Abstract
Background The vast majority of patients with psychological problems are seen solely by their GP, but little is known about patients' perspectives regarding the variety of consultation skills that may be used in routine GP consultations with these patients.
Aim To identify which aspects of GP consultations patients presenting with psychological problems experience as helpful or unhelpful.
Design Qualitative study.
Setting Nine general practices in north central London.
Method Twenty patients, who had discussed psychological problems as a significant part of their index GP consultation, were asked in detail using the tape-assisted recall (TAR) method, about aspects of the consultation they had experienced as helpful or unhelpful.
Results All patients described how the relationship with the GP helped or hindered them in discussing their problems; this was central to their experience of the consultation. An underlying attitude of genuine interest and empathy, within a continuing relationship, was highly valued. Patients also described how the GP helped them make sense of, or resolve their problems, and supported their efforts to change.
Conclusion These patient accounts suggest that routine GP consultations for psychological problems can have a powerful impact, at least short-term. The GP role in providing a safe place where patients feel they are listened to and understood should not be underestimated, particularly in the mental health context. Further research is required to investigate the longer-term impact of different GP behaviours on patient health outcomes. The TAR method has potential applications in primary care research and in the training of GPs and other health professionals.
INTRODUCTION
Twenty-five to forty per cent of general practice consultations have a significant psychological component.1 Some involve relatively minor or selflimiting episodes of anxiety, depression and adjustment reactions. However, a substantial number involve more severe and chronic problems, with associated medical, social and psychological morbidity.2 Ninety to ninety-five per cent of patients with psychological problems are seen solely by their GP or by primary care counsellors, psychologists or community psychiatric nurses, with a small minority referred to secondary care psychiatric services.3 In addition to prescribing medication, such as antidepressants, GPs use a variety of consultation skills in trying to understand and help such patients.
This qualitative study examines patients' experiences of GP consultations in which the patient presents explicitly with a psychological problem. The importance of obtaining patients' views on services has been emphasised4 and there are some indications that patients' views may at times diverge from professionals' perspectives.5,6 The current study aimed to investigate which aspects of routine GP consultations patients considered helpful or unhelpful, and what impact the doctor's communication had on the patient. By routine consultations we mean consultations in which the GP uses ordinary consultation skills, rather than attempting to employ any specialist psychological interventions.
Most studies of patients' views of consultations have relied primarily on interviews or questionnaires to elicit patients' perceptions.7,8 One way of obtaining a richer, more detailed account is to use actual recordings of the consultation to prompt patients' memories of what was said and how they reacted to it. This approach, known as tape-assisted recall (TAR),9 has been found to give useful information in studying psychotherapy and other forms of helping relationships,9,10 and has been used in one previous study of GP consultations in video form.11 The present study extends the method to systematically examine patients' thoughts and feelings at specific moments in the consultation, enabling links to be made between patients' accounts and what the GP actually said.
METHOD
Setting and recruitment
We recruited from nine general practices in north central London. Of 30 GPs approached, 12 agreed to participate. Consent to record the consultation was requested from all patients attending 60 target surgeries (distributed across the 12 GPs), if aged above 18 years and fluent in English, regardless of the presenting problem. Consultations of consenting patients were recorded on mini-disc by the GP, who conducted an otherwise normal consultation. Consultations were taken as ‘stand alone’ contacts, although it was clear from patient interviews that some had consulted the same GP before.
Patients were invited to participate in the TAR interview if their consultation had a substantial psychological component, defined as containing more than 20 GP or patient statements coded as psychological, using an established content analysis scheme12 (or, exceptionally, fewer if the psychological content was clinically important). Patients were informed that recordings of non-psychological consultations would be immediately erased.
TAR interview
The TAR interview occurred within 1 week of the consultation, at the surgery, patient's home or university, according to patient preference. Patients were initially asked open-ended questions about their general impression of the consultation. The recorded consultation was played back and patients were asked to identify the most helpful and least helpful parts. These segments were played back once more and patients asked about their detailed reactions to them (Box 1). If the patient was unable to identify helpful or less helpful parts of the consultation, the interviewer located segments where psychological problems were being discussed and asked about the patient's reactions to several consecutive GP responses.
