Most surveys show that patients are satisfied with the care they receive through general practice, but patients often say that their consultations are too short and that doctors do not use this time well (Wilson, 1991; Bener et al., 1993). Studies about the length of consultations have investigated the effect of characteristics of the physician and the patients and the reason for the consultation on the length of consultation (Morell et al., 1986; Roland et al., 1986; Morell and Roland, 1991; Car-Hill et al, 1998; Deveugele et al., 2002; Knight, 1987). The size of a doctor's list is not an important determinant of consultation length, except when lists are extremely large or extremely small (Knight, 1986; Anderson et al., 1993). Doctors spend more time with patients who have new problems than those with already discussed problems (Morell et al., 1986; Roland et al., 1986; Howie et al., 1991; Cape, 2002). Many studies showed that general practitioners have a significant effect on primary health care services and health promotion (McPhee et al., 1984; Wilson, 1985; Howie et al., 1991; Engstrom, 2001;). In the developed and developing countries, the debate on the respective roles of medical specialists and generalists has tended to portray them as alternatives rather than seeking ways to build on the complementary skills of these professional groups (Lowe, 2000). One may evaluate the impact of a selective admitting policy that attempts to exploit the complementary strengths of specialists and generalists. Generally, the comparison of specialist versus primary care load and performance is not an easy task (Alsever, 1995). Generalist or specialist - who does it better? - needs further investigation (Cram and Ettinger, 1998). Consultations about psychosomatic and behavioral problems are longer than those for other problems ( Wilson, 1985; Alsever, 1995; Cram and Ettinger, 1998; Lowe, 2000).

Lack of time in consultation with doctors is a frequent patient concern (Roland et al., 1986; Knight, 1987; Morell and Roland, 1987; Wilson, 1991; Howie, 1991; Bener et al., 1993; Carr-Hill et al., 1998; Deveugele et al., 2002; Morell et al., 2002; Cape, 2002). To evaluate and compare the effectiveness of tertiary hospital and primary health care and specialist care is a complex task and there are methodoligical differences and limitations in all studies. However, the length of consultation can be used as a marker for quality of consultation in health care assessment. We have used a recent report on consultation length in General practice in six European Countries by Deveugele et al. (2002) as a model study for Qatar. The objective of this study was to assess the consultation length in a tertiary care teaching hospital and in general practice in the developing State of Qatar. Additionally, we aimed to compare determinants of consultation length given in the literature with those identified in general practice.

Socio-demographic background:
The State of Qatar lies on the western coast of the Arabian Gulf. Qatar is characterized by a hot summer and winter is warm with little rainfall. Oil revenues and gas constitute a corner stone in the economy, which had been used wisely to build a sophisticated social and health infrastructure. Investment in health and social development has resulted in dramatic gains in the health and well being of the people. The State of Qatar's population has been estimated to be over 850,000 in year 2006; expatriates consist of 70% of the total population.

Study design:
This was a prospective descriptive study conducted at the Hamad General Hospital and PHC Centers in Doha City and suburban area of Qatar during the period from April to June 2005.

Questionnaire and interview:
The questionnaire and criteria for the consultation length in general practice defined and proposed by Deveugele et al. (2002) was used. In the analysis, we differentiated between the presence of psychological problems and their importance. Presence of psychosocial problems for the doctor meant that the diagnosis could be coded into one of the psychosocial categories of the International Classification of Primary Care (Deveugele et al., 2002). For the patient, it meant that the patient's reason for the encounter could be coded into one of the psychosocial categories. The general practitioners assess the importance of psychosocial problems on a five point Likert scale (5= very important; 1= least important). The importance of medical and psychosocial aspects of consultation for the patient was measured by a questionnaire derived from the patient request form that used 10 of the relevant items. A translated Arabic version of the questionnaire was revised by the Consultant (SAM) [bilingual] and back translated by a bilingual GP, unacquainted with the original English version. Both translators met and made necessary corrections, modifications and rewording after considering the minor differences and discrepancies, which had occurred. The questionnaire was validated.

Primary Care:
A multi-stage stratified cluster sampling design was developed using an administrative division of Qatar into 21 PHC Districts each of approximately equal size in terms of number of inhabitants. The sample size was based on need to detect an effect size of 0.35 at a significance of 0.05 with power of 80. On this basis the computer program indicated that we needed 750 subjects to achieve the objective of our study. The PHC clinics were instructed to structurally interview and complete a questionnaire for randomly selected patients attending their clinics in each stratum.

Patient's views were recorded through a face-to-face interview by a physician or qualified nurse to determine their view on the psychosocial component. Consultation times were then recorded. A total of 750 patients were approached and 599 expressed their consent to participate in this study.

Secondary care:
The hospital waiting time data was collected prospectively with a person dedicated to collecting accurate data.

Student-t test was used to ascertain the significance of differences between mean values of two continuous variables and for non-parametric test; Mann-Whitney's mean test was used. We used an analysis of principal components with a Varimax rotation on answers to question on the patients' questionnaire about the importance of psychosocial and medical aspects of the consultation. The level p<0.05 was considered as the cut-off value for significance.

We included 7970 patients from the Hamad General Hospital according to type of visit and physician ranking. Table 1 shows the mechanism of type of visit, mode of appointment, specialty of doctor and delay at the tertiary care Hamad General Hospital.

