In the last few decades the emphasis in health care has shifted from acute to chronic diseases, from instrumental interventions to lifestyle related health promotion, from cure to care, and from doctor-centred to patient-centred behaviour. In all these respects, doctorpatient communication has become even more important and the need for good communication skills will only increase. Communication is crucial, because discovering the true nature of a patient's health problem, the translation into a diagnosis and the physician's treatment depend on good doctor-patient communication. This communication is carried out through an exchange of verbal and non-verbal information. The position of general practitioners is stronger in some countries than in others according to the part they play in the health care system 23 . In countries where they act as gatekeepers to secondary care, patients see their general practitioners first even when they require specialist services. A fixed patient list encourages general practitioners to take personal responsibility for the medical problems of their registered patients. The employment status of general practitioners is also closely associated with the structure of the health care system.In most West-European countries general practitioners are predominantly self-employed.Differences in structure reflect important cultural values, as people have strong, often positive, feelings about their health care system. 22 But at the same time differences in structure have important economic consequences; countries with a primary care-based structure have more cost-effective services. 24The main objective of the study was to investigate how the characteristics of various health care systems affect doctor-patient communication in general practice. This objective is consistent with the need for research on the efficiency and quality of health care delivery.
The gatekeeping role of GPs is hardly important in explaining doctor-patient communication. The relationship is more complex than expected. Patient and GP characteristics are more important. Cultural factors should be included in future studies.
PURPOSE Within the time constraints of a typical physician-patient encounter, the full patient agenda will rarely be voiced. Unexpectedly revealed issues that were neither on the patient's list of items for discussion nor anticipated by the physician constitute an emerging agenda. We aimed to quantify the occurrence rate of emerging agendas in primary care practices and to explain the variation between patients and practices. METHODSThis observational cross-sectional study involved 182 primary care practices in 9 European cultural regions. Consecutive primary care consultations were videotaped and rated. Patients completed preconsultation and postconsultation questionnaires assessing their expectations and perceived care. Emerging agenda, determined by using 11-item preconsultation and postconsultation questionnaires, was defi ned as care perceived by the patient to be in addition to expected care, after adjustment for cultural variations of patient expectations. RESULTSFor consultations involving 2,243 patients (mean age, 44.8 years, 58.4% women), every sixth (15.8%) consultation revealed emerging psychosocial agenda. Biomedical agenda emerged in14.5% of the consultations. Rates for unmet expectations were 13.6% and 10.3%, respectively, for psychosocial and biomedical problems. Practices showed considerable heterogeneity of occurrence of emerging agenda (biomedical, median 13%, range 0%-67%; psychosocial, median 14%, range 0%-53%). After controlling for region and patient baseline characteristics, variables signifi cantly related to emerging agenda were patient expectations and biomedical or psychosocial discourse content, but not consultation time or sex of the patient. A large proportion of the variance attributable to physicians remained concealed in a practice dummy variable (explaining up to 8% of the variance).CONCLUSION Unexpected agenda emerges in every sixth to seventh consultation in outpatient primary care visits. INTRODUCTIONT he core activity in primary care is consultation.1 Whether patients consult for cure, services, counseling, prevention, or care, a widely accepted model views the consultation as a dialogue involving elements of negotiation 2 to create a common reality 3,4 to which agenda setting is paramount. 5 Within the time constraints of a typical physician-patient encounter, however, the full patient agenda will rarely be voiced. 6 Eliciting the patient's agenda requires physicians to read cues. 7 The following case illustrates this point: A 33-year-old overweight woman with poorly controlled diabetes visits her physician for her regular checkup. In scenario A, the physician rapidly proceeds to discussing the unsatisfactory levels of glycosylated hemoglobin. He provides advice on her lifestyle and insulin regimen, probably meeting her expectations. In scenario B, the physician takes her pensive mood upon receiving the latest levels of glycosylated hemoglobin as a cue for further exploration. During the consultation the theme of her concerns about a future pregnancy unexpectedly ...
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