Two core, inter-related themes emerged regarding patients' views of quality of consultation with GPs. These concerned perceptions of (1) the perceived competence of the doctor, and (2) the doctors' empathic concern.
Competence
This theme included references to the doctor's technical competence, including medical skills, knowledge, and training. However, perceptions of competence were also influenced by the patients' 'image' of the doctor as an individual, including appearance and mannerisms. In general, patients assumed that doctors were technically competent, seeing them as 'medical experts'. This was especially the case among the elderly patient group;
"you say well he must know best, so everybody takes it that he does know best" (focus group B).
Treatment and health outcomes
Patients' confidence in the doctor's competence was affected by prior experiences (or the experiences of other family members) with that doctor, and the effect they felt this had on their health outcomes and/or the treatment they received. Their perception of the doctors' competence was thus heavily reinforced by successful outcomes in the past;
"I'll give you a classic example. I had bother with my bowels and they're back to normal now, and that's thanks to the doctor, who came and gave me medicines and that" (both focus group C).
"...luckily enough the doctor came out and spotted this and got him emergency into the hospital straight away, and my dad used to say, thank you, thank you, you saved my life, if it wasn't for you I'd probably be dead, so I mean she is good" focus group F).
Conversely, the doctor's competence would be questioned when experiencing an apparently inaccurate diagnosis, lack of examination, and/or treatments which did not result in improved heath outcomes. In these instances patients would often be critical, more specifically placing judgements on the doctor's medical skills, knowledge, education, appearance or mannerism;
"The doctor is just like a wee boy out of college, he was just a daft wee boy, and then the guy was like oh aye your chest is bad, my mum ended up having to get an ambulance and going up to the hospital" (focus group F).
"Aye, I went down once and I had pure bellyaches and all that, and I went down and they said it was just a bug. And then two weeks later I had to the doctor out and got took into hospital. My appendix burst and I was in hospital for two weeks.... that could have been prevented if they examined us better" (focus group L).
Patients' input on understanding of symptoms
At other times the competence of the doctor was judged on how seriously he or she took patients' own understanding of their symptoms, which were based on having had similar health complaints in the past or in relation to their children:
"...I say I mean if you're there with that kid all the time you know that that's not normal for that kid so it might just be a wee silly symptom that you're seeing but you know that's not them so if you go to see a doctor they should take that on board that you know you might not be trained as a doctor but you do know your own kids" (focus group A).
Clearly there is considerable overlap between views on competence and views on the doctors' empathic concern and caring, which are further elucidated below.
Empathic concern
Patients emphasised the importance of 'genuine' relationships with GPs. Patients perceptions of the 'approachability' of individual GPs had a powerful influence on the ease with which they felt they could talk to them. Being friendly and approachable however did not mean avoiding straight talking, which was seen as an important part of being "genuine". This was closely related to the idea of a "positive attitude" in which the doctor contributed energy, enthusiasm and a clear direction to a situation which otherwise appeared bleak and hopeless. Whether plain speaking was interpreted positively however depended on the context in which it took place. Without 'respect' – the direct approach simply belittled the patient.
Specific attributes involved (a) feeling listened to by the doctor and feeling able to talk; (b) feeling cared for and valued as an individual (c) feeling the doctor understood the 'bigger picture' (d) having, and being able to understand, explanations. These are further described below;
Being listened to/being able to talk
As indicated above, patients described the ability to talk to the doctor and explain their health concerns as being dependent on the doctors 'approachability' – whether or not they felt the doctor was able and willing to take the time to listen and really pay attention;
"I've got Dr X and Dr Y and the two of them have got totally different attitudes when it comes to talking to you, Dr X will take the time and listen to you... (focus group D)."
Being treated as an individual
This theme related particularly to the feeling of being respected as an individual as opposed to being 'treated as a number':
"And going away they forget about you most of the time I think as soon as you walk out of that door" (focus group A)
"your body's just a machine to them"(focus group B).
This also related to perceptions of the doctors' sensitivity (or lack of sensitivity) towards the patient, and non-judgmental (or prejudicial) attitude;
"When I go in to see my doctor, I want him to see me, the person, not a bottle of methadone, I'm not that, I'm a person that's got needs and everything like every body else, because I'm on methadone, I just don't get treated properly (focus group I)
Understanding the 'bigger picture'
This theme related to a strong desire by patients to tell their 'story' in the consultation, and to feel that the GP genuinely understood the 'bigger picture' in relation to their wider environment, such as family issues, poverty, and community problems.
Many patients felt that because the GPs did not live or socialise in the area, they could therefore not really understand "the sort of life that people in Drumchapel are actually living". For example, advice on 'healthy living' was often regarded as failing to adequately take into account the realities of daily life in the area. The many examples given of 'social distance' included GPs lack of awareness of limited local shopping facilities, public transport issues, difficult choices on low incomes, and the effects of poor housing, conflicting family demands, fear of violence, and social isolation.
Having explanations/being able to understand
This theme referred to explanations and information given by GPs. Patients described the need for more explanation in a way they could understand. Patients often felt that GPs "just prescribe" without clear explanations of how to use the medication, the potential side effects, or why a certain treatment is given. Alternative ways of gaining such information included going to see the practice nurse in the health centre, attending a support groups, or looking up medical books. In all groups there was a desire for more information, but this did not necessarily reflect a desire for participation in decision making. Younger patients, such as parents of children with medical problems were more eager to participate in 'shared-decision making'. However, in general it was a lack of clear explanations that resulted in confusion and stress, whereas understandable explanations could result in better concordance;
"...I'm kind of afraid to take tablets and I not one of these, you know a pill taker, you know if I have to take them, but I remember that once she explained what these tablets would do and that you have to take them, you don't want to take a stroke..." (focus group B).
"... some of them make you feel inadequate, you know you're getting old and you're getting senile and you're not able to take things in, I mean sometimes you feel that way, you feel as if och I'll just lift my bag and jacket and go" (focus group B).