Yonder: Patient complaints, after-visit summaries, rectal bleeding, and the doorknob phenomenon

Ahmed Rashid

doi:10.3399/bjgp18X699221

Yonder: a diverse selection of primary care relevant research stories from beyond the mainstream biomedical literature

Patient complaints

Despite the fact that communication skills training is now a much bigger part of undergraduate and postgraduate medical curricula than it once was, many patient complaints continue to relate to poor communication. So what’s going on? A group of clinical researchers from Singapore sought to find out, analysing 38 cases of anonymised negative patient feedback about junior doctors.¹ Four main themes of communication errors were identified, namely: non-verbal (eye contact, facial expression and paralanguage), verbal (inappropriate choice of words), content (poor quantity and quality of information provided); and poor attitudes (lack of respect and empathy). The authors conclude that non-verbal communication is too often overlooked in communications curricula, and that there should be a greater emphasis on dialectical learning, particularly at a postgraduate level. More interestingly though, they suggest that regular such analyses of patient complaints could help to iteratively improve local communication skills training content.

After-visit summaries

Reading hospital discharge summaries can be one of the most frustrating tasks that we do as GPs. They highlight all the misunderstandings and miscommunications that take place at the interface between secondary and primary care. However, as patient empowerment becomes increasingly important to policymakers, it has been suggested that after-visit summaries could also be useful in primary care, as a means to remind patients about relevant and actionable information discussed during their consultation. A US-based research team asked patients with acute and chronic primary care presentations to help them develop these summary documents, and found that they were popular with all groups.² Although the authors are keen to develop these further, in the UK this will almost certainly be drowned out by the much bigger, ongoing changes around patient access to online records.

Rectal bleeding

There has recently been much discussion about the rapidly increasing incidence of colorectal cancer in younger people, following the Never Too Young campaign by Bowel Cancer UK. The reality is, though, that most young people who present with rectal bleeding have benign pathology, and there’s no magic way of knowing which will have cancer. In a recently published study, a Harvard research team sought to assess the degree to which primary care physicians document risk factors for colorectal cancer among patients with rectal bleeding.³ They assessed the records of 300 adults who presented with rectal bleeding to primary care clinics between 2012 and 2016. Risk factors for colorectal cancer were documented between 9% and 66% of the time. Although 89% met the threshold for a colonoscopy (according to the US guideline), only 74% were referred, and only 56% got one within a year. The authors conclude that care for patients presenting with rectal bleeding is suboptimal, and based on their data it’s hard to argue with them.

The doorknob phenomenon

You come to the end of a balanced, friendly consultation with a patient you’ve met several times before. You get up and walk over to the door. Your hand is on the doorknob and you’re just about to open it when the patient tells you some crucial information that changes everything. You begrudgingly stomp back across the room to your chair, wondering just how late you’re going to be running by the end of this. Choosing which issues to discuss in the limited time available in primary care consultations is challenging, especially for complex patients with chronic conditions. A Michigan-based study recently looked at the thorny issue of visit agendas in primary care from the perspective of both patients and GPs.⁴ Patient hesitancy to bring up embarrassing problems, record keeping requirements, difficulties balancing current symptoms versus future medical risk, and differing philosophies about medication and lifestyle interventions all came up. The primary factor that leads to well-aligned consultations, the authors conclude, is the ability for patients and physicians to proactively negotiate the visit agenda at the beginning of the visit. So simple, so true.

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