Top

18-10-2017 | Gout | Article

“I can’t bend it and it hurts like mad”: direct observation of gout consultations in routine primary health care

Journal: BMC Family Practice

Authors: Anthony Dowell, Caroline Morris, Lindsay Macdonald, Maria Stubbe

Publisher: BioMed Central

Abstract

Background

Gout is the most common form of inflammatory arthritis and is associated with considerable co-morbidity. It is usually managed in the primary care setting with a combination of lifestyle modification and pharmacological therapy. This study describes patterns of communication about gout observed in interactions between patients and primary care practitioners during routine consultations.

Methods

Secondary analysis of video-recordings of individual healthcare consultations between patients and a range of primary care practitioners (including general practitioners, practice nurses, podiatrists and dietitians) from an archived database. Consultations that included any discussion about gout were eligible for inclusion (n = 31) and were not restricted to those where gout was the main presenting complaint. The consultation transcripts were analysed using a qualitative inductive approach from clinical and linguistic perspectives and supplemented with visual observation of the interactions.

Results

Two main themes emerged from the data; the importance of gout and ‘telling’ versus ‘listening’ in consultations. The first theme had two distinct strands; gout as an incidental part of the consultation and the impact of gout on patients. A trend towards more didactic practitioner communication encompassed by the second theme occurred at many different consultation points including diagnosis, in more general post-diagnosis discussion, and when discussing biochemical test results and lifestyle advice. In contrast, when discussion about treatment with medicines occurred a tendency towards a greater degree of listening to patients was observed.

Conclusion

Our observation of the communication patterns in these consultations illustrates an inherent complexity of gout consultations in primary care. Gout may be more important to patients than is often apparent to practitioners in routine consultations. Consultation management needs to take into account the impact of the condition and the balance of information provided around lifestyle advice versus long-term management with medicines.

Roddy E, Mallen CD, Doherty M. Gout. Br Med J. 2013;347:f5648. https://doi.org/10.1136/bmj.f5648.CrossRef

Ting K, Graf SW, Whittle L. Update on the diagnosis and management of gout. Med J Aust. 2015;203:86–8.CrossRefPubMed

Dalbeth N. Management of gout in primary care: challenges and potential solutions. Rheumatology. 2013;52:1549–50.CrossRefPubMed

Paskins Z, Sanders T, Croft PR, Hassell AB. The identity crisis of osteoarthritis in general practice: a qualitative study using video-stimulated recall. Ann Fam Med. 2015;13:537–44.CrossRefPubMedPubMedCentral

Salisbury C, Procter S, Stewart K, Bowen L, Purdy S, Ridd M, et al. The content of general practice consultations: cross-sectional study based on video recordings. Br J Gen Pract. 2013; https://doi.org/10.3399/bjgp13X674431.

Te Karu L, Bryant L, Elley CR. Maori experiences and perceptions of gout and its treatment: a kaupapa Maori qualitative study. J Prim Health Care. 2013;5:214–22.PubMed

Martini N, Bryant L, Karu LT, Aho L, Chan R, Miao J, et al. Living with gout in New Zealand: an exploratory study into People's knowledge about the disease and its treatment. J Clin Rheumatol. 2012;18:125–9.CrossRefPubMed

Lindsay K, Gow P, Vanderpyl J, Logo P, Dalbeth N. The experience and impact of living with gout: a study of men with chronic gout using a qualitative grounded theory approach. J Clin Rheumatol. 2011;17:1–6.CrossRefPubMed

Harrold LR, Mazor KM, Velten S, Ockene IS, Yood RA. Patients and providers view gout differently: a qualitative study. Chronic Ill. 2010;6:263–71.CrossRef

10.

Richardson JC, Liddle J, Mallen CD, Roddy E, Prinjha S, Ziebland S, et al. “Why me? I don’t fit the mould… I am a freak of nature”: a qualitative study of women’s experience of gout. BMC Womens Health. 2015; https://doi.org/10.1186/s12905-015-0277-z.

11.

Liddle J, Roddy E, Mallen CD, Hider SL, Prinjha S, Ziebland S, et al. Mapping patients’ experiences from initial symptoms to gout diagnosis: a qualitative exploration. BMJ Open. 2015; https://doi.org/10.1136/bmjopen-2015-008323.

12.

Vaccher S, Kannangara DRW, Baysari MT, Reath J, Zwar N, Williams KM, et al. Barriers to Care in Gout: from prescriber to patient. J Rheumatol. 2016;43:144–9.CrossRefPubMed

13.

Chandratre P, Mallen CD, Roddy E, Liddle J, Richardson J. “You want to get on with the rest of your life”: a qualitative study of health-related quality of life in gout. Clin Rheumatol. 2016;35:1197–205.CrossRefPubMed

14.

Humphrey C, Hulme R, Dalbeth N, Gow P, Arroll B, Lindsay K. A qualitative study to explore health professionals’ experience of treating gout: understanding perceived barriers to effective gout management. J Prim Health Care. 2016;8:149–56.CrossRefPubMed

15.

Dalbeth N, Petrie KJ, House M, Chong J, Leung W, Chegudi R, et al. Illness perceptions in patients with gout and the relationship with progression of musculoskeletal disability. Arthritis Care Res. 2011;63:1605–12.CrossRef

16.

Harrold L, Mazor K, Peterson D, Naz N, Firneno C, Yood R. Patients’ knowledge and beliefs concerning gout and its treatment: a population based study. BMC Musculoskelet Disord. 2012;13:180. https://doi.org/10.1186/1471-2474-13-180.CrossRefPubMedPubMedCentral

17.