How this fits in
Most patients with psychological problems receive help just from their GPs, but little is known about how patients experience these consultations. The human qualities of the doctor–patient relationship were central to patients' experiences of the consultation; attitudes of genuine interest, understanding and acceptance were more important than specific communication skills. We may underestimate the power of routine GP consultations, which have the potential to facilitate the exploration and resolution of patients' psychological problems. The tape-assisted recall method can contribute to research and training in this area, for both GPs and other health professionals.
Clinical interview schedule
After the tape assisted-recall interview, patients completed the computerised (PROQSY) version of the Clinical Interview Schedule-Revised (CIS-R),13 administered in order to determine which patients met formal psychiatric diagnostic criteria.
Data analysis
Verbatim transcripts of the interviews were analysed inductively, simultaneous with data collection, using established procedures of qualitative analysis.14 The constant comparison method15 was used to identify similarities and differences within and across patients' accounts of their consultations, in order to arrive at a set of common themes; links weremade between what was said in the recall interview and what the GP said in the index consultation. Every transcript was first analysed independently, then through discussion the team arrived at a consensus about how best to represent and organise key ideas in the data. This ‘consensual’ team approach has been recommended for increasing the validity of qualitative analysis.16 Data collection ended when saturation occurred,15 that is, when little new information emerged from interviews and a rich set of themes had been developed.
Box 1. Questions used in the TAR semi-structured interview.
Initial questions:
▸ What do you remember about what the doctor said?
▸ How did you feel after the consultation?
▸ Was it similar or different to other consultations you have had?
Questions after tape of GP consultation played back (in whole or segments):
▸ What about this part of the consultation was helpful/unhelpful?
▸ What were you thinking and feeling at that point?
▸ What do you think the doctor was trying to do at that point?
▸ Has anything that was said here made you think or feel differently afterwards, or made you do anything differently?
RESULTS
Sample characteristics
Four male and eight female GPs (mean age 40 years, range = 32–55 years) participated. One hundred and seventy-three patients agreed to have their initial GP consultation recorded, of which 48 (28%) met the inclusion criteria for psychological consultations (the other 125 consultations being insufficiently psychological in content). Twenty (42%) of these 48 took part in the TAR interview (seven men, 13 women, mean age 44 years, range = 23–81 years). The main reasons for non-participation were unavailability within the required time, no telephone contact possible, and withdrawal of consent.
On the CIS-R, four of the 20 interviewed patients had diagnoses of depressive disorders, two of generalised anxiety disorder, four of mixed anxiety and depression and eight had sub-threshold scores (missing data on two). Of those with sub-threshold scores, three were recovering from treatment of depression, three discussed feelings of anxiety and depression in the consultation, one was troubled by memories of childhood sexual abuse, and one presented with fatigue and insomnia and was prescribed antidepressant medication. Of the two patients who had not completed the CIS-R, one was being treated with paroxetine for depression and the other was attending a local psychiatric day hospital.
Patients' views of the consultation
The qualitative analysis yielded six themes, within two distinct clusters (Box 2): the first, developing a working relationship, was present in all patient interviews; the second, facilitating change, was less frequent but had powerful consequences when it occurred. Each theme is labelled according to its helpful aspect, reflecting the generally high level of patient satisfaction with the consultations. In most cases there were also examples of these helpful processes not occurring, leading to a perceived difficulty in the relationship with the doctor. We have, therefore, presented both positive (helpful) and negative (unhelpful) examples relating to each theme. Following the presentation of the two clusters of themes, we provide illustrations of the link between the consultation and the patient's reactions in the TAR interview.
Box 2. Themes elicited from the TAR interviews.
