and, where its prevalence has been measured, active elicitation of patients' concerns is fairly infrequent. Have we been somewhat premature to promote it to the extent that it has become a criterion of merit standard in the MRCGP video examination?
- © British Journal of General Practice, 2004.