Table 2 depicts consultation length and waiting time for patients in specialist clinics at the Hamad General Hospital. In the present study in Qatar the average consultation time at the Hamad General Hospital ranged from 7.0 to 17.4 minutes. There is substantial inter-practice variation in consultation length.

Table 3 presents consultation lengths for patients at the Primary Health Care Centers in urban and semi-urban areas. The presented data showed that in Qatar the average consultation time ranged from 4.7 to 8.4 minutes. In some practices the longest average GP consultation time was about twice that of the shortest.
We performed a factor analysis of patients' questionnaires to look at how important medical and psychosocial aspects of consultations were in determining the consultation length. This analysis revealed two subscales - a biomedical scale with six items and a psychosocial scale with four items (Table 4). Cronbach's was 0.85 for the biomedical scale and 0.83 for the psychosocial scale.

In Qatar, both Tertiary care and PHCs provides curative and prevention services. There is no difference in the quality of service provided by PHC centers. Investment in health and social developments has resulted in remarkable gains in the health and well being of the people.

Table 5 presents information and comparison for the consultation length for patients of general practitioners in Europe (Deveugele, 2002), and in the Arabian Gulf States. The mean length of consultation for all consultations in Europe was 10.7 ± 6.7 minutes and in Arabian Gulf countries was 5.9 ± 2.4. The Six European countries could be divided into three pairs that differed significantly from each other with respect to total consultation time. Belgium and Switzerland had the longest consultation times while Germany and Spain had the shortest consultation times. The consultation times for the United Kingdom and Netherlands were average. We compared our results with six European countries; and our results are consistent with those from Germany, Spain and the United Kingdom. It seems general practitioners in Belgium and Switzerland operate in an "open market", in which patients have direct access to more than one general practitioner and specialist. In fact, the situation in Qatar is similar to that in Belgium and Switzerland where general practitioners are paid mostly by direct payments from the patient at the beginning of a consultation. Although the United Kingdom and the Netherlands, which had intermediate consultation lengths, have well-organized primary healthcare systems, with restricted patient lists and gate keeping, which general practitioners paid by capitation.

The presence of psychosocial problems in the consultation was an important factor influencing the length of consultation, and patients' and doctors' perceptions concerning psychosocial problems affected the length of the consultation. In fact the differences between the effect on doctors' and patients was highly significant. Generally, when doctors perceived a psychosocial problem, the duration of consultation increased. From the patient's perspective, the consultation time was longer when the patient expected some help on psychosocial aspects from the doctor, than when they did not. Furthermore, when the doctor perceived a psychosocial problem, the increase in consultation time was nearly twice as long as that as when the patient perceived a psychosocial problem. In fact, the physician had the largest impact on the duration of the consultation. Overall, our present study results are consistent with those from results of Wilson (1991) , Carr-Hill et al. (1987) and Deveugele et al. (2002) who stated that most differences in the consultation lengths will disappear when factors relating to physicians are controlled for.

The impact of the proportions of the consultation dedicated to health promotion has received much attention in the literature. Many studies agree that consultations lasting less than 10 minutes do not have a significant effect on health promotion (McPhee et al., 1984; Wilson, 1985; Howie et al., 1991; Alsever, 1995; Lowe, 2000; Engstrom et al., 2001; Ogden et al., 2004). In British general practices the average consultation time ranged from 5.5 to 6.6 minutes (Wilson, 1985; Roland et al., 1986; Wilson, 1991; Carr-Hill et al., 1998; Deveugele, 2002;). In Australia the average GPs consultation time ranged from 3 to 39 minutes with a mean of 14.8 minutes (Britt et al., 2002) and in the United States (Levinson and Chaumenton, 1999) the mean visit length was 13 minutes. It was observed in Saudi Arabia, a neighboring country, time of 5.69 minutes (Al-Shammari, 1991; Bener, 1992), and in the United Arab Emirates it ranged 5 to 6 minutes (Annual Health Report 2000), and in the present study in the State of Qatar the average consultation time ranged from 4.7 to 8.4 minutes.

Managed care companies encourage primary care physicians to limit referrals to specialists and provide as much of the needed services themselves. As a result, generalist and specialist physicians are now in direct competition with one another (McPhee et al., 1984; Alsever, 1995). Many physicians in urban areas are specialists whose expertise is not really relevant to the general population, but their numbers augment the physician-population ratio (Alsever, 1995). Also, competition between generalists and specialists in a fragmented system only serves to further weaken the position of physicians in the health care industry (Cram and Ettinger, 1998). Furthermore, the referral system and communication between generalists and specialists can be further explored in Qatar and other neighboring countries populations.

Finally, efficient medical communication depends on an understanding of the patient perspective. When consulting the regular doctor, trust and satisfaction are associated. (Baker et al., 2003) The feeling of not having to hurry during the consultation is more important than the actual number of minutes (Steine et al., 2000). Patients' level of emotional involvement and their specific expectations are often undisclosed. However, short consultation time in Primary care and tertiary care and also of generalist and specialist physician competition, would always be a problem in the developing and developed countries.

The consultation length has increased in Qatar during the decade; however, it is still short by international and western standards. The care provided by generalist and specialist physicians differ in terms of workload, quality and cost. Furthermore, in part both specialists and general practitioners are blamed for failure to deliver high quality care.

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