Patients' perspectives on factors facilitating adherence to tuberculosis treatment in Iquitos, Peru: a qualitative study.

BACKGROUND: Tuberculosis is a major global health problem and one of the greatest barriers to its control is poor adherence to treatment. Peru has one of the highest burdens of TB in South America, with an incidence rate of 123 per 100,000 populations. There is currently a lack of evidence in South America about factors that facilitate adherence to treatment, with most previous research focusing on factors that negatively influence adherence to TB treatment. SETTING: This study was conducted in Iquitos, the capital city of the Loreto region, north-eastern Peru. Loreto has a high incidence of tuberculosis, estimated at 99 per 100,000 population, and a high poverty rate. METHODS: Twenty face-to-face, semi-structured interviews were conducted at two healthcare centres. Data collected from the interviews was analysed using thematic content analysis. RESULTS: Three main themes emerged from the data set. Personal Qualities, such as responsibility and determination, were perceived as important factors facilitating adherence. Participants described their Trust in Healthcare Providers positively, particularly focusing on their trust in clinical staff, although knowledge of tuberculosis and its treatment was limited. Social Support, from a variety of sources, was also seen as a driving factor for continued adherence. CONCLUSIONS: The results suggest that more emphasis should be placed on educating tuberculosis patients about their disease and its treatment. Additionally, consideration should be given to improving the social support available to patients, for example with tuberculosis support groups involving 'expert' tuberculosis patients.

Language, Philosophy, and Medical Education.

ISSUE: When medical schools began to recognize, a generation ago, that clinical "communication skills" could not be taken for granted among students, a process began of researching them, and introducing the results into curricula. This allowed for a discussion, for the first time, about how doctors should talk to patients, and manage interviews with them. However, there was a focus on a set of behavioral processes which were often unsophisticated with respect to the role of language in communication, or of language as a means of sustaining and describing ambiguity, or language as the primary impetus for educational reflection. EVIDENCE: This paper looks at literature from language studies, the philosophy of language and the philosophy of education to establish the point that, where natural languages are concerned, it is possible and useful to talk of the purposes for which language is used. It is also important to recognize that the meaning of a particular language use is to a substantial extent defined by context: and that languages are excellent vehicles for maintaining and describing ambiguity, where it is impossible to reduce a state of affairs to the well-defined conclusion of empirical research. IMPLICATIONS: In the light of this understanding, there is a need for "communication," and particularly the methodologies through which it is taught, to reflect these points. Simulation exercises, designed to develop clinical communication, should be clear that there is no single correct way of "talking to patients," no set of behavioral processes which is always effective. It is, in the end, the awareness and wisdom of the doctor, selecting from among a range of available approaches, which is at stake. In addition, methodologies should account for the recognition that awareness comes only from reflection, and that helping medical students and doctors alike to reflect is central to good practice.

A qualitative study on the use of long-lasting insecticidal nets (LLINs) for the prevention of malaria in the Peruvian Amazon.

BACKGROUND: Malaria is a huge global health burden due to its mortality, morbidity and cost to economies. It is necessary to eliminate the disease in all countries where possible to achieve the World Health Organization target of > 90% reduction by 2030. Successful previous campaigns suggest elimination is feasible in Peru. However, the incidence has recently been rising, focalized to the region of Loreto. Currently, the distribution of long-lasting insecticide-treated nets (LLINs) is a major part of Peru's malaria control strategy, however these may be having a limited effect in Loreto, because of the recent behavioural adaption of the mosquito vector, Anopheles darlingi, to earlier biting times, as well as local perceptions and practices towards LLINs. It was, therefore, necessary to investigate how perceptions, practices and lifestyle factors affect the efficacy of LLINs in Loreto. METHODS: Qualitative research was carried out in 5 rural communities along the Iquitos-Nauta Road in Loreto, which have increased exposure and have received nets in a distribution scheme prior to the study. Twenty semi-structured interviews as well as observations of the bed nets were conducted in participants' homes, using a topic guide. Thematic content analysis was used to produce the findings. RESULTS: All participants viewed malaria prevention as a high priority, and the use of bed nets was deeply embedded in the culture. They expressed preference for LLINs over traditional-type nets. However there were too few LLINs distributed, participants did not maintain the nets correctly, washed them too frequently and did not repair holes. The earlier mosquito biting times were also problematic. Additionally, poor housing construction and proximity to mosquito breeding sites further increased transmission. CONCLUSION: The positive findings in attitudes of the respondents can be used to improve malaria control in these communities. Interventions providing education on effective LLIN use should be implemented. A change in strategy away from vector control methods is also necessary, as these do not provide long-term protection due to the adaptability of An. darlingi. Interventions focusing on parasite control are recommended, and socio-economic factors which increase malaria risk should be addressed.

