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An analysis of the establishment and running of a general-practitioner medical unit in a district general hospital has shown that it fulfills a useful and positive role in the area health services and is well used. It shows that selectivity of admission can and does work and that the theoretical drawbacks to such a unit did not materialize in practice during the study.
OBJECTIVE: The study aimed to explore contemporary collaborative experiences of nurse practitioners (NPs) in providing care with general practitioners (GPs) and allied health care professionals. DESIGN: A qualitative descriptive, exploratory design was considered the most appropriate to achieve the study objectives. This allowed the researcher at first hand to gain a thorough understanding of the nurse participants' experiences. SETTING: The study was conducted in urban, rural and remote clinics and hospitals throughout New South Wales, Australia, where the NPs were authorised to care for the community. PARTICIPANTS: Nine authorised NPs were the key participants in the study. RESULTS: Analysis identified one main theme of Collaboration and three sub themes that were named as Total Collaboration, Partial Collaboration and Non Collaboration. CONCLUSION: In this study, most NPs reported dissatisfaction from working in ineffective collaborative relationships with medical and allied health care professionals. Total collaboration did not automatically occur and was identified as the exception. Sustainable collaborative partnerships should be developed with all heath care providers by acknowledging each others unique, valuable contribution. Despite this challenging and complex situation, NSW NPs remained determined to provide advanced nursing care for patients and to establish and maintain effective collaboration with all health care professionals.
BACKGROUND: There is an assumption that men and women general practitioners adopt different practice styles in the management of gynaecological disorders. However, there is little evidence to support this view. AIM: A study was undertaken to compare the practice styles of men and women general practitioners in the management of menorrhagia. METHOD: The study took place in 73 general practices in the Oxford Regional Health Authority area. A total of 348 patients who consulted 74 men general practitioners and 43 women general practitioners with a complaint of menorrhagia were recruited into the study and completed postal questionnaires nine and 18 months after entry into the study. Main outcome measures were men and women general practitioners' awareness of patients' treatment preferences, treatment received by patients, patients' involvement in treatment decisions and patients' satisfaction with treatment received. RESULTS: There were no statistically significant differences in treatment received by patients of men and women general practitioners. Fewer patients consulting women general practitioners were referred to a gynaecologist compared with patients consulting men general practitioners (56% versus 64%) and fewer underwent surgery (39% versus 47%). More patients consulting women general practitioners reported participation in treatment decisions (63% versus 53%) but more patients consulting men general practitioners were satisfied with the care they received (66% versus 55%). Again, these differences were not statistically significant. CONCLUSION: Although some indications of sex-associated differences in practice style were found in this study, the similarities in practice styles of men and women general practitioners were more striking than the differences.
County Sligo in the Republic of Ireland is a rural area where general practitioners generally work single-handed and in geographical isolation from library facilities. In order to facilitate access to current medical journals for general practitioners a project was started to supply them with the contents pages of recently received general practice literature from a central medical library. Following telephoned or written requests, reprint articles of interest were forwarded by return post. The detailed costs and analysis of the exercise for one year are included.
BACKGROUND: Liaison meetings between psychiatrists and general practitioners are now well established. Much has been written about their purpose and structure but little about their content. AIM: A study aimed to describe the clinical focus of meetings between a community mental health team and general practitioners and the nature of the professionals' interactions. METHOD: Audiotapes of six consecutive monthly meetings between a community mental health team and general practitioners in two general practices were analysed. RESULTS: Attendance rates among professionals were over 70%. Over 90% of discussion time was focused on patient-centred clinical matters. Almost two thirds of interactions were focused on patients receiving ongoing joint care; few interactions were devoted to new referrals or to patients who had not been assessed. Psychotic patients, although accounting for 15% of referrals, occupied 54% of patient-centred discussion time. Most interactions consisted of reciprocal information exchange between members of the community mental health team and general practitioners. CONCLUSION: The high attendance rates indicate that both general practitioners and community mental health team members considered these meetings as high priority. The steady move towards management of severely ill psychiatric patients in the community rather than in hospital requires close collaboration between primary and secondary care teams. The meetings described in this paper appear to be a simple, manageable and sustainable response to this need.