Developing a working relationship:
▸ Shows interest and listens
▸ Shows understanding and acceptance
▸ Provides continuity
Facilitating change:
▸ Makes sense of problems
▸ Advises and facilitates decision making
▸ Supports action and progress
(1) Developing a working relationship
All patients commented on how aspects of the relationship with the GP helped or hindered them in talking about their problems; this was central to their experience of the consultation. The human qualities of the GP were paramount for many:
‘[It's] a human touch … [you can] say what you feel, it's OK … if I could identify and bottle it, it would be worth a fortune.’ (P7)
Shows interest and listens
Positive experiences
The majority of patients particularly valued instances when the GP showed a genuine interest in what they had to say and listened to their problems in a warmand attentive way. Sometimes patients identified specific GP behaviours (verbal and non-verbal) conveying interest and attentive listening, but often they described a more general feature of the relationship:
‘It's a real human being, isn't it, responding to another one.’ (P14)
Being listened to was linked with a sense of being known as an individual:
‘She pays attention, and I'm a person, not just a body…from-one consultation to another she does remember things. So she must be listening.’ (P8)
This often helped patients to open up and talk about difficult issues:
‘[She] was able to unlock my voice.’ (P12)
Being listened to was especially important in the context of experiencing psychological problems:
‘It's important when you feel lonely, isolated and depressed and desperate … someone's taking you seriously.’ (P7)
Negative experiences
Patients contrasted instances of GP interest occurring in the index consultation to instances of previous, less helpful consultations with other doctors when it was absent. There were also a few instances when patients felt that GPs consulted in this study were not appropriately attentive. Sometimes this was quite subtle:
‘I was giving her little leads [about being stressed and drinking alcohol to get to sleep] and I felt like maybe if she'd have prompted me a little bit more on that … it would have been a little more sort of helpful.’ (P3)
Shows understanding and acceptance
Positive experiences
Some patients indicated that their experience went beyond feeling that the doctor was listening and attentive, and expressed a sense of being more fully understood and accepted:
‘It made me feel like he was on my side, as if he understood how I felt and what I was going through.’ (P18)
This enabled patients to trust the GP with very vulnerable aspects of themselves:
‘I felt relaxed and able to express things that had been very painful … I felt in a safe environment.’ (P19)
Negative experiences
In contrast, some patients described occasions when they perceived the doctor as not having understood, or having judged or blamed them. For example, a seemingly straightforward question about how a patient became HIV positive was perceived by the patient as blaming:
‘… because I felt that it pointed the finger back at me … a subtext is that I was being irresponsible.’ (P6)
Patients described in the research interviews how some GP responses had annoyed or discomforted them, but GPs were unlikely to pick these up, as patients did not refer to this during the consultation.
Provides continuity
Positive experiences
Patients valued being known and remembered by the doctor from previous consultations, especially when this was unexpected:
‘… you know, shock, horror, he actually remembers me.’ (P1)
This was particularly important in the context of mental health problems:
‘He knows where I am; he knows where I've been; he knows the steps I've took.’ (P2)
This same patient experienced the GP as a secure base to which she could return if necessary:
‘… it's like, “Go out there, see how you feel, but I'm here if you need me”—that's how it felt.’ (P2)
Patients also appreciated GPs saying they were available for future contact:
‘… so you don't feel like when you've walked out of there vulnerable, you've been dropped like a hotcake; there's this ongoing care all the way through.’ (P9)
Negative experiences
Lack of continuity was generally experienced as inhibiting contact:
‘If guaranteed to see the same doctor, I would go back for a chat, but not to tell the same story to a new GP.’ (P12)
(2) Facilitating change
The second cluster of themes concerned patients' accounts of how the GP helped them make sense of or resolve their problems and supported their efforts to change.
Makes sense of problems
Positive experiences
Explanations of the mechanisms of anxiety and depression and the psychosocial determinants of problems were experienced as very valuable by some patients:
‘She's the first one that's explained all these things [the physiological link between anxiety and the patient's stomach problems] and I've been to anxiety meetings … in the hospital.’ (P13).
