No description available.

No description available.

No description available.

No description available.

No description available.

No description available.

Medical students are taught both the underpinning theory of, and the skills to operationalise a patient-centred approach, as required by the General Medical Council (1993). Yet research has shown that students become more doctor-centred and less patient-centred, in their approach towards patients, as they progress through medical school. In addition to this, it has been demonstrated there is a decline in both students' empathy with patients and their history taking skills, in particular regarding a patient's social history.

Drawing on a Grounded Theory approach, this interpretivist study explores the multiple influences on a pre-registration house officer's (PRHOs) response to a judgement call within a clinical setting. The study aim was to generate a conceptual understanding of judgement in a 'risky' situation and reflected this researcher's dissatisfaction with explanations in the medical literature about how clinicians think about 'risk' in practice. In a phased approach to data collection (Phase One n=32, Phase Two n=21) semi-structured interviews were conducted with individual PRHOs. A third phase developed the emerging theory. The PRHOs needed to recognise and weigh up, amongst a myriad of identified 'risks', those that had clinical relevance. One such judgement was whether or not to gain senior intervention. The factors mediating this judgement were: tenets that needed to be balanced to ensure safe practice within a training context ('act responsibly' and 'progress and develop') and estimating the chance and severity of potential consequences, not only to the patient, but to himself and the team. What was needed to make these judgements was knowledge of the patient's condition, one's ability to understand and manage the situation, and recognition of contextually meaningful cues. A perceived lack of knowledge or understanding was also influential. The PRHOs' judgement of 'risk' was a dynamic process, akin to a heavily ornate mobile with interconnecting elements and exemplified by the need to create counterbalances between multiple consequences. No prescribed action could have allowed the PRHOs to deal with the multiple configurations that they faced and needed to take into account. It is argued that judging whether it was appropriate to contact a senior, mirrored essential attributes for clinical practice: an independent yet co-operative and discerning practitioner who was able to balance multiple considerations whilst ensuring patient care. The PRHOs were practising what they needed to become.

This study explores the nature of shared decision-making (SDM) in general practice consultations. It has been claimed that patient involvement in their own health and healthcare improves concordance, patient satisfaction and outcomes. Although this approach to treatment decision-making is widely advocated the process of sharing decisions has, to date, been little understood. Cognitivist or intra-psychic assumptions about decision-making have underpinned the traditional methods of investigation into the doctor-patient consultation and as a result interactional dynamics have not taken centre stage. Participants' motivations and emotions have been 'read' as enduring entities rather than as discursive constructions attending to interactional matters. As a consequence most of the work into the medical encounter has tended to be one-sided and addresses only one participant at a time. Thus, one half of the interaction may be neglected. Therefore, only a partial picture of the nature of interaction is provided. In summary therefore, traditional approaches have not considered the medical encounter as a process of joint-production and decision-making as an emergent property of the interaction. In contrast this study adopts a discourse analytic approach that allows for a fine-grained examination of what might be described as the minutiae of the interactional flow and trajectory of consultation. An examination of the content and form of the consultation-as-interaction has been undertaken in order to identify and describe a variety of discursive devices and resources that participants deploy to accomplish particular activities. As a result, the analysis provides an insight into the actual processes of the SDM consultation and how treatment decisions are arrived at. The primary data source was audio-recorded consultations having been initially identified from a questionnaire survey and patient interviews. Three analytic themes that are key aspects of the SDM consultation are examined. These are, the generation of patient involvement using first-person pronouns; the construction of direct, successful and unsuccessful requests from patients; the rhetorical construction of risk and evidence, with attention to the locating of agency. The analytic conclusions illuminate the complexities arising within the medical encounter and highlight problem aspects which impact on the theoretical and philosophical foundations SDM. Notably, SDM does not happen with the ease implied by current models and may work to maintain a biomedical GP as 'expert' approach rather one in which the patient is truly involved in partnership. In short, new information is available on the consultation process. This information has implications for health care practice and communication skills training and existing models of SDM may need to be re-evaluated.

It is common in all areas of medicine for patients to present with symptoms which cannot be adequately explained by the Western biomedical criteria of recognisable organic pathology. In this situation the social and clinical predicament of the patient is characterised by uncertainty and can lead to unnecessary emotional, social and legal difficulties. Since primary care is the forefront of diagnosis and management in the UK, General Practitioners deal regularly with uncertain and contested illness. Patients presenting Medically Unexplained Symptoms (MUS) represent a challenge to GPs in terms of their professional abilities and GPs may feel, rightly or wrongly, a 'pressure to prescribe' from patients, whilst also experiencing a pressure not to prescribe from their colleagues in secondary care specialisms. The widely held view of primary care is that a familiarity between doctor and patient is the most auspicious milieu, particularly in terms of managing chronic illness. However the concept lacks precision, whilst a growing body of research suggests a more complex picture. Drawing on the concept of researcher as 'Bricoleuse(1)', an innovative methodological approach was adopted for exploring the nature of familiarity and non-familiarity within the primary care setting and its impact on doctor-patient interaction in terms of the management of MUS. Consecutive patients attending primary care physicians were recruited and their consultations recorded. GPs identified consultations containing MUS. Semi-structured, tape-assisted recall interviews were conducted with participating GPs and, where possible, with the patients. Transcripts were analysed thematically, triangulating between the three data sources. Data collection was conducted at five primary care surgeries across Merseyside: three large practices which had several GPs and other available services, and two single GP practices. The total number of cases collected was 23, 12 of which were 'full', consisting of three data sources: consultation, post-consultation interviews with GPs and post- consultation interviews with patients. A further 11 cases consisted of two data sources: consultations and post-consultation GP interviews. Interpretation of the data revealed that the familiarity or non-familiarity a patient had with the health care setting generally, and more specifically a particular surgery and/ or GP, often did conspicuously influence the nature and course of the interaction during the consultation. This was confirmed by GPs reflecting on their familiarity or non-familiarity with particular patients and specific communities. Interestingly examples emerged of positive and negative aspects of familiarity and of non- familiarity. The findings of this research provide an original contribution to the understanding of Medically Unexplained Symptoms within the wider context of contested illness and uncertainty in the primary health care setting. The complex social and clinical nature of this cohort of patients warrants an equally complex approach in terms of meeting their needs, including recognition that whilst in some cases familiarity may be conducive to management, in other cases non-familiarity may be just as useful and desirable. These findings have further resonance for the field of primary care more generally since they highlight the complexity of GP work and promote the value of 'choice '. 1 In most of the literature where reference is made to the person performing the act of 'bricolage', the term 'bricoleur' is used; however this is the masculine form of the noun, and since the researcher is female, the feminine form 'bricoleuse' is used (WordReference.com accessed 7th December 2011).