BACKGROUND: Many patients visit their general practitioner (GP) because of problems that are psychosocial in origin. However, for many of these problems there is no evidence-based treatment available in primary care, and these patients place time-consuming demands on their GP. Therefore, GPs could benefit from tools to help these patients more effectively and efficiently. In this light, it is important to assess whether structured psychosocial interventions might be an appropriate tool for GPs. Previous reviews have shown that psychosocial interventions in primary care seem more effective that usual care. However, these interventions were mostly performed by health professionals other than the GP. OBJECTIVES: To present a systematic review of the literature addressing the effectiveness of psychosocial interventions by general practitioners by assessing the clinical outcomes and the methodological quality of selected studies. SEARCH STRATEGY: The literature search was conducted using the CCDAN Trials Register, the Cochrane Library and reference lists of relevant studies for citation tracking. Also, personal communication with experts took place. SELECTION CRITERIA: Randomised controlled trials, controlled clinical trials and controlled patient preference trials addressing the effectiveness of psychosocial interventions by GPs for any problem or disorder. Studies published before January 2002 were eligible for entry. DATA COLLECTION AND ANALYSIS: Methodological quality was independently be assessed by two reviewers using the Maastricht-Amsterdam Criteria List and the CCDAN Quality Rating Scale. The qualitative and quantitative characteristics of selected trials were independently extracted by two reviewers using a standardised data extraction form. Levels of evidence were used to determine the strength of the evidence available. Results from studies that reported similar interventions and outcome measures were meta-analysed. MAIN RESULTS: Eight studies were included in the review. Selected studies addressed different psychosocial interventions for four distinct disorders or health complaints. There is good evidence that problem-solving treatment by general practitioners is effective for major depression. The evidence concerning the remaining interventions for other health complaints (reattribution or cognitive behavioural group therapy for somatisation, counselling for smoking cessation, behavioural interventions to reduce alcohol reduction) is either limited or conflicting. REVIEWER'S CONCLUSIONS: In general, there is little available evidence on the use of psychosocial interventions by general practitioners. Of the psychosocial interventions reviewed, problem-solving treatment for depression seems the most promising tool for GPs, although a stronger evidence-base is required and the effectiveness in routine practice remains to be demonstrated. More research is required to improve the evidence-base on this subject.
OBJECTIVE: To investigate general practitioners' attendance at and views on child protection conferences and their confidence in dealing with sexual abuse in children. DESIGN: Anonymous postal questionnaire sent to all general practitioners in Tower Hamlets and review of consecutive case conferences held by social services for three months in 1989. SETTING: Tower Hamlets health district. SUBJECTS: 91 general practitioners, 56 of whom (62%) responded. MAIN OUTCOME MEASURES: Number of conferences attended, reasons for non-attendance, and reported confidence in dealing with sexual abuse. RESULTS: General practitioners estimated that 202 child protection conferences had been held in 1989 on their patients and that they had attended 85 of these. Information from social services for three months suggested that general practitioners had attended only nine of the 114 conferences reviewed. Timing of the conference was the most important reason for non-attendance. All respondents wanted access to the minutes of these conferences irrespective of their own attendance. Most general practitioners were very or moderately confident of their ability to detect child sexual abuse and non-accidental injury and to communicate with the family. CONCLUSION: More effort should be made to ensure that general practitioners are notified of case conferences and that the timing and location of conferences is compatible with their other commitments.