Receiving an explanation contributed to this patient's feeling of great relief after the consultation:
‘I come out of there and I feel oh like one of the seven dwarfs, you know, whistling down the road.’ (P13)
Sometimes the explanation was a clarification that the patient was not abnormal or ‘mad’, which was also experienced as reassuring:
‘He's just really put me at ease, that I'm not abnormal … I'm not mentally unstable.’ (P1)
A joint process of finding meaning was also valued:
‘We basically managed to outline that it is due … to the stressful levels of my job, and that's why I had the problem.’ (P1)
Negative experiences
Sometimes patients felt the GP was either too quick to give an explanation for their problem or provided an explanation that didn't fit with their own perception:
‘I was saying I was stressful … I didn't think I sounded depressed … she probably meant it really good, but I feel disappointed because, I don't know, I don't feel particularly depressed.’ (P14)
Advises and facilitates decision making
Positive experiences
Advice was perceived as particularly helpful when it occurred in the context of a collaborative approach:
‘We talk about my strategies [for coping with depression] … she gives me good advice … and I listen to her. So it's like a team process, but it's subtle.’ (P9)
Patients appreciated having options discussed with them, but then being able to make the final choice about treatment or a particular course of action:
‘She gives me the information [about coming off antidepressants] and then lets me make the choice.’ (P8)
Negative experiences
Although advice was often experienced as a helpful aspect of the consultation, sometimes (even occasionally within the same consultation) it was perceived as unhelpful. This sometimes occurred when patients felt the GP did not take their view into account, thereby reducing the patient's autonomy. For example, one GP gave advice about psychosocial rehabilitation, which the patient felt reticent to challenge:
‘But I do sink very easily…into patient-mode when I'm meeting with the professionals who are dealing with my mental health problems, it's difficult for me to be open.’ (P5)
Similarly, advice given without sufficient understanding of the situation or context was usually rejected.
Supports action and progress
Positive experiences
Patients felt encouraged and validated by the GP's support of actions they had taken or progress they were making. For example, one patient described the impact of the GP congratulating her on getting through a panic attack:
‘… it gives you a boost … it's like when a kid does something for the first time … it's a big step for me.’ (P2)
Positive feedback was especially valued:
‘… [she] looks to my strengths and not the things that are falling apart … that helps me to be more assertive and more confident.’ (P9)
Encouragement that things could get better gave patients a sense of hope and direction:
‘I get a positive feeling from her which just makes me kind of want to fight.’ (P8)
Negative experiences
No negative examples of this theme occurred in patients' accounts.
Link between the consultation and the patient's reactions
In order to demonstrate the link between what the GP said (taken from the transcript of the consultation) and the patient's subsequent thoughts, feelings and behaviour (taken from the transcript of the TAR interview) we present two excerpts from our data set. These illustrate two of the themes, one from a positive and one from a negative aspect.
Example of theme ‘Shows interest and listens’ (positive experience)
Mrs X, in her mid-50s, consulted her GP for problems about coming off hormone replacement therapy (HRT) patches. This was not her first consultation with this doctor.
What the GP said
The following excerpt occurred about a third of the way into the consultation. Mrs X had been talking about the physical effects of coming off HRT patches a week ago, following a visit to the hospital consultant. (The asterisk indicates the GP response identified by Mrs X as helpful.)
Mrs X: ‘… I do get more weepy, I must say. I know I've had a terrible time at home recently, but I don't know whether that's just— [the hormone]. You know, not having that. I don't know what it is, but I'm prepared to try it [staying off the HRT patches] for 3 months’.
GP: ‘Yeah. So you've been, are you feeling weepy just since you've come off them—the patches—or you were anyway?’
Mrs X: ‘Well, I suppose, yes. No, no. No, I could cope with them. The problems perhaps have got worse in the last week …’
GP*: ‘There's a lot of stress at home, is there?’
Mrs X: ‘Yes. With my partner.’
The patient's interpretation of what was said. Following this excerpt, there was some discussion about the nature of Mrs X's relationship problems and possible sources of support.
‘She was interested in, you know, the stress at home … encouraging me to talk about it … she might have by-passed that and gone on to something else, but she didn't.’
The patient's immediate experiences:
‘It was what I needed at the time … I didn't go round there particularly to talk about my stresses at home. But it came up and I was quite pleased to unbottle it … I felt she would listen … it all flooded out then, I suppose. It was quite a relief to get it out.’
Changes following the consultation:
‘I certainly felt better when I came out to come home … Still got my aches and pain(s), but mentally I felt better, I suppose, from talking to her.’
Referring to the consultation as a whole, Mrs X said:
‘I was able to come home and talk to him [her partner] about it [their relationship problems].’
Example of theme ‘Advises and facilitates decision making’ (negative experience)
Mr Y, in his 40s, had a history of high blood pressure and had recently been feeling stressed at work (he had a manual job in engineering). This was his first consultation with this doctor.
