The Missing Evaluation at the End of GP's Consultation

Evaluation at the end of a consultation is an element of a successful encounter. The doctor should inquire if patient's expectations were fulfilled and sum up the information given, the examinations performed, and the decisions made with the patient. This way the patient would be fully aware of what has been decided and that the problems and expectations of the patient had been taken into account. Twenty consultations of four general practitioners (GPs) in Finland were videotaped. The doctors were men and women, two of them had a long experience and two were trainees in general practice. The data (videotapes, questionnaires, and interviews) were analysed by multiple research methods with investigator and methodological triangulation. MAAS-Global Rating List was used as an assessment tool. The evaluation of the consultation was often missing or having shortages; only one-third was assessed to be better than doubtful. The assessments done by experienced GPs and the medical student were similar. According to the result of this study as well as the information in the current literature, doctors in all periods of their career should repeatedly be reminded about the importance of the evaluation at the end of the consultation.


Introduction
Patient centred approach, good patient-doctor relationship, and good communication skills are related to patient satisfaction, better outcome, and lower health care costs [1][2][3]. On the other hand, problems of patient-doctor communication are oen the reason for complaints to medical regulatory authorities [4]. Poor information and lack of support by the health care personnel are related to a lack of adherence to treatment [5].
Some of the GP's core competencies are person/patient centred care, holistic modelling and comprehensive approach [6,7]. ere has been a discussion of the de�nition of patient centred care and, for example, patients' participation in the shared decision making [7][8][9]. e patients �nd it important to share their own view during the consultation, but, on the other hand, they expect their doctor to be an expert and an authority [10]. e patients do not always want to be involved in decision making, depending on the problem, age, or social class [11]. Doctors need skills to change their consultation style consistent with their patients' expectations and needs [8,11].
According to some studies, longer consultations have been related to better communication and patient satisfaction [1,7,12]. And yet, the consultation length varies in different countries and is in�uenced by doctor and the country (i.e., the health care system) as well as by patient's gender and age and the number of problems discussed [13]. If the average length of the encounter is sufficient, the way it is in Sweden and Finland, the variation in length has no effect on the quality of communication [14,15]. e factors to successful communication might be the GP's person and working style and the sufficient time reserved for patient's problem [12,14].
Most of the patients come to the consultation with a particular agenda [16]. ey might have several, unstructured problems, and only the minority of the patients expresses all items of their agenda during the consultation [17,18].
GPs tend to bypass the patients' clues [19]. Patient centred consultation style encourages patients express their agendas [18]. e patients appreciate a competent and caring doctor who handles their problem seriously and with respect [20].
It is difficult for many, particularly elderly, patients, to remember GP's instructions and health information [21]. A carefully made evaluation of consultation supports the patient. It is an important and crucial element of a successful meeting between the patient and a doctor. At the end of the consultation, doctor should ask a general question if the patient's expectations were ful�lled and allow the patient to respond to this question. e doctor should sum up the basic information given, the examinations performed, and the decisions made with the patient. In this way the patient would be fully aware of what has been decided and that all the problems and expectations of the patient have been taken into account. Shared decision making and agreement between the patient and the doctor give support to the patient and provide better outcome [3].
In our study, we needed a practical, reliable, and valid method to assess GP's communication skills in the day to day practice. ere are several methods to assess GP's communication skills, some of them are based on thorough analysis, and some are suitable only for educational purposes with simulated patients [22]. e methods measure different categories of communication skills and are variably practical [22,23].
Video recording is a feasible and acceptable tool to assess GP's consultation. Both patients and GPs usually approve video recordings for research purposes. Video recordings have some effect on GP's and patient's performance, and some patients �nd videotaped consultations to be less con�dential. Anyway, recordings are not likely to have negative effect on the quality of the consultation [24]. Nonverbal communication can be assessed and recordings can be analysed more deeply than in audiotaped or observed consultations.
e MAAS-Global method is a valid, reliable method which has been used to assess authentic GP's consultations and quality improvement [25,26]. e MAAS-Global contains three sections: communication skills for each separate phase of consultation, general communication skills, and medical aspects. e method is concerned with the doctor's behaviour, not the patient's one. e items of communication skills are to be rated on a scale ranging from 0 up to 6: the best score (6), excellent, means that the GP could not have behaved better; the lowest (0) means that the item was not present at all [26].
e criterion corresponding to the rating "excellent" on item evaluation of consultation is as follows. At the end of the consultation doctor should ask a general question what the patient thinks or feels at that moment. is question needs not to concern any speci�c aspect of the consultation. e doctor should also check whether the patient's request for help has been adequately addressed and whether the patient has been offered perspective for the time being [26].
In our former study we compared patients' and GPs' assessments of the quality of consultations using questionnaires aer consultation [15]. Similarly to other studies, both GPs and patients were very satis�ed with the GPs communication skills [27,28]. Patients are generally very positive about their GPs; some aspects of practice management are evaluated negative [29].
In this study we assessed GP's communication skills of the videotaped consultations with MAAS-Global method and compared the ratings with the information of the questionnaires and patient interviews. e aim of this study was to �nd a practical and economic tool to asses GP's communication skills. In this paper we focus on one characteristic of GP's communication skills, the evaluation at the end of the consultation.

Material and Methods
Altogether twenty consultations of four GPs in a primary health care centre in Turku, Finland, were videotaped. Our aim was to �nd two GPs, one male and one female with a long experience (over 10 years) in general practice and two trainees in general practice (<�ve years in general practise). To �nd voluntary GPs we sent an e-mail to all GPs ( on average) in one health care centre in Finland. We had no answers to this "�rst call. " When invited personally, it was quite easy to recruit experienced GPs, and a female trainee in general practice. It was more difficult to �nd a voluntary, less competent, male doctor-the fourth effort succeeded. We videotaped 4-6 consultations of each GP's normal day practice (for technical reasons every second encounter). e only exclusion criterion was patient's refusal. Only three patients declined to participate in the study. We did not ask the reason of refusal.
e informed consents were given, and the patients were interviewed in short before they went into the consultation room. In this before consultation interview we asked the patient's reason for the encounter, and if patient had any speci�c expectations concerning the consultation. e interview was brie�y noted. e camera and digital audio recorder were installed in the consultation room before the consultation, and the camera was focused on the patient and the GP at the desk so that the examination desk was not seen (the discussion during the examination could be heard). e researcher was not present in the consultation room. e patients were interviewed (semistructured) once more aer the consultation and it was audio recorded. In this aer consultation interview we asked if patient's expectations were ful�lled and if something had remained unclear. e before consultation interview was made with 17 patients and the aer consultation interview was made with 19 patients. e recordings and the interviews were transcribed. Both the patients and GPs separately completed a questionnaire concerning the satisfaction they experienced on the consultation. is questionnaire was also used in our earlier study [15].
Multimethod research with investigator and methodological triangulation was used in analysis. e videotapes were analysed by two researchers who were experienced GPs, both were specialists in general practice; they had worked years as GPs and as teachers in general practice and communication skills. e other one had also experience in the �eld of qualitative research. Deductive analysis was made according to the model of Maastricht University, the MAAS-Global Rating List in which the characteristics of consultation are assessed on a scale 0-6. e reliability of the assessment was guaranteed by parallel and also by consecutive evaluation. e characteristic "evaluation of the consultation" was also analysed by a third researcher, a fourth year medical student of a six years' basic medical education as a part of her medical studies. She analysed this item consecutively with one-month interval. ese assessments were compared with the assessments of two other researchers. e �nal scores were reached at a mutual agreement aer discussion in order to guarantee the reliability of the content analysis.
Two of the video recordings and translated (in English) transcriptions were sent for parallel assessment to Dr. Paul Ram, one of the developers of MAAS-Global method. To ensure the reliability of our assessments on expression of emotions, this item was also assessed by a psychologist who focused especially on the expression of emotions and on nonverbal communication.
One of the researchers (MK) analysed patients' questionnaires and prints of interviews to �nd out patients' problems, un�lled expectations, and other points which were not discussed during the encounter.

Results
e descriptions of the participating GPs are found in Table  1. We assessed the videotapings of 20 consultations (Table 2). e average age of the patients was 59 years and 60% of them were men. e average consultation time was 17.9 minutes (7-31 minutes). Four consultations were not counted in the mean, because the GPs and the patients le the room during the consultation (e.g., for operations). Consultation time included only the time when the patient was in the consultation room. In the GPs' opinion, patients brought up 2.4 problems in average (variation 1-7) during the encounter.
e mean scores of each GP are shown in Figure 1. In general, the scores of the items physical examination, follow-up consultation, information, and diagnosis were good. e lowest scores were given for items emotions and evaluation of consultation. e scores of the experienced GPs were higher than younger GPs in all items; the greatest differences were shown in evaluation of consultation, summarisations, structuring, and empathy.
All three researchers assessed the item evaluation of the consultation of 18 consultations with high mutual agreement ( Table 2). Only in one case we could not reach agreement, mainly because of the consultation's unstructured form.
e evaluation of consultation was quite oen missing or having many shortages. Two-thirds of the consultations did not have an evaluation that had been assessed to have more than three (3) points out of six (6).
e item emotions was missing in most of the consultations. e psychologist who assessed the expression of emotions agreed with the researchers. e expression of emotions was missing but, on the other hand, the patients' problems or complaints were not very emotive.
In the questionnaires, the quality of GP's communication skills was mostly assessed to be good or very good. Only in one consultation the patient assessed his GP's communication skills to be average, and in another consultation the GP assessed his/her own communication skills as average.
ere were no crucial hidden agendas found in before or aer consultation interviews. In one case the patient forgot to ask about tinnitus she had mentioned in the before consultation interview, and in another case patient remembered in the aer consultation interview that he had forgotten to ask for a prescription.
Doctor Paul Ram, one of the developers of the MAAS-Global method, agreed with our assessment concerning one of the two translated consultations, except for the items request for help, evaluation of consultation, and emotions, where we had 1-2 points' differences. e assessment of the other translated consultation on the basis of the text was not  accomplished because the consultation was very long and unstructured.