Harrold LR, Mazor KM, Negron A, Ogarek J, Firneno C, Yood RA. Primary care providers’ knowledge, beliefs and treatment practices for gout: results of a physician questionnaire. Rheumatology. 2013;52:1623–9.CrossRefPubMedPubMedCentral

18.

Doherty M, Jansen TL, Nuki G, Pascual E, Perez-Ruiz F, Punzi L, et al. Gout: why is this curable disease so seldom cured? Ann Rheum Dis. 2012;71:1765–70.CrossRefPubMed

19.

Spencer K, Carr A, Doherty M. Patient and provider barriers to effective management of gout in general practice: a qualitative study. Ann Rheum Dis. 2012;71:1490–5.CrossRefPubMed

20.

Jordan KM, Cameron JS, Snaith M, Zhang W, Doherty M, Seckl J, et al. British Society for Rheumatology and British health professionals in rheumatology guideline for the management of gout. Rheumatology. 2007;46:1372–4.CrossRefPubMed

21.

Khanna D, Fitzgerald JD, Khanna PP, Bae S, Singh MK, Neogi T, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res. 2012;64:1431–46.CrossRef

22.

Zhang W, Doherty M, Bardin T, Pascual E, Barskova V, Conaghan P, et al. EULAR evidence based recommendations for gout. Part II: management. Report of a task force of the EULAR standing committee for international clinical studies including therapeutics (ESCISIT). Ann Rheum Dis. 2006;65:1312–24.CrossRefPubMedPubMedCentral

23.

Shulten P, Thomas J, Miller M, Smith M, Ahern M. The role of diet in the management of gout: a comparison of knowledge and attitudes to current evidence. J Hum Nutr Diet. 2009;22:3–11.CrossRefPubMed

24.

Byrne PS, Long BE. Doctors talking to patients: a study of the verbal behaviours of doctors in the consultation. London: Her Majesty’s Stationary Office; 1976.

25.

Heritage J, Maynard DW. Introduction: analyzing interaction between doctors and patients in primary care encounters. In: Heritage J, Maynard DW, editors. Communication in medical care: interaction between primary care physicians and patients. Cambridge: Cambridge University Press; 2006. p. 1–21.CrossRef

26.

Mishler EG. The discourse of medicine: dialects of medical interviews. Norwood, NJ: Ablex; 1984.

27.

ARCH. Corpus of health interactions. Wellington: University of Otago. http://www.otago.ac.nz/wellington/research/arch/corpus/. Accessed 7 Sept 2017.

28.

Boyatzis R. Thematic analysis and code development: transforming qualitative information. London: Sage Publications; 1998.

29.

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.CrossRef

30.

Fereday J, Muir-Cochrane E. Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2006;5:80–92.CrossRef

31.

Pomerantz A. Extreme case formulations: a way of legitimizing claims. Hum Stud. 1986;9:219–29.CrossRef

32.

Maynard DW, Heritage J. Conversation analysis, doctor–patient interaction and medical communication. Med Educ. 2005;39:428–35.CrossRefPubMed

33.

Freeman J, Loewe R. Barriers to communication about diabetes mellitus. Patients’ and physicians’ different view of the disease. J Fam Pract. 2000;49:507–12.PubMed

34.

Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients' unvoiced agendas in general practice consultations: qualitative study. Br Med J. 2000;320:1246–50.CrossRef

35.

Noordman J, Koopmans B, Korevaar JC, van der Weijden T, van Dulmen S. Exploring lifestyle counselling in routine primary care consultations: the professionals’ role. Fam Pract. 2013;30:332–40.CrossRefPubMed

36.

Barton J, Dew K, Dowell A, Sheridan N, Kenealy T, Macdonald L, et al. Patient resistance as a resource: candidate obstacles in diabetes consultations. Sociol Health Ill. 2016; https://doi.org/10.1111/1467-9566.12447.

37.

Balfe M. Diets and discipline: the narratives of practice of university students with type 1 diabetes. Sociol Health Ill. 2007;29:136–53.CrossRef

38.

Schoenberg NE, Amey CH, Coward RT. Stories of meaning: lay perspectives on the origin and management of noninsulin dependent diabetes mellitus among older women in the United States. Soc Sci Med. 1998;47:2113–25.CrossRefPubMed

39.

Sheridan NF, Kenealy TW, Kidd JD, Schmidt-Busby JI, Hand JE, Raphael DL, et al. Patients’ engagement in primary care: powerlessness and compounding jeopardy. A qualitative study. Health Expect. 2015;18:32–43.CrossRefPubMed

40.

Morris C, Macdonald L, Stubbe M, Dowell A. “It’s complicated” - talking about gout medicines in primary care consultations: a qualitative study. BMC Fam Pract. 2016;17:114. https://doi.org/10.1186/s12875-016-0515-y.CrossRefPubMedPubMedCentral

41.

Rees F, Jenkins W, Doherty M. Patients with gout adhere to curative treatment if informed appropriately: proof-of-concept observational study. Ann Rheum Dis. 2013;72:826–30.CrossRefPubMed

42.

World Health Organization. Primary health care: now more than ever. Geneva: World Health Organization; 2008.

43.

Dowell A, Macdonald L, Stubbe M, Plumridge E, Dew K. Clinicians at work: what can we learn from interactions in the consultation? N Z Fam Physician. 2007;34:345–50.