What the GP said
The following excerpt occurred just over half-way through the consultation. Mr Y had been talking about the pressures at work, his symptoms of anxiety, and his use of alcohol to ‘wind down’ and relieve worry. The GP had mentioned the usefulness of exercise for decreasing anxiety, and returned to this topic here. (The asterisk indicates the GP response identified by Mr Y as unhelpful.)
Mr Y: ‘… I mean the drinking does affect my weight as well … I've put on a lot of weight … in the last few year … but I mean probably put it down to that [the drinking] really.’
GP*: ‘We can refer you to the local gym to exercise, if you want to. It's a way of both decreasing weight, and … it is quite a good stress reliever. They can put a special exercise programme together that's good for blood pressure, good for weight …’
Mr Y: ‘I mean that was the other thing, I mean—I mean, with this blood pressure, the reason I first started having it done was my dad died like of a couple of strokes.’
Immediately following this excerpt, the topic switched away from exercise, but shortly afterwards the GP returned to the possibility of referral to a gym.
The patient's interpretation of what was said
Mr Y viewed the GP's suggestion of exercise (and similar suggestions from other healthcare professionals in the past) as misguided because it was inappropriate to his situation:
‘… they don't understand what you do … I mean, when you come home from a night's [manual work], you—every joint of you is aching and the last thing you want to do is go down the gym.’
Later in the interview, he commented:
‘Well, it's just like… exercise is good for stress … or losing weight … but it can't be the same for someone who has, say, a desk job, for someone who's [doing my job] … stripped down to your sort of, just a T-shirt, and it's wringing wet from sweat. So I know I must be getting exercise …’
He attributed the suggestion to GP training:
‘… they seem to learn these things, you know, stress management, or where they go on a course for that, and … they'll recite that back to you … So that's not her fault, I mean that's what she's been told or taught … but it doesn't really work with me, anything like that.’
The patient's immediate experiences
Mr Y's tone of voice indicated that he felt annoyed, although he did not state this explicitly. As is evident from his comments above, he did not find the GP's advice about exercise helpful.
Changes following the consultation
Consistent with the above, Mr Y did not report any changes following the consultation. Referring to the consultation as a whole, Mr Y said:
‘… there was nothing there that really helped me as such.’
DISCUSSION
Summary of findings and comparison with existing literature
The doctor–patient relationship was central to all patients' experience of the consultation, and genuine interest and empathy, within a continuing relationship, was highly valued. Our study adds to the evidence for the importance of a good working relationship in general practice, both for psychological and non-psychological problems.5,17 Studies of the doctor–patient relationship in primary care have identified listening, showing interest and understanding as important,18 helping patients to build a relationship of trust in the doctor.19 These are likely to be particularly important in consultations about psychological problems, as patients may be embarrassed or ashamed to tell the doctor about what they are experiencing. The GP's role in providing a safe place for such patients to feel listened to and understood should not be underestimated.
The second cluster of themes related to the GP's attempts to facilitate change. Such themes occurred less frequently, but were often associated with strongly felt experiences, both positive and negative. Patients indicated they were helped by clear explanations of their difficulties, particularly somatic manifestations of anxiety and depression,20 and by simple advice and support. Unlike the first cluster, this second cluster involved doctors drawing upon their expert knowledge. Patients particularly appreciated a shared decision-making approach. Their accounts support the value of a low-key intervention comprising shared problem clarification, understanding and action planning. This resembles formal problem-solving approaches for psychological problems shown to be effective when used by GPs,21 but in this study GPs used a less structured approach, which may be more feasible in routine consultations.
Expanding on previous qualitative studies of doctor–patient communication6,11 this study highlights the patient's active role in interpreting and evaluating what the GP says during the consultation. Apparently similar GP behaviours were experienced differently by different patients within different contexts, and not all interactions were experienced positively. Approaches to communication skills training taking such complexity into consideration22 are supported by our data, suggesting that a positive experience of the doctor–patient relationship is not simply a function of specific types of doctor responses within the consultation. Our findings have potential relevance to all clinician interactions with patients, both within primary care as well as in other medical arenas, given the high percentage of healthcare contacts containing a significant psychological or emotional component.23
Strengths and limitations of the study
There was potential selection bias in our sample of participants, who may have been more positive about their GPs or more responsive to GP input to their problems. They consulted the GP about a heterogeneous array of psychological problems, and only half met CIS-R criteria for an ICD-10 diagnosis of psychological disorder. This is reflective of general practice, where depression and anxiety often present as a continuum rather than discrete disorders and comorbidity is common.3 Analysis of the transcripts revealed no difference in themes between those patients who did or did not meet formal diagnostic criteria.
