Medical generalism in the UK - Caring against the clock

Medical generalism in the UK: Caring against the clock:

Greg IrvingClinical Lecturer in General Practice

“Many respondents talked about having adequate time to do really good diagnostic practice, especially in the context of more complex patients, more investigative and management options to explore”

複雑な背景を持ち、多くの検査が必要だったり、マネジメントを色々考える必要があったり。回答者は、しっかりとした診療の実施のための、十分な時間の確保について触れていた。

“…ten minutes is now very short to combine a patient-centred approach to information gathering, do a proper examination….”

情報を集め、適切な検査をし、患者中心の医療を提供するには、 10分という診療時間では、とても足りなくなっている。

Constraints to generalism

• Qualitative study identifying constraints to delivering expert generalist care

• Participants from 14 WONCA Europe countries• Generalist capacity assessment framework

(questionnaire & topic guide) – Sense making – Engagement – Action– Monitoring

ジェネラリズムを制約するもの

Generalist capacity assessment framework

https://www.surveymonkey.com/s/QCL6R3K

Constraints to generalism

• Lack of time in consultation was a key constraint to delivery expert generalist care.

GP trainee: “Time spent looking after complex patients is well spent but there is often no time for this on a busy day.’

Hasegawa H et al. PHCRD 2005; 6: 320–328

“7 minutes had become the summary statistic of the day”

Sir Denis Pereira Gray PRCGP 1998

Pereira Gray D. BJGP. 1998;48:1816–1817

Year 1997 2006 2008 2014

Mean consultation length (mins)

9.37

Mean no. consultations (any

health professional) /

year

4.01

Mean number of GP consultations /

year

2.92

Total time /year (mins)

27.8

Irving G et al. BJGP 2012;62:404

Year 1997 2006 2008 2014


9.37 11.7



year

4.01 5.22


year

2.92 3.23


27.8 37.8


Year 1997 2006 2008 2014


9.37 11.7 -



year

4.01 5.22 5.5


year

2.92 3.23 3.4


27.8 37.8 -


Year 1997 2006 2008 2014


9.37 11.7 - -



year

4.01 5.22 5.5 8.3


year

2.92 3.23 3.4 3.49


27.8 37.8 - ~40.8


SAGE consultation model

• SAGE = School for Advancing Generalist Expertise • Assumes a competence in the basics of consultation• Not a replacement for, but an extension of the work

described by Pendelton, Neighbour, and etc

Cochrane review (Wilson et al 2009)• 4 trials : Short term, not of high quality, 1978-1992

• Insufficient evidence to say whether increasing consultation length provides patient benefit (or not)

• With longer consultations• More health promotion • GP did not run more tests• Patients were not any more satisfied with care • Patients did not alter follow-up behavior

Wilson A et al. Cochrane Database of Systematic Reviews 2006;1:CD003540

Systematic review (Hutton et al 2007)

• Focus on psychological problems

• 29 studies included

• Consultations with a recorded diagnosis of a psychological problem were longer.

• GPs reported that time pressure is a major barrier to treating depression.

• Evidence that increased consultation length is associated with more accurate diagnosis of psychological problems.

Hutton C et al. BMC HSR 2007; 7: 71

Care plus trial (Mercer)

• Pilot cluster randomised trial

• Intervention - longer consultations for patients with multimorbidity

• Longer consultation led to increased :– Patient satisfaction – Patient enablement – Quality of Life

Summary• Lack of time is a key system constraint to delivering expert generalist

care

• Large number of GPs is associated with increased consultation length

• Evidence limited to say whether increasing consultation length provides patient benefit (or not) – more needed

• Small increase in time may help enable patients with complex needs

• Increased consultation length is associated with more accurate diagnosis of psychological problems.

診療時間が足りないことが、優れたジェラリストケアを提供する上での主な制約

多くの GPが診療時間の延長に関連している

診療時間の延長が患者にとって有益かどうかについて、まだエビデンスは弱いーもっと研究

多少の診療時間の延長は複雑な背景を持つ患者にはよいかもしれない

診療時間の延長と、心理的問題の正確な診断は関連している

Healthcare

Medical generalism in the UK - Caring against the clock