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BACKGROUND AND OBJECTIVES: Many patients in general practice present with complex health problems. It is argued that the GP who is in a prime position to counsel patients with such problems, will, however, often perceive a lack of tools to manage them. The aim of the present study was to develop a novel instrument in terms of a patient-administered questionnaire, the Patient Perspective Survey (PPS), designed to enhance the quality of clinical communication in the consultation. It is based on a biopsychosocial patient perspective, patient centredness, patient resources, involvement and coping, and quality of life orientation. METHODS: Development of the PPS has included comprehensive literature research, discussions and advice, during several phases, from groups of GPs, patients, broad panels of experts and testing in pilot studies. After many revisions, a 102-item version, consisting of a main somatic, mental and social domain axis, was evaluated by GPs and patients in 213 consultations. RESULTS: The basic idea, theoretical elements and purpose of the PPS appeared in general to be well accepted. Seventy-five to eighty-five per cent of the patients found the questions relevant and easy to understand and there were high positive scorings regarding influence on the doctor-patient relationship, communication, resource and coping aspects, occurrence of new information and general satisfaction with the consultation. Similar scorings were obtained from the GPs' evaluation. Both parties agreed that there is a need for a shorter and more specific PPS version, and that the resource and coping dimension should be even more extended. CONCLUSIONS: We consider it well documented that there is a need for this new instrument to deal with complex health problems in general practice, and that it has promising potentials for consultation improvement.

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The aim of the experiment, in which four general practitioners met an actress who played a patient, was to explore how different doctors approach an identical patient problem. According to the patient role the actress had two reasons for encounter: (i) tachycardia and (ii) fear of HIV infection, which she had great difficulty in telling and presented only by indirect cues. The doctors knew they were meeting an actress, but the patient role description was unknown. Most of the time in each consultation was spent on tachycardia, the first presented symptom. None of the doctors paid real attention to the patient's signals of emotional distress and did not discover her fear of being HIV positive. Evaluation of the recordings and transcripts revealed some keys to understand why the doctors missed essential signals from the patient and felt stuck. It was difficult for the doctors to see their own role in blocking communication until the patient perspective was fully explored during the process of evaluation.

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We are seven general practitioners who have developed and tested a two-year programme to follow up the group-based training programme for general practice in Norway. The basic idea is to learn by reflecting on one's own consultations with patients. All consultations are registered by each doctor on a special form which allows both a narrative description of the consultation and a formal registration of data, including reasons for contact, diagnostic considerations, the doctor's attempts to elicit the patient's concerns and provide information, and specification of the doctor's satisfaction or dissatisfaction with the consultation. The material is shared and deepened at monthly group meetings. Simple statistical analysis is used. Each doctor also shows videotaped consultations to the group. Our learning has taken place at four levels: clinical medicine, knowledge about one's own practice and about general practice as a discipline, and experience of collecting and analyzing clinical data. We conclude that the programme is enjoyable and feasible, we recommend it to other groups.

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In a survey among 3,739 patients belonging to 36 general practices in northern Norway, 33% reported difficult access to their local surgery by telephone. 43% reported difficulty in obtaining access to the doctor once they had obtained contact with the reception. The proportion of patients reporting problems of accessibility by telephone varied greatly, from 5 to 75%. Patients belonging to practices located in towns, with long waiting lists and many doctors, were most dissatisfied with the telephone service. Stable doctor/patient-relationships made direct contact with the doctor easier, while a scheduled time when patients could call the office made direct contact more difficult. We discuss ways to improve accessibility by telephone.

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Doctors and professional health administrators have been the principal decision-makers and the patients have hardly had any direct influence on the planning and organization of primary health care in Norway. In 1987, in order to draw attention to patient opinions, the Institute of Community Medicine, University of Tromsø, conducted a questionnaire survey among patients attending general practices in North Norway. The question were selected to cover issues in the contemporary debate on the ideology, organization and standards of services of general practitioners. 36 teaching practices in the region were included in the survey. Altogether 3,739 questionnaires were returned, a response rate of over 60%. The respondents reported more than 16,000 consultations during the last year. This paper presents the methods used and the main findings concerning the representativeness of the results and the potential for generalization. Subsequent publications will present detailed results from the study within the framework of patient experiences, preferences and expectations.

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