Understanding professional development: Case studies of remedial support.

This study reports on work undertaken by the Interactive Studies Unit (ISU), University of Birmingham. A total of 727 doctors were referred to the ISU for one-to-one remedial support in a variety of non-clinical areas between 2010 and 2018. The close-in scrutiny which one-to-one support offers provides an opportunity to study and reflect on such issues as values and professionalism, which are notoriously difficult to define or reach objective judgments about. There are fundamental difficulties, in particular, in inferring underlying values from an individual's behavior. The basic taxonomy of referrals the ISU works with, and which echoes those developed elsewhere, considers problems as being at the level of the self, interactions with others, or working in an institutional or societal context. Six common generic problems are identified, and presented and discussed as generic cases. These are designed to be representative of the complex manner in which behavior and values interact, and problems at the three levels above impinge on each other. All cases are accompanied by details of suggested educational activities.

Patient-centred orientation of students from different healthcare disciplines, their understanding of the concept and factors influencing their development as patient-centred professionals: a mixed methods study.

BACKGROUND: A patient-centred approach to care is increasingly the mandate for healthcare delivery. There is a need to explore how health professional students develop patient-centred attributes. This study aims to understand the extent of patient-centred orientations of health professional students, their perceptions and factors influencing their adoption of the approach. METHODS: The study used a cross-sectional, parallel mixed methods design combining a survey using the Patient-Practitioner Orientation Scale (PPOS) followed by focus groups with medical, nursing, physiotherapy and speech and language therapy students. Data included students' age, gender, programme, and placements experienced. Pearson's chi squared and the non-parametric equivalent Kruskal-Wallis H test were done to test for differences in demographics for appropriate variables. One-way ANOVA or Welch test was done to explore differences in PPOS scores. Regression analysis was done to test the influence of the demographic variables on PPOS scores. Data from focus groups were coded, categorised and organised under themes appropriate to the research aims. RESULTS: Of the 211 complete responses, significant differences were observed between medical and physiotherapy students in total PPOS scores, (MD -8.11 [95% CI -12.02 - 4.20] p = 0.000), Caring component (MD -4.44 [95% CI - 6.69, - 2.19] p = 0.000) and Sharing component (MD -3.67 [95% CI -6.12 -1.22] p = 0.001). The programme in which students were enrolled i.e. Medicine and SALT were the only indicators of higher PPOS total scores (F = 4.6 Df 10,69; p = 7.396e-06) and caring scores (F = 2.164 Df 10, 69 p = 0.022). Focus groups revealed that students perceived patient-centredness as holistic yet individualised care through establishing a partnership with patient. They identified that their student status, placement pressures, placement characteristics especially mentoring influenced their development of patient-centred attributes. CONCLUSION: This study highlights the fact that the pressures of training in the National Health Service affects the development of students' patient-centred orientation. There is a need for further work to explore aspects related to mentor training, for the development of patient-centred attributes, in a curricular framework structured on students' needs from this study.

Is the practice of goal-setting for patients in acute stroke care patient-centred and what factors influence this? A qualitative study.

OBJECTIVE: To explore whether goal-setting for rehabilitation with acute stroke survivors is patient-centred and identify factors which influence the adoption of patient-centredness in goal-setting practice. SETTING: Acute stroke unit in a large teaching hospital in England. PARTICIPANTS: Patients with stroke who had no cognitive or significant communication problems and health care professionals who had a significant engagement with an individual patient were approached for participation. METHOD: Multiple qualitative methods were used. Perceptions and beliefs about patient-centredness, within the context of goal-setting, were collected from patients and corresponding professionals using qualitative semi-structured interviews. Adoption of patient-centred behaviour was triangulated using analysis of patient records and observation of team meetings related to participating patients. DATA ANALYSIS: Interview transcripts and field notes were coded, clustered under categories and descriptively summarised. Additionally, data from patients' documents were summarised. These summaries were then mapped on to an a-priori frame work of patient-centredness from which further interpretative themes were derived. RESULTS: Seven patients and seven health-care professionals participated. Goal-setting was not consistently patient-centred as evidenced by a) incongruities between patients and professionals in setting, communicating and prioritising of goals and b) dysfunctional therapeutic relationships. The factors that influenced patient-centred goal-setting were both professional and patient beliefs and attributes, work-culture, practice model, limitations in knowledge and systems that disempowered both professionals and patients. CONCLUSION: It may be possible to infer that current local practice of goal-setting was inadequately patient-centred. Further research is required to identify strategies to overcome these challenges and to develop patient-centred goal-setting methods.