The doctors were also self-selected and may have been more interested in working with patients with psychological problems; certainly the taped consultations showed considerable practitioner skill. It is also possible that GPs may have conducted these consultations differently as a result of being taped, and spent more time with patients than usual. However, patients who had seen the same GP before indicated that the index consultation was representative of their previous experience. Even if the consultations in this study represent those that are well-conducted and perceived positively by patients, they are valuable in documenting what can occur under favourable circumstances. Finally, the use of audio rather than video recordings meant that our findings were restricted to doctors' verbal and paralinguistic behaviours. However, in a previous study using video techniques for TAR, visual cues were rarely remarked on by patients and it was their verbal communication with the GP that patients referred to in their search for meaning within the consultation.11
Implications for future research and clinical practice
Our data make clear that the routine GP consultation is not a single entity and that individual consultationsmay be very different, not only in form and content, but also in the impact they have on patients with psychological problems. This raises questions about the design of much primary care mental health research, where it is assumed that all GP consultations are likely to be similar in their impact on patients within the grouping ‘GP treatment as usual’.
Our findings also raise the question of how patients' experiences of consultations may have an impact on the outcome. The patients' accounts suggest that routine GP psychological consultations can have a powerful impact, at least in the short term. Talking about psychological problems in the context of a good doctor–patient relationship may in itself be therapeutic. In counselling and psychological therapy patients have better clinical outcomes where there is a better ‘therapeutic alliance’,24 and there is also preliminary evidence of this in general practice.25,26 Further research is needed to examine whether patients' views of helpful or unhelpful aspects of the consultation are associated with longer-term outcomes, for example, whether a perceived facilitative relationship leads to a quicker or more sustained improvement in symptoms or, conversely, whether behaviours perceived as unhelpful may be associated with poorer outcomes. There may also be a ‘sleeper effect’, in that things the GP said or did may only come to fruition later.
The tape-assisted method has an important potential role in primary care health services research. Compared with usual semi-structured research interviews it has far greater specificity, in that what is discussed in the interview is prompted by the actual recorded consultation, both as regards the interviewee and the researcher. It enables researchers to identify patients' reactions to specific things that the doctor (or other health professional) said or did during the consultation, and thus to work out why a particular consultation was successful or not from the patient's perspective, despite apparently similar consultation skills often being employed in both ‘successful’ and ‘unsuccessful’ consultations. There is also scope to apply this method to examine health professionals' reactions to what their patients say during the consultation, which may give indications about potential mis-communication.
Our findings have practical implications for the training of GPs and other health professionals and how they conduct their consultations. Firstly, it is essential to establish a working relationship in which the patient feels listened to and understood. Secondly, since the meaning made by the patient of the doctor's response is not necessarily predictable from what the doctor says, it is important for doctors to actively ascertain patients' reactions to their interventions. This type of ‘meta-communication’ may be one way for doctors to access during the consultation the important material that the TAR method can generate in the context of a research interview. Patients can be encouraged to give feedback if the consultation is not proceeding in a way they find helpful; the doctor may not always be able to provide patients with what they are seeking, but such explicit feedback and discussion can lead to a more collaborative approach.
Acknowledgments
We would like to acknowledge Frank Frasquilho for help in recruiting patients and carrying out the research interviews, Glyn Lewis for his permission to use the PROQSY computerised version of the CIS-R and Irwin Nazareth for commenting on an earlier draft of this paper. We are very grateful to all the GPs and patients who participated in the study.
Notes
Funding body
The North Central Thames Primary Care Research Network (NoCTeN)
Ethical approval
Ethical approval was obtained from the Camden and Islington Local Research Ethics Committee (reference 99/118)
Competing interests
The authors have stated that there are none
- Received June 8, 2005.
- Revision received October 25, 2005.
- Accepted January 4, 2006.
- © British Journal of General Practice, 2006.