OBJECTIVES: To describe the recruitment and retention of general practitioners and changes in their time commitment from 1 October 1990 to 1 October 1994. DESIGN: Retrospective analysis of yearly data. SETTING: England and Wales. SUBJECTS: General practitioners in unrestricted practice. MAIN OUTCOME MEASURES: Numbers of general practitioners moving into and out of general practice; proportion of general practitioners practising less than full time; proportion of general practitioners having unchanged time commitment over the study period; and proportion of general practitioners leaving general practice in 1991 who were subsequently practising in 1994. RESULTS: Numbers of general practitioners entering general practice (1565 in 1990, 1400 in 1994) fell over the study period as did the numbers leaving general practice (1488 in 1990, 1115 in 1994). The net effect was an increase in both the total and full time equivalent general practitioners practising from 1 October 1990 (26,757 full time equivalents) to 1 October 1994 (27,063 full time equivalents). Numbers of general practitioners practising full time were decreasing whereas part time practice was increasing; women were more likely to practise part time. 35.5% (43/121) of women practising full time and 17.8% (24/135) of men practising full time who left practice in 1991 were practising again in 1994. CONCLUSION: Simply using total numbers of general practitioners or net increase to describe workforce trends masks much movement in and out of general practice and between differing time commitments. Recruitment and retention issues need to be separated if reasonable policies are to be developed to assure the necessary general practitioner workforce for a primary care led NHS.
An analysis of the distribution of general practitioners by electorates during the six years 1984 to 1989 showed that the maldistribution of practitioners in Australia has worsened despite significant increases (26%) in total general practitioner numbers. One in five rural electorates had worse population-to-general-practitioner ratios in 1989 than in 1984. The changes in distribution of general practitioners ran counter to the changes in distribution of the population over the period studied. In 1984, the 38.7% of the population living in rural Australia was served by 33% of the nation's general practitioners. By 1989, more of the population (39.8%) lived in rural areas but they were served by a smaller proportion (32%) of the general practitioner workforce. It is clear that many urban electorates have fewer people per general practitioner than the most generous ideal ratios, while most rural electorates have more people per general practitioner than the least generous.
OBJECTIVE: To assess the attitudes of general practitioners in Harare, Zimbabwe, towards the use of clinical practice guidelines (CPG's). DESIGN: Cross sectional survey. SETTING: General practitioners in private practice within the urban Harare (Zimbabwe) environs. SUBJECTS: Two hundred and thirty two general practitioners in Harare, Zimbabwe. MAIN OUTCOME MEASURES: The response to a questionnaire enlisting attitudes to CPGs. RESULTS: Questionnaires were sent to 232 general practitioners. Of these, 137 (59.1%) returned a completed questionnaire. Among the respondents, 95.6% felt that general practitioners should be involved in the development of guidelines, 72.6% had read at least one guideline, 65.9% were prepared to use guidelines in their practice, 61.6% thought that guidelines would improve their treatment ability, and 59.7% thought that guidelines would improve their knowledge of disease. 76.5% felt that the government should not legislate, 66.2% felt that guidelines reduce practitioners' flexibility and 57.9% felt that guidelines would not improve their diagnostic ability. CONCLUSION: The respondents were, in general, favourably disposed towards CPGs. Most had already read some guidelines, and about two thirds were prepared to use them. Almost all respondents felt that general practitioners should be involved in the development of guidelines for use in general practice. These general practitioners felt that guidelines were likely to help them treat patients than to make a diagnosis. Despite these favourable attitudes, many practitioners felt that guidelines would limit their personal flexibility in caring for patients. Organisations developing or implementing CPGs in general practice should address these concerns.
The views of general practitioners about their responsibilities for patient care have not been canvassed. A survey of general practitioners was therefore carried out to determine their views. A postal questionnaire, in which general practitioners were asked what they saw as their responsibilities, was sent to 525 principals in Avon and completed by 424, giving a response rate of 81%. The doctors generally agreed that their responsibilities for patient care included problems related to internal medicine, such as managing diabetes and hypertension. Less consensus was found in the replies to questions about technical procedures, such as resection of ingrowing toenails, and gynaecological, orthopaedic, or psychosocial problems. The results supported the view that general practitioners are gradually abandoning technical aspects of medicine to specialists without a compensating role having been defined. In the light of this trend the responsibilities of general practitioners should be clearly defined by the profession.