Receptionist rECognition and rEferral of PaTients with Stroke (RECEPTS) study - protocol of a mixed methods study.

BACKGROUND: As the first point of contact for patients and witnesses of stroke, General Practice receptionists can be instrumental in deciding the urgency of clinical contact. Despite the considerable complexity of this task, reception staff are not clinically trained. Minimising the time taken to access thrombolysis is crucial in acute stroke as treatment must be initiated within 4.5 hours of the onset, and the earlier the better, to achieve the best outcomes. Research suggests that patients who first contact their General Practice following the onset of stroke symptoms are less likely to receive thrombolysis, in part due to significant delays within Primary Care.This study therefore aims to understand the role of General Practice receptionists, with particular interest in receptionist's ability to recognise people who may be suffering from a stroke and to handle such patients as a medical emergency. METHODS: The Receptionist rECognition and rEferral of PaTients with Stroke (RECEPTS) study will be a Primary Care based mixed methods study. 60 General Practices in the West Midlands will be recruited. Each practice will receive 10 unannounced simulated patient telephone calls, after the 10 calls questionnaires will be administered to each receptionist. These will examine the behaviour of receptionists towards patients presenting in Primary Care with stroke symptoms, and their knowledge of stroke symptoms. An embedded qualitative study will use interviews and focus groups to investigate the views of General Practice staff on the receptionists' role in patient referral and whether training in this area would be helpful. DISCUSSION: The results of the RECEPTS study will have important implications for providers of Primary Care. The study will establish current practice in UK primary care in terms of General Practice receptionists' knowledge of the presentation and appropriate referral of those who may be suffering a stroke. It will highlight training needs and how such training might be best delivered.

"If it helps..." the use of microarray technology in prenatal testing: patient and partners reflections.

The objective was to gain insight into the experiences of women and their partners diagnosed with a fetal abnormality on prenatal ultrasound examination and receiving genetic testing including microarray. Twenty-five semi-structured interviews were performed with women +/- their partners after receiving the results of prenatal genetic testing. Framework analysis was performed to elicit themes and subthemes. Five main themes were recognized; diagnosis, genetic testing, family and support, reflections of the treatment received and emotions. Our results showed that women recall being told about QFPCR for trisomy 13, 18, and 21 but often no further testing. Women expected the conventional karyotype and microarray result would be normal following a normal QFPCR result. There were frequent misconceptions by couples regarding aspects of counseling/testing. Communication of variants of unknown (clinical) significance (VOUS) presents a particularly difficult challenge. Good clear communication by health care professionals is paramount. When counseling women and their partners for fetal chromosomal testing it should be reinforced that although the most common, trisomy 13, 18, and 21 only account for some of the chromosomal changes resulting in abnormal scan findings. Couples should have literature to take home summarizing scan anomalies and reinforcing information about genetic testing.

The simulation game: an analysis of interactions between students and simulated patients.

CONTEXT: Institutional interactions are often asymmetrical in that the professional has more control over the conversation. It is difficult to say who the professional is in simulated consultations between simulated patients (SPs) and medical students because these feature a real (educational) institutional context and a simulated (medical) institutional context. This study describes this asymmetry and makes educational recommendations based on the description. METHODS: One hundred assessed conversations between SPs and Year 3 students were transcribed and analysed using discourse analysis (DA). We aimed to find linguistic patterns in predefined parts of the conversations (questions, topic initiations, openings, closings) that might suggest conversational dominance. RESULTS: The SP is conversationally more dominant, despite performing the role of the patient, in that he or she asks more direct questions, is more likely to initiate topics, is more likely not to follow topic changes by students, and closes the consultation. The student is likely to follow topics initiated by the SP and to seek permission to pre-close the consultation. CONCLUSIONS: The apparently greater dominance of the SP indicates that the simulated consultation differs from the doctor-patient consultation in certain key aspects. It is in that sense unrealistic. We argue, however, that 'realism' ought not to be a goal of simulated consultation and that what matters is that such consultations are sufficiently realistic for their educational purpose. We discuss the educational implications that follow from this.

Knowledge, skills and beetles: respecting the privacy of private experiences in medical education.

In medical education, we assess knowledge, skills, and a third category usually called values or attitudes. While knowledge and skills can be assessed, this third category consists of 'beetles', after the philosopher Wittgenstein's beetle-in-a-box analogy. The analogy demonstrates that private experiences such as pain and hunger are inaccessible to the public, and that we cannot know whether we all experience them in the same way. In this paper, we claim that unlike knowledge and skills, private experiences of medical learners cannot be objectively measured, assessed, or directly accessed in any way. If we try to do this anyway, we risk reducing them to knowledge and skills-thereby making curriculum design choices based on what can be measured rather than what is valuable education, and rewarding zombie-like student behaviour rather than authentic development. We conclude that we should no longer use the model of representation to assess attitudes, emotions, empathy, and other beetles. This amounts to, first of all, shutting the door on objective assessment and investing in professional subjective assessment. Second, changing the way we define 'fuzzy concepts' in medical education, and stimulating conversations about ambiguous terms. Third, we should reframe the way we think of competences and realize only part of professional development lies within our control. Most importantly, we should stop attempting to measure the unmeasurable, as it might have negative consequences.

Learning to be patient-centred healthcare professionals: how does it happen at university and on clinical placements? A multiple focus group study.

This article was migrated. The article was marked as recommended. Background: Developing patient-centred skills in health professional students relies on their learning experiences at the university and on clinical placements. It is not known what students perceive about their teaching on patient-centredness and their views to develop the curriculum in this aspect. Methods: Multiple focus groups were conducted with students who had experienced a minimum of two clinical placements from Medicine, Physiotherapy, Nursing and Speech and language therapy programs. Thematic analysis was conducted independently by two researchers and then themes were compared and integrated. Findings: Five focus groups with 26 participants with a mean age of 23.8 years contributed to 286 minutes of recorded data. The key findings were that their curriculum focussing on patient-centred skills used artificial methods and teaching focussed largely on biomedical aspects, but, shared modules and specialist training enabled learning. Longer and diverse placements with good role models to emulate, enabled learning. As strategies they suggested reflections and role-modelling were vital along with further interprofessional working, goal-setting and understanding of human psychology. Conclusion: Though the study is limited by its generalisability, strategies suggested by students can be further developed by superimposing them on learning theories. These strategies need to be tested in future studies.

The reality of role-play: interruptions and amount of talk in simulated consultations.

CONTEXT: The language and structure of doctor-patient consultations have been widely researched. Although simulated patients (SPs) are much used in communication skills teaching, the language of the simulated consultation has not received much attention. OBJECTIVES: This study aimed to resolve the following questions. How are interruptions and numbers of words distributed in simulated consultations? Do they correlate with set variables (e.g. gender, scenario) or outcome variables (e.g. grade)? METHODS: A total of 100 videotaped assessed consultations between SPs and Year 3 medical students were transcribed. Words by each participant were counted, and interruptions were coded and counted. Amount of talk and interruptions were chosen because they are potential markers of conversational dominance. RESULTS: We found that SPs talk (55% versus 45% for students) and interrupt (74% versus 26% for students) significantly more than medical students. The scenario is significantly associated with the number of words and interruptions. Multivariable testing shows that female SPs are associated with more words. The number of words is significantly and positively associated with examination grade. The number of student interruptions is significantly and positively associated with grade. CONCLUSIONS: Because the simulated consultation takes place in an institutional setting, the SP may have institutional power over the student. This may explain how findings from these role-play interactions differ from actual doctor-patient consultations. This suggests that simulated consultations are educational devices rather than exact representations of doctor-patient interactions. The authors hope this paper will contribute to a discussion about the nature of role-play in medical education.

Heartlift patients? An interview-based study of GP trainers and the impact of 'patients they like'.

BACKGROUND: The concept of the 'heartsink patient' is well known and much used when talking about general practice. The opposite of this type of patient, however, has been little explored. OBJECTIVE: To identify patient characteristics valued by GPs. METHODS: Structured interview to collect narratives from GPs of individual patients, analysed qualitatively through thematic analysis and word frequency. SETTING: Primary Care in Ireland. PARTICIPANTS: GP trainers. MAIN OUTCOME MEASURES: Emergent themes from four lead questions: Tell me about a patient you like, Tell me about the patient's personality, What have you learned about yourself as a GP?, What is different about being a GP as opposed to any other kind of doctor? In addition, a corpus linguistic analysis of word frequencies disclosed further themes, not identifiable on the surface of discourse. RESULTS: Ten themes were identified: GPs valued patients who were likeable, a challenge, involved them in negotiation of the doctor-patient relationship, were interesting or virtuous and had a positive effect. GPs valued their profession in that they were facilitators, gave and elicited loyalty, formed personal attachments and had a different perspective. CONCLUSIONS: 'Heartlift patients' may be a robust concept, to counterbalance heartsink patients. Data collected are suitable for training, and could help GPs enhance a sense of vocation.

The need for education on health related-quality of life.

BACKGROUND: Health-related quality of life is increasingly recognised as an important outcome measure that complements existing measures of clinical effectiveness. The education available on this subject for different healthcare professionals is varied. This article describes the design, implementation and evaluation of a Special Study Module on Health-Related Quality of Life for undergraduate medical students at the University of Birmingham. METHODS: The course involves 10 hours of "guided discovery learning" covering core concepts of Health-Related Quality of Life assessment including methodological considerations, use in clinical trials, routine practice and in health policy followed by self-directed learning. The taught components aim to provide students with the skills and knowledge to enable them to explore and evaluate the use of quality of life assessments in a particular patient group, or setting, through self-directed learning supported by tutorials. RESULTS: The use of case studies, recent publications and research, and discussion with a research oncology nurse in task-based learning appeared to provide students with a stimulating environment in which to develop their ideas and was reflected in the diverse range of subjects chosen by students for self-directed study and the positive feedback on the module. Course evaluation and student assessment suggests that quality of life education appears to integrate well within the medical curriculum and allows students to develop and utilise skills of time-management and independent, self-directed learning that can be applied in any context. CONCLUSION: We suggest that education and training initiatives in quality of life may improve the quality of studies, and help bridge the gap between research and clinical practice. Resources for curriculum development on health-related quality of life have been developed by the International Society for Quality of Life Research and may prove a useful tool to educators interested in this area.

Learning from patients: trainers' use of narratives for learning and teaching.

BACKGROUND: There is a growing interest in how doctors learn from narratives about individual cases, reflected, for example, in the use of e-portfolios. AIM: This study aimed to evaluate how GP trainers conceptualised 'learning from patients', and what use they currently made of narrative recounts in training. DESIGN & SETTING: Thematic analysis (TA) and corpus-linguistic (CL) analysis, with data collected from a convenience sample of trainers in the UK, Ireland, and Spain. METHOD: GP trainers in the three settings were contacted, and volunteers recruited (22 in UK, 24 in Ireland, and 16 in Spain). Volunteers were interviewed and asked to offer a narrative about 'a patient you learned from' and whether they used narratives as a training device. RESULTS: There were no differences between settings. Trainers described an engaged and personal relationship with patients. They described learning about themselves, the human condition, and about how to live and die well. Their narratives were structured in various ways. At times, they led to precise conclusions: at times, they were perceived as meaningful, but resisting analysis. As regards teaching through narrative, it was reported as commonly used, but present practice appears ad hoc rather than planned. DISCUSSION: The lack of difference between settings suggests a degree of commonality about how trainers perceive learning and teaching in the areas explored, but cannot be generalised further. The level of personal engagement was more than anticipated, and suggests the label 'doctor-patient relationship', as the term is used, may not be adequate to describe the nature of some interactions.

A profile of communication in primary care physician telephone consultations: application of the Roter Interaction Analysis System.

BACKGROUND: Telephone consultations are a part of everyday practice, there is surprisingly little research on the subject. AIM: To describe the variation of consulting skills within a body of telephone consultations in primary care, highlighting the performance of one method of assessing the process of the consultation-- the Roter Interaction Analysis System-- with telephone consultations. DESIGN OF STUDY: Cross sectional study of 43 recordings of telephone consultations with GPs. SETTING: One rural county in the Midlands. METHOD: Recordings were made of 8 GPs, purposively selected for maximum variance in one region of the UK. Forty-three consultations were coded using the Roter Interaction Analysis System. From the descriptive categories, six composite categories were compiled reflecting a number of domains of interaction in a consultation: rapport, data gathering, patient education and counselling, partnership building, doctor dominance and patient-centredness. Analysis of variance was undertaken to explain variations between consultations for the different domains. Comparison was made to findings from similar work for face-to-face consultations. RESULTS: These telephone consultations feature more biomedical information exchange than psychosocial or affective communication. Length of interaction accounts for much of the variation seen between consultations in the domains of rapport, data gathering, patient education and counselling and partnership. Male doctors are more patient centred in this study. There is the suggestion of more doctor dominance and a less patient-centred approach when comparisons are made with previous work on face-to-face consultations. CONCLUSIONS: Although the telephone is increasingly being used to provide care, this study highlights the fact that telephone consultations cannot be taken as equivalent to those conducted face to face. More work needs to be done to delineate the features of telephone consultations.

Everything you were afraid to ask about communication skills.

'Communication skills' is now very well established in medical education as an area that needs to be taught at both undergraduate and postgraduate level. But it is a discipline with a low level of challenge--it allows itself constantly to take seriously questions about its fundamentals (such as whether it works at all) although common sense and everyday experience tell us that skills are indeed improved through training and practice. This slows progress. Much research has also concentrated on listing and defining a set of skills, yet although all doctors must understand and utilise a range of skills as a precondition for good communication, the findings themselves are often equally common-sensical, and are not, in any case, restricted to medicine. They often tend to form part of a general consensus in favour of lay-centredness, which has been studied in other types of professional encounter, particularly the language of teachers and pupils. Moreover, insofar as teachers of medical communication limit their aims and their own classroom language to terms associated with skills, they offer little scope for more important questions about how these skills should be deployed, and about the attitudes to medicine and professional life that underpin them. A central educational question is: should we concentrate on teaching skills in the belief that attitudes will follow, or attitudes in the belief that they will generate appropriate skills?

Receptionist rECognition and rEferral of Patients with Stroke (RECEPTS): unannounced simulated patient telephone call study in primary care.

BACKGROUND: Stroke is a leading cause of morbidity and mortality. Timely recognition and referral are essential for treatment. AIM: To examine the ability of receptionists in general practices to recognise symptoms of stroke and direct patients to emergency care. DESIGN AND SETTING: Unannounced simulated patient telephone calls and prospective cross-sectional survey study in general practices in the Birmingham and Solihull area. METHOD: A total of 52 general practices participated in a total of 520 simulated telephone calls, with 183 receptionists completing questionnaires. Logistic regression analyses were used to examine likelihood of referral for immediate care by ease of vignette recognition and number of common stroke symptoms present. RESULTS: General practice receptionists correctly referred 69% of simulated calls for immediate care. Calls classed as 'difficult' to recognise were less likely to be immediately referred. Compared with 'easy' calls: 'difficult' calls odds ratio (OR) 0.15, 95% confidence interval (CI) = 0.08 to 0.26; 'moderate' calls OR 0.55, 95% CI = 0.32 to 0.92. Similarly, calls including one or two 'FAST' symptoms were less likely to be referred immediately (compared with three FAST symptoms: one symptom OR 0.30, 95% CI = 0.13 to 0.72; two symptoms OR 0.35, 95% CI = 0.15 to 0.83). CONCLUSION: General practice receptionists refer patients with stroke for immediate care when they present with several symptoms; however, they are less likely to refer patients presenting with only one symptom or less common symptoms of stroke. Optimum management of acute stroke in primary care requires interventions that improve receptionists' knowledge of lesser-known stroke symptoms.

A concordance-based study of metaphoric expressions used by general practitioners and patients in consultation.

BACKGROUND: All languages use metaphoric expressions; some deliberately chosen, some (for example, 'digesting information') not usually perceived as metaphoric. Increasingly, it is suggested metaphoric expressions constrain the way we conceptualise the world, as well as being a means of achieving stylistic effect. AIM: To study metaphoric expressions used by doctors and patients in general practice. DESIGN OF STUDY: Concordance-based language analysis of spoken data. METHOD: A database containing transcriptions of 373 consultations with 40 doctors in a UK general practice setting was scrutinised for metaphoric expressions, using 'concordancing' software. Concordancing enables identification of strings of text with similar lexical properties. Comparators (for example, 'like'), selected verb-types (for example, of feeling), and the verb 'to be' were used as starting points for systematically exploring the data. Quantitative and qualitative thematic methods were used in analysis. RESULTS: Doctors and patients use different metaphors. Doctors use mechanical metaphors to explain disease and speak of themselves as problem-solvers' and 'controllers of disease'. Patients employ a range of vivid metaphors, but fewer metaphors of machines and problem/solution. Patients use metaphors to describe symptoms and are more likely to use metaphoric language at the interface of physical and psychological symptoms ('tension, 'stress'). CONCLUSION: The different patterns of metaphoric expression suggest that doctors make limited attempts to enter the patients' conceptual world. This may not be a bad thing. One function of the consultation may be to reinterpret vivid and unique descriptions as accounts of the familiar and systemically comprehensible. Doctors may use different conceptual metaphors as a reassuring signal of expertise.