As frontline clinicians, family doctors very often are the first point of contact for patients. This has far reaching potential implications in the use of resources as we act as gatekeepers to hospital care as well as the gateway to prescribing, investigations and referrals. What decisions do patients expect doctors to take within consultations?

In a recent study in the UK, doctors believed that a significant minority of examinations, prescriptions, and referrals, and almost half of investigations, were only slightly needed or not needed at all.¹ Perceived pressure from patients was a strong independent predictor of whether doctors examine, prescribe, refer or investigate.¹ These results were in line with a previous study suggesting that patients' expectation of management and their anxiety associated with the presenting problem might influence general practitioners' prescribing and referral behaviour.²

Doctors often perceive patients to have the expectations for consultations to end with prescriptions of medications. In a study involving 21 general practitioners (GPs) in the UK, all the GPs interviewed believed that they experienced pressure for a prescription from patients and all said that they had prescribed when they would not otherwise have done.³ This is an example illustrating that if patients' expectations or hidden agendas are not explored frankly, unnecessary prescriptions will follow. Furthermore, these unnecessary prescriptions attract poor compliance, resulting in wastage of resources.

Investigations can help clinicians to confirm or exclude clinical diagnoses. However, if tests are ordered just as a routine, there will be other potential risks. For example, some investigations may have inherent procedural hazards and cause potential harm. In addition, if unnecessary tests are performed, the patient will have to put up with the uncertainty whilst waiting for the results, causing anxiety that could be avoided.

By the same token, if referrals are made unnecessarily or inappropriately, patients have to put up with the uncertainty and anxiety whilst waiting to be seen. The hospital or specialist resources could be better used in managing other more urgent and needy patients. The worst scenario would be that the patients may become entangled in the "cycle of care" or "revolving door syndrome" when they get even more referrals to other specialties after the initial referral.

It is high time that doctors and health care professionals should look closely at how communication with patients can be enhanced especially during the consultations. It is well established that patients prefer doctors who listen and encourage them to discuss all their problems, and patients are often passive in consultations.⁴ Open discussions and clear explanations will go a long way in involving patients' active participation in the management plans. Health care resources are running very tight and they need to be used appropriately.