Given the high incidence of depression, it is necessary and desirable that as many cases as possible should be treated by general practitioners. However, general practitioners are on the whole ill-prepared to meet the needs of depressed patients. In the last few years a big effort has been made in certain countries to improve the psychiatric training of general practitioner and to enable him the better to detect and treat depression. Communication between psychiatrists and general practitioners is made difficult by the lack of a common language and terms used should be defined clearly. Some of the problems in practice are diagnostic in nature: detect of the depressive syndrome, of the minor or masked forms; differential diagnosis of depression and anxiety. The commonest problems in treatment are: selection of drug, monitoring of side-effects, duration of treatment. The general practitioner needs information also on such questions as: how to evaluate the risk of suicide; when to call in the specialist; how far to use supportive psychotherapy. Some types of depression are particularly likely to come to the general practitioner: depression masked by physical symptoms, depression associated with or secondary to physical disease, depression in the elderly.
OBJECTIVE: To examine the beliefs of general practitioners concerning intrapartum care. DESIGN: Postal questionnaire survey. SUBJECTS: All general practitioners with patients in Nottinghamshire Family Health Services Authority in September 1993. MAIN OUTCOME MEASURES: General practitioners' current involvement in maternity care, and beliefs on intrapartum care. RESULTS: Of 694 general practitioners sent questionnaires, 550 (79.2%) replied. 529 of these were on the obstetric list; 437 had not attended a delivery in the past 12 months; 36 had attended two or more; 358 general practitioners did not wish to provide more intrapartum care; 349 did not feel competent to do so. Reasons for not wanting to provide intrapartum care included current workload (453), disruption to personal life (407), and the fear of litigation (377). General practitioners who already booked women for home delivery were more likely to wish to do more deliveries (62/42 v 61/316, chi 2 = 85.3; P < 0.0001) and to have more positive attitudes towards increasing women's choice in maternity care (90/22 v 195/151, chi 2 = 227; P < 0.0001). CONCLUSIONS: The involvement of general practitioners in intrapartum care in Nottinghamshire is low, and most general practitioners are unwilling to increase their role. However, general practitioners who already book for home delivery are keen to do more.
BACKGROUND: Since 1996, prescribing buprenorphine in high dosage as a drug maintenance treatment has been allowing French general practitioners to undertake drug addicts with a pharmacological support. In France, buprenorphine prescriptions seem to spread over general practitioners (buprenorphine was given to 74,300 patients in 2001). This paper assesses the different factors associated with buprenorphine prescription by general practitioners and with the different degrees of general practitioners' commitment in actually caring drug addicts with the help of buprenorphine. METHODS: Two representative samples of private general practitioners, either prescribing buprenorphine (345 over a population of 876) or not prescribing (355 over a population of 1380) have been questioned through a phone interview in the department of South-Eastern France in November and December 2002. Samples have been constituted with the help of a random stratified survey according to sex, age and volume of services (acceptance rate: 65.5%). Survey data have been completed with general practitioners' activity data from Health Insurance and local socioeconomic data from Insee. RESULTS: 37.5% of general practitioners have at least once prescribed buprenorphine during the considered period, but only 26% of the prescribers treated 75% of patients. Prescribers are most often men, younger than 49 years, working in the fixed fees sector and having group practice. They are also most often members of a health care network, trained for drug maintenance treatments and, from an individual point of view, have relatives suffering cancer, or having HIV, or hepatitis C, or who are drug addicts. Low socioeconomic status of the area where GPs exert seems to be particularly associated with general practitioners' prescription of buprenorphine. CONCLUSION: Data handled in this paper show that supply of substitutive treatments is concentrated among a reduced number of general practitioners and in particularly deprived geographic areas. Workload in deprived areas combined to great professional commitment in maintenance treatment reveals unexpected and unwanted specialisation behaviours by general practitioners, as well as more isolated behaviours by general practitioners who do not ask for particular training program or help by colleagues. These results question the consistency of the general framework of support to general practitioners proposed by health authorities with general practitioners actual practice and needs.
OