Doctors' perceptions of patients' wishes influence decision to prescribe drugs.
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Attitude of Health Personnel↗
Biomedical subjects
M M Kochen
Publications and source records attributed to M M Kochen.
Nonformulary drug requests at an academic hospital in Germany--the role of general practitioners' long-term medication.
OBJECTIVE: To determine the influence of general practitioners' outpatient medication on nonformulary drug requests in university hospitals. METHODS: During a period of 1 year every nonformulary drug request at the Göttingen University Hospital was analysed (reason for request, drug class). A second analysis examined whether the introduction of a new order form that allowed the prescribing physician to mark a box to declare that this request is due to general practitioner's outpatient therapy influenced the rate of requests. RESULTS: During 12 months a total of 6,281 nonformulary drugs were ordered from the pharmacy, 1,077 (17.1%) of them because of outpatient medication. The percentage of requests according to general practitioners' outpatient medication was about 11% in both the medical and the surgical departments. The rate was rather high in the departments of psychiatry and orthopaedic surgery (39% and 60%, respectively). With the introduction of the new order form, there was a significant increase in the general practice based rate of nonformulary requests on the general surgical wards (from 10.8% to 19.9%). Only a minority of requests (14%) represented drugs of unproven efficacy. CONCLUSION: Since nonformulary requests attributable to previous outpatient medication accounts for less than 20% and since only a minor portion of them lack scientific proof of efficacy we suggest that hospital doctors and clinical pharmacologists should avoid a drug policy, which is too restrictive, and support maintenance of chronic medication initiated by general practitioners. Especially in the department of psychiatry, nonformulary requests seem to be justified by patient needs.
Drug Prescriptions↗
[Evaluation of scientific publication: a recommendation (not only) for general medicine].
A Proposal (not only) for General Practice/Family Medicine: Medical faculties and other institutions increase their pressure on scientific societies and colleges to present and set standards to evaluate publications from their discipline. After discussing the quality of different literature and publication indices the authors take a critical look at the impact factor which arouses much controversy among medical faculties. The evaluation standard presented for general practice comprises three categories of quality to which (A) Top Journals, (B) Standard Journals and (C) other Journals (but also books and book contributions) are allocated. Assessment criteria are mainly based on indexation (Index Medicus) and independent peer review. Within that system original papers are valued higher than reviews and editorials or comments. The impact factor is not considered to be helpful for judgement. The authors are convinced that any numerical point system would not be likely to lead to a reasonable assessment of an individual publication. Furthermore, there could be an increased risk that members of committees would prefer the point system for their judgement rather than to read papers in detail. The suggested standard could serve as an aid for referees from disciplines other than general practice. However, their expert decision regarding the quality of publications could not be replaced by even the most sophisticated valuation system.
Faculty, Medical↗
[Re: Barandun J: Inhalation therapy in chronic obstructive bronchial diseases. Schweiz Med Wochenschr 1996; 126: 1693-1703].
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Adrenergic beta-Agonists↗
Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice.
OBJECTIVE: To test the hypotheses that patient expectations are a driving force in drug prescribing and that fulfilment of expectations is followed by higher satisfaction. DESIGN: Pre- and post-consultation survey of patients; parallel doctor survey (matched pairs). SETTING: Primary health care in Göttingen, a town of about 130,000 inhabitants in Germany. SUBJECTS: Ten general practitioners and 185 randomly addressed patients. MAIN OUTCOME MEASURES: Patient expectations with respect to the result of the consultation; doctor's perception of patient expectations; agreement between patient and doctor; patient satisfaction. RESULTS: Nearly half of the patients (86/185) expected a drug prescription from their doctor; 68% (125/185) received a prescription. The doctors recognized the expectation of a prescription in only 40.7% of the patients. A high percentage (82.6%) of patients expecting a drug were issued a prescription. Nearly all the patients (45/48) who expected a drug according to their doctor's judgement left the surgery with a prescription, and 58.4% of the remaining patients were prescribed a drug. There was no difference in satisfaction scores between patients whose expectations were or were not fulfilled. CONCLUSION: These results are in some contrast to the main hypotheses. As fulfilment of expectations was not associated with higher satisfaction, physicians need not necessarily worry that patients will change their doctor if he or she refuses a pharmacologically dubious prescription.
Adult↗
Management of involuntary childlessness in general practice--patients' and doctors' views.
In order to determine whether general practitioners (GPs) are interested in infertility counselling and whether infertile patients seek help from their family doctor, we personally interviewed doctors and infertile patients. Almost all of the board-certified GPs in Göttingen, Germany, and two independent samples of infertile women and men attending the Göttingen University Hospital participated. The majority of the GPs did not routinely ask childless patients about their desire to have children, although half of the infertile men and one-quarter of the infertile women would prefer it if their doctor were to raise the subject. About half of these doctors emphasized their role as an important source of information and advice during assisted conception and almost half of the patients expected emotional support from their GP.
Attitude to Health↗
Management of involuntary childlessness.
Any definition of involuntary childlessness has to consider the difference between sterility and subfertility. As the latter affects about 20-30% of all couples at least once in their lives, general practitioners (GPs) may be the first to be confronted with this problem. This review presents the most relevant diagnostic and therapeutic options in cases of female or male infertility, and discusses the new assisted reproductive technologies (such as insemination, in vitro fertilization, gamete transfer and intracytoplasmatic sperm injection) so that GPs may adequately inform their patients about these procedures and their risks and outcomes. Although controversial, involuntary childlessness and its clinical treatment seem to have a strong psychological impact on a couple's social, emotional and sexual life. Being available for discussion with childless couples and offering ongoing support may be the most important role for the GP in this context.
Family Practice↗
Changes in drug prescribing under the Public Health Reform Law--a survey of general practitioners' attitudes in East and West Germany.
The aim of the study was to examine general practitioners' attitudes towards drug prescribing in times of economic pressure, and to determine the relevance of different factors for changed prescribing behavior. A random sample of general practitioners in Eastern Germany and in Western Germany was surveyed, after the Public Health Reform Law, a budgetary initiative to reduce prescribing costs in Germany, had come into effect. Multiple logistic regression was performed to analyze the association between self-reported prescribing behavior and covariates (such as sex and age, level of certification, doctors' prescribing costs, criteria of prescribing, sources of drug information). Response rates had been 53.4% (n = 550) in Eastern Germany and 56.8% (n = 579) in Western Germany respectively. About two thirds of the doctors (East: 60.4%, West: 73%) believed that they had changed their prescribing behavior under the new law. They used generic drugs more often (East: 29.5%, West: 52.3%) and often used more generic drugs (East: 29.5%, West: 52.3%) and were less liberal in meeting patients' wishes (61.0% and 72.8%, respectively). Doctors whose total prescribing costs were above the average of their colleagues, more frequently reported change in prescribing behavior in response to the new law (OR: 3.11, 95% CI: 1.63, 5.91 for Eastern doctors and OR: 5.90, 95% CI: 2.49, 13.98 for Western doctors). This was also true for doctors who considered the price of a drug to be a very important criterion for drug selection (OR: 4.34, 95% CI: 2.69, 7.01 and OR: 3.23, 95% CI: 1.9, 5.49, respectively). "Price-oriented" and "cost-concerned" doctors were also more likely to handle patient prescription wishes less liberal and to prescribe generic rather than original brand name drugs more often. We conclude that budgetary initiatives, such as the German Public Health Reform Law, seem to influence general practitioners towards a more economic prescribing behavior. Doctors concerned about their prescribing costs or about drug costs may be more responsive to such administrative regulations.
Adult↗
[Is "involuntary childlessness" within the realm of family medicine responsibility of the general practitioner?].
The aim of the study was to assess whether or not management of infertility is within the domain of the general practitioner in his capacity as a family physician. All accredited family physicians in the wider area of Goettingen were invited to take part in our survey. A total of 57 doctors (84%) participated. In personal interviews the family physicians were encouraged to frankly discuss the following main topics: the frequency of infertility in their own practice as well as their care for and attitudes towards infertile patients. Many family physicians interviewed were reluctant to address involuntary childlessness and underestimated its frequency. According to their patients' needs and demands, however, family doctors--above all in rural practices--have been participating in the screening and counseling of, and providing emotional support for, involuntarily childless patients. A qualitative analysis of the interview data revealed that many family physicians regarded infertility as the patients' private matter and placed it within the domain of specialists. About one-third of the physicians expressed negative attitudes towards infertile patients. Moreover, assisted reproduction techniques were sometimes rejected as "unnatural" methods. If a family-oriented approach should be amplified in family practice by offering supportive counseling for infertile patients, continuing medical education will have to take these attitudes into account.
Adult↗
[Patient initiative and referral decision of the primary care physician].
Using the German data of the European referral study from primary to secondary care this paper attempts to answer the following questions: which are the specialties GPs refer to, and which referrals were initiated by the patients. According to the study's methodology the gatekeeper function of the GPs or the patient initiative should be described by distinguishing between direct and indirect referrals. A direct referral is defined by a face to face encounter between patient and GP, while an indirect referral requires no such contact. For direct referral the GPs recorded the influence of the patient on their referral decision. In 71 practices (only the western part of the Federal Republic of Germany) 2077 direct and 1665 indirect referrals were documented. Every second direct referral was influenced by the patients. Women had a greater influence than men. An analysis by specialty showed that most of the direct referrals were directed to orthopaedics (14%), surgery (12%) and internal medicine (10%) and most of the indirect referrals to ophthalmology (25%), gynaecology (20%) and dermatology (8%) (64% of all indirect referrals were given to women). These results could be taken as an example how patients take over the responsibility of managing their complaints and illnesses by themselves in a health system with free access to specialist care. The role of the German GP as a gatekeeper and co-ordinator in the health care system turned out to be very limited. In consequence this might result in future problems such as a lack of co-operation, deficiencies in the continuity of medical treatment, over-medication unnecessary parallel investigations and additional costs.
Adolescent↗
[Relevance of general practitioner's prescriptions for hospital pharmacotherapy. A survey of hospital physicians].
BACKGROUND AND OBJECTIVE: At hospital admission drugs prescribed by the general practitioner (GP) are often changed. This may have a negative impact on the relationship between family and hospital physicians as well as on the family doctor-patient-relationship. The study set out to examine the attitudes of hospital physicians towards GPs' prior ambulatory medication, especially in the case of drugs of unproven efficacy (e.g. certain drug combinations and homeopathic or herbal drugs). PARTICIPANTS AND METHODS: A total of 129 doctors of the surgical and medical wards of the Göttingen University Hospital received a standardized questionnaire focusing on drugs prescribed by referring GPs (response rate: 65.9%). Three case vignettes were presented describing "popular" GP prescriptions. Doctors of surgical and medical departments were asked whether or not they would follow these prescriptions. Differences in the answers between the groups of doctors were tested by Fisher's exact test. RESULTS: More doctors on the surgical than on the medical wards would usually follow GPs' medication (82 vs 25%; P < 0.001). According to these attitudes, more doctors of medical departments would stop the prescription of drug combination (82 vs 41%; P < 0.001); both groups would be hesitant to accept homeopathic drugs (89 vs 59%; P < 0.01) or herbal drugs (89 vs 55%; P < 0.01) as prescribed by the GP. The critical attitude especially of doctors of the medical departments towards drug combinations and herbal drugs was in line with their decision in the case vignettes (e.g. Capozide, Tebonin forte). CONCLUSION: Especially doctors working in medical departments keep in line with conventional clinical pharmacological criteria. If they have to decide whether or not to follow patients' ambulatory medication, they may overlook GPs' decision-making process underlying their prescribing.
Aged↗
What happens to long-term medication when general practice patients are referred to hospital?
OBJECTIVE: The aim of the study was to determine changes in drug treatment of general practitioners' patients on hospital admission and after discharge, and to identify communication problems. METHODS: During 15 months all chronically ill patients of one general practice who were referred to hospital (n = 130) were followed-up prospectively with regard to long-term medication in general practice, drugs recommended in hospital for continuing treatment and medication after discharge from hospital. RESULTS: Before hospital admission the 130 patients were receiving 420 medicines long-term (14% generic drugs). The hospital doctors cancelled 28% (116/420) of the drugs, 6% were replaced by other drugs, 11% by another brand name (identical chemical substance but different producer) and 31 generics were replaced by brand name drugs. Hospitals exhibited specific drug profiles (e.g., total replacement of some generics by brand name drugs; and exclusive administration of a certain preparation regardless of the general practitioner's prescription). After discharge from hospital, the general practitioner continued 329 of the 496 drugs (66.1%) recommended by hospital, 105 (21%) drugs were replaced by other drugs (49 of them by generics) and 62 drugs (13%) were cancelled. The general practitioner received detailed information about drug change in only five of the 130 hospital discharge letters. CONCLUSION: 50% turnover in drug use between general practice and hospital and some of the patterns of drug change in hospital may be unnecessary. They may also complicate the difficult task of the general practitioner of maintaining a patient's drug regimen.
Aged↗
Drug prescribing in hospital as experienced by general practitioners: East versus West Germany.
BACKGROUND AND OBJECTIVES: Drugs prescribed by the general practitioner (GP) are often changed during hospitalization. This study set out to test the hypothesis that the extent of drug change and the information provided by the hospital determines the GPs' assessment of hospital co-operation. The perception of drug change and hospital co-operation may also be influenced by the degree of institutional separation of primary and secondary care. Therefore we compared GPs' respective attitudes in 'East' and 'West' Germany. METHOD: In 1993, a representative sample of 'eastern' and 'western' German doctors received a structured questionnaire; 554 doctors (63%) participated. RESULTS: Fifty-seven per cent of the western and 39% of the eastern GPs believed that their medication was changed in hospital in more than 60% of their patients. Only a minority of eastern (10%) and western (15%) doctors described the information provided by the hospitals as more or less satisfactory. More western than eastern doctors (56% versus 32%) expressed dissatisfaction with hospital co-operation. Respondents in eastern Germany who felt sufficiently informed about hospital drug change were more likely to express satisfaction with the hospital doctors' co-operation. In the former area of West Germany the judgement of co-operation was significantly better if the extent of drug change and the frequency of generic drug replacement by original brand-name drugs were lower. CONCLUSIONS: The study showed that hospital-initiated drug change is a matter of concern, especially for GPs who are working in an area with a tradition of strictly separated primary and secondary care.
Adult↗
Cancer incidence on a small island--research opportunities in general practice.
OBJECTIVE: To test the impression of an increased cancer incidence on the island of Pellworm (in the far North of Germany) and to illustrate the feasibility of a general practice-based approach in epidemiological research. DESIGN: Cancer incidence on Pellworm was prospectively registered in the only general practice on the island from 1986 to 1992. Age-standardized rates and expected rates were calculated on the basis of the Saarland cancer registry, the only registry in Germany. Standardized incidence ratios and 95% confidence intervals (CI) for Poisson-distributed events were also calculated. The cancer data were summed up over a seven-year period. SETTING: The only general practice on the island of Pellworm, a North Frisian marshland-island. SUBJECTS: The total practice population between 1986 and 1992 (N = 1172) RESULTS: The crude annual cancer incidence rate for Pellworm was, according to the impression, unexpectedly high: 634/100 000 for men and 502/100 000 for women. After age standardization, however, this increased rate of cancer incidence was even lower than in the Saarland (ratios: 0.86 for men and 0.95 for women). Only the incidence of neoplasms of the lymphatic and haematopoietic tissue in men exceeded the limits of statistical likelihood (ratio: 3.21; 95% CI: 1.17-7.10). CONCLUSION: The impression of an increased rate of cancer on Pellworm could not be validated. The overall incidence rate was even lower than expected. Only the rate of leukaemia/lymphoma (men) was significantly higher. Reasons for this result could not be detected by a descriptive approach. General practice is a suitable place for studies in cancer epidemiology, especially in such ideal circumstances as a clearly limited area and complete and reliable documentation.
Adolescent↗
[Evaluation of the educational curriculum in psychosocial fields and general medicine in human medicine subjects--results of a total Germany pilot study in the 1995 summer semester].
With the discussion of the quality of medical education in Germany the importance of evaluating the curriculum has grown. A working group of representatives of the German scientific societies for general medicine and the so-called "psychosocial" disciplines in medical education had adapted a questionnaire from Harvard Medical School and tested this version for the first time in summer 1995. 56 teachers and 1250 students took part in this pilot study. The instrument proved to be sufficiently valid to evaluate the quality of different types of teaching lessons. The disciplines (Medical Sociology, Medical Psychology, Social Medicine, General Medicine, Psychotherapy/Psychosomatics) were valued equally with concern to their relevance for medical education. They got significantly better values for quality of teaching and teaching engagement of the professors. It is recommended to notice these results in the actual debate on the reform of the medical curriculum and to include other disciplines in further evaluative investigations.
Curriculum↗
[Factors influencing the prescribing of nootropic drugs. Results of a representative inquiry in Lower Saxony].
AIM OF INVESTIGATION: To discover (1) to what extent patients' wishes and the extent of any abnormality of brain performance influence the frequency with which "nootropic" drugs (those thought to affect brain activity, e.g. piracetam, pyritinol, or improve cerebral circulation, e.g. xanthine derivatives, Ginkgo biloba, secale alkaloids, calcium antagonists) are prescribed; (2) the medical practitioner's expectations of the effectiveness of such medications. METHOD: In a personal interview, 145 family doctors and 14 neurologists in private practice in the Göttingen area of Germany (participation rate: 83.2% of those asked to participate) were questioned about fictitious cases (case 1: mild memory problem with or without expressed wish for medication; case 2: moderate dementia, of Alzheimer or multi-infarct type). The previously arranged interviews, which took place in the doctors' practice rooms, consisted of standardized open questions to the written case reports. RESULTS: Regardless of the wish of the patient and the extent and type of the abnormal brain function about 70% of all participating doctors would prescribe those drugs, even though about 56% had doubts about their effectiveness. About 28% expected a positive effect on brain performance. A nearly equal proportion of doctors would continue an existing drug regimen as would prescribe one. CONCLUSION: The prescription of the named group of drugs is influenced less by medical criteria than by factors which concern doctor-patient relationship.
Adult↗
How do academic heads of departments of general practice organize patient care? A European survey.
BACKGROUND: Compared with other clinical disciplines, academic general practice is in a difficult situation with respect to patient care. There are at least three different possible models of working arrangements for heads of departments of general practice: to work in a surgery in a medical school; to work in a surgery in the community, separate from a part-time university post; or to work part-time in a surgery in the community, separate from a university post. AIM: A study was undertaken to explore these models and to gain an understanding of academic teachers' organization of patient care in Europe. METHOD: A total of 77 heads of departments in universities in 12 European countries were sent a questionnaire enquiring about important characteristics of their department, the number of patients they treated per week and how they allocated their time. RESULTS: Sixty nine heads of department (90%) responded. Of respondents, 55% worked part-time in a surgery, separate from a university post, nearly one third worked mainly in a surgery, separate from a part-time university post, and 16% worked in a surgery in a medical school. Those working in a surgery with only a part-time university post spent most time in patient care compared with those working in other models (mean of 57%). Respondents working in a surgery in a medical school spent most time on administration (34%); they spent 22% of their time on patient care and 20% on education. Respondents working in a surgery in a medical school spent 25% of their time on research, those working in a surgery separate from a part-time university post spent 12% of their time on research, and those working mainly in a university with a part-time practice post spent 24% of their time on research. Those working mainly in a university post spent only 17% of their time in patient care. CONCLUSION: Working in a surgery in a medical school represented a well-balanced model of time allocation between patient care, research and education and seemed to be a good approach for the integration of general practice into medical schools. Working part-time in a surgery with a university post is an appropriate model for academic integration, but patient care seemed to be neglected. Those doctors working mainly in the community with a part-time university post were able to provide continuity of care and to come into close contact with the everyday problems of general practitioners. However, they might have to struggle for academic recognition.
Europe↗
COOP-WONCA charts: a suitable functional status screening instrument in acute low back pain?
BACKGROUND: Functional status is considered an important measure of health status in primary care. The COOP-WONCA charts, which comprise six single-item scales, have mainly been used to determine functional ability in chronically ill patients. AIM: A study was carried out to determine whether the charts are able to measure the degree of functional impairment associated with acute illness and the improvement in functional ability accompanying the process of recovery. METHOD: A total of 95 patients presenting with acute low back pain were recruited from 15 single-handed general practices in northern Germany. At presentation and at two-week follow up, these patients completed self-administered questionnaires which included the COOP-WONCA charts. The charts ask patients to use the timescale of the past two weeks when rating their condition. Baseline and follow-up measurements of the charts were compared and correlations of chart scores with patients' measurements of pain intensity on a visual analogue scale, general practitioners' ratings of impairment and patients' measurements of recovery were analysed. RESULTS: Only the chart measuring change in health revealed a deterioration in functional ability associated with the onset of pain and an improvement in functional status at follow up. Two of the other charts indicated a deterioration at follow up. Only the chart measuring change in health was correlated with ratings of pain and impairment at baseline. At follow up, strong correlations were found between general practitioners' assessments of impairment, patients' ratings of pain and patients' ratings of recovery for all scales except for those measuring social activities and daily activities. The patients interpreted the instructions for using the COOP-WONCA charts differently; some included the period of acute back pain while others did not. CONCLUSION: Of the six charts only the change in health chart proved to be a suitable scale for measuring short-term changes in functional ability among general practice patients with acute low back pain. This may partly be a result of patients misunderstanding the instructions. If the COOP-WONCA charts are used with acutely ill patients, the fixed two-weeks timescale is not appropriate. It is suggested that patients consider their present complaints when rating their condition.
Activities of Daily Living↗