Discussion
In this study, the GPs did not evaluate the consultation adequately with their patients. e evaluation of the consultation was missing quite oen or having shortages; only one-third was assessed to be better than doubtful. e GPs performed well in the items physical examination, follow-up consultation, and information and diagnosis. e lowest scores were given for the item emotions. e scores of the experienced GPs were higher than younger GPs in all items; the greatest differences were shown in evaluation of consultation, summarisations, and structuring and empathy. e assessments done by the experienced GPs and a medical student were similar. e MAAS-Global method seems to be a useful tool for assessing GPs' communication skills. e strength of this study can be considered to be in the multiple research methods and the combination of materials, the number of evaluators, and the use of external experts. We used a validated method and the reliability of the assessment was guaranteed by parallel and consecutive evaluation. Moreover, we could supplement our videotaped data with the questionnaire data.
ere are also few limits in the study. It is not possible to generalize these results in the Finnish primary health care because generalization is not in the scope of the qualitative study design. However, our material generated important information about GP's communication skills and the assessment of those skills.
It is possible that we selected doctors who have better interaction skills than average doctors. It is unclear if the better skills of the competent specialists arise from the postgraduate specialist training, experience, or doctors' personal qualities. It is likely, however, that basic medical training provides insufficient ability to meet the patient, and these skills will be learned later, over the years in practice.
e selection of patients was not very strong. e expression of emotions was missing in most of the consultations; it is possible that the problems of the three refusals could have been more difficult and more emotive to deal with. It is also possible that video recordings have inhibited the expression of emotions.
Video recording have some effects on both GPs' and patients' behaviour [24]. ese effects are not always negative. One of our patients even suspected that it had positive impact on the course of the encounter.
e MAAS-Global is a suitable tool for research use, and it is also useful in basic or postgraduate specialist training and in continuing medical education [25]. Although we found this method useful and our ratings were quite similar, we found it very time consuming. e method cannot be recommended for routine quality assessment in general practice without a proper familiarisation of the method. However, the video recordings of the consultations give valuable data for the doctors themselves to discover features and mannerisms in their work which they may not have even thought about.
e questionnaires and interviews did not provide as much information about the GP's communication skills as the MAAS-Global method. Both the GPs and the patients were very satis�ed with the quality of the communication. e MAAS-Global method was capable of �nding the differences in the GP's communication skills and the objectives for development.
MAAS-Global is a valid and reliable tool to assess GP's communication skills in the day to day practice [25][26][27]30]. We modi�ed the method and accepted minor differences in researchers' scores. Optimal ratings with MAAS-Global could be achieved only when the consultations are uncomplicated, in cases where the patient presents only one complaint and the consultation comprises all phases [26]. In this study, GPs estimated that patients presented 2.4 problems on the average. e researchers' opinion of the average number of problems was quite similar to GPs' , although there were some differences in individual cases. Only �ve of our consultations ful�lled all the criteria of another MAAS-Global research [30], all the other had too many complaints, the consultations were too long, or the patients were too old. Anyway, the developer of MAAS-Global method (Dr.Paul Ram) agreed that it was a valid tool to assess our consultations.
Like in other studies, the GPs in our study did not adequately employ the evaluation of the consultation [25]. It is possible that some kind of summarisations and evaluation could have been found in the medical records. e original study design and research authorisation did not allow us to study the records. Anyway, the evaluations in the medical records do not bene�t the patient; without the information it is not possible to ask, comment, or search agreement between the patient and doctor.
It is obvious that the perfect evaluation of the consultation, with respect for the patient's autonomy, promotes patient empowerment and self-management. e patient will be able to understand his symptoms better and will be more active and adherent to treatment. is is prerequisite for good health outcome, and therefore the evaluation of the consultation is an important item of GP's consultation skills.
In GPs' day to day work, the systematic assessment of communication skills seems to be rare in Finland. Communication skills can be improved with individual improvement activities based on performance assessment and feedback [25]. e evaluation and improvement of communication skills are an important part of doctors' professional development and must be included in continuing medical education. e importance of the careful evaluation of the consultation should be underlined.

Conclusion
Video recordings analysed with MAAS-Global method provide more information about the GP's communication skills than questionnaires and interviews.
According to the result of this study as well the information in the current literature, doctors in all periods of their career, from the start of basic medical education until the end of the continuous professional development, should repeatedly be reminded about the importance of the conclusion at the end of the consultation. GPs should pay attention to performing a patient centred and careful evaluation of each consultation to guarantee the best outcome of the consultation by promoting the patient empowerment.
Ethical Approval is study is approved by the Ethical committee of Intermunicipal Hospital District of Southwest Finland.

Con�ict o� �nterests
e authors report no con�ict of interests. expert advice, Heile Tofferi for language checking, and the Finnish Medical Association for �nancial support.