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A discussion of the problems and challenges of moore medical

Topic changes were another tactic employed by GPs to defuse sensitivity and acknowledge interactional delicacy. Some patients appeared complicit with that tactic and as seen in examples 2, 5 and 11 did not challenge that. However, in Example 8, the sudden topic switch appeared to take the patient by surprise, prompting him to point to his presenting sore eye.

Challenges to alcohol and other drug discussions in the general practice consultation

Even when the AOD topic was first raised by patients, some GPs understated the importance of the problem, recommending intake reduction and rolling with resistance, as in Example 9. Shared humour female patient, age 27; male GP, age 48 Consultation code: Navigating humour male patient, age 66; male GP, age 47 Consultation code: Mitigated advice male patient, age 40; male GP, age 31 Consultation code: Some shorter discussions demonstrated motivational interviewing techniques of rolling with resistance, handling the interactional delicacy and relationship building.

Primary care interviews All three GPs who were approached for the interview to explore these findings granted the request. A primary health organization manager also explained that the user-pays primary care system offers no incentive for doctors to spend additional consultation time discussing AOD problems that might arise: Discussion These findings are consistent with other studies that have identified that doctors do not always take up opportunities to discuss AOD with patients 91223 — 25 even when the patients themselves voluntarily divulge information about that.

Many possible factors impact on whether or not AOD discussion opportunities are taken up by GPs and their patients.


In the subset of consultations analysed for this paper, AOD use itself was not the primary presenting complaint, although it could be inferred to have been a factor in the presentation in some examples. AOD topics were generally introduced in the context of exploring presenting symptoms, systems enquiry or general health screening.

Smoking discussions occurred more often than alcohol, but in general, smoking dialogue also appeared to be more comfortable for both parties than alcohol dialogue. Factors contributing to the uptake of opportunity for an AOD discussion can be grouped into three broad categories: Interactional, Clinical and System or Policy factors.

Interactional factors include the interpersonal skills of both GP and patient, verbal and non-verbal communication and the perceived delicacy of the topic. The GPs themselves mentioned the sensitivity of the topic as a potential barrier to discussion when interviewed. In this study, the GPs typically enquired about AOD use in non-threatening ways, used a mix of open and closed statement questioning styles, and sometimes put forward statements for patient agreement.

Patients typically minimized, rationalized or gave defensive or socially acceptable answers. GPs accepted patient statements largely without challenge, although the analysis suggests that this stance can be justified, for example to build relationships.

Video footage also captured body language reflecting discomfort.

This may be signalled by apparent dysfluency in the consultations, which is in part a normal feature of any spoken interaction, but in excess can be indicative of an interactional dilemma. Socio-legal constraints may add to the observed interactional delicacy since patients may naturally be reluctant to divulge and GPs reluctant to explore, illicit activity or socially unacceptable behaviour.

Prior studies also note that smoking and drinking advice may be given and received differently 1223 and the discomfort of GPs in handling an AOD discussion with patients has been considered as a contributory factor. General practice is a wide ranging specialty branch of medicine demanding great breadth of knowledge and skills. Consultations are also complex and multi-faceted—during any consultation GPs actively triage multiple issues.

The interviewed GPs mentioned that time pressure and the obligation to primarily manage the presenting complaint determine that AOD topics cannot always be attended to immediately, even when raised. Literature about competing demands in the general practice consultation 32 has identified that the potential of the GP to engage with preventive activity is unlikely to be activated on all occasions.

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While smoking and alcohol consumption are more common behaviours than other recreational drug use in New Zealand and other OECD countries, 736 the lack of discussion about other drug use is an important issue for further debate.

Third person support is often encouraged in health consultations, but this consultation subset did also include examples where the third party a spouse or caregiver had introduced additional issues of their own, impacting on the GP's attempt to engage the presenting patient in an AOD discussion.

The role of third persons as a potential distraction from engaging in AOD discussion deserves further investigation. System or policy factors include workplace practices and policies, systems for managing routine screening and consultation time, funding, referred service availability, eligibility criteria and waiting lists. It was not possible to ascertain, from analysis of the data, why AOD topics were not always raised or pursued and why advice was not always given or early intervention offered.

Some of the apparent missed opportunities may have occurred for very good clinical reasons. The sample involved a limited number of consulting GPs and their patients and an even smaller number of GPs were interviewed regarding the interpretation of findings. Therefore, the extent of generalizability and transferability is unclear.

The data examined for this study provides only a snapshot, a single consultation in each case, and therefore lacks information about AOD enquiry or intervention that may have taken place subsequently or previously. Although no mention was made of AOD at the time of data collection as this was not the focus of the studies from which this data was drawnvideo recording of consultations may have introduced bias to this particular study if it discouraged patients wishing to discuss illicit drug use topics with their GPs from participation or encouraged them to opt to not discuss drug use on that recorded occasion.

Patients who decide to reveal illicit drug use to their doctors need to trust in the privacy and confidentiality of their medical information. This study does not establish whether the apparent compromise between a patient-centred approach and the need to routinely screen for AOD use in some consultations is appropriate or inappropriate, nor can it judge appropriateness of the advice given.

Within this small sample of consultations, there were instances where the clinical interaction and advice given did not follow existing New Zealand primary care guidelines.

It may be necessary to explicitly explain to trainees the patient-centred reasons for apparent omissions from the consultation and to ensure that practices have systems in place to ensure that postponed opportunities for AOD discussion will be followed up at a later appointment. Guidelines and tools for screening and brief intervention in primary care carry the expectation that GPs will use all opportunities to discuss AOD in primary care, but these naturally occurring consultations have shown that this expectation is unrealistic.

Re-design of clinical guidelines to better fit the patient-centred approach used by GPs to develop and maintain therapeutic relationships over time with their patients may be beneficial. The findings also carry implications for vocational trainers and providers of continuing professional development programmes to incorporate resources to help to build the clinical skills needed to facilitate use of opportunities for AOD discussion within the consultation.

The subset of consultations used for this a discussion of the problems and challenges of moore medical were collected for two prior projects: Approval for analysis of the subset for the purpose of this current project was obtained from the University of Otago Ethics B process for studies involving human participants. None to declare Acknowledgments The authors would also like to thank the following for their support: All authors had full access to all data reported here and provided comment on the results and conclusions prior to their being reported.

All authors have contributed to and approved the final version. Alcohol and public health. Wilkins C, Sweetsur P. Trends in population drug use in New Zealand: Findings from national household surveying of drug use in 1998, 2001, 2003, and 2006. Reduction of alcohol consumption by brief alcohol intervention in primary care: Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews.

Cost effectiveness of brief interventions for reducing alcohol consumption. Case finding of lifestyle and mental health disorders in primary care: Br J Gen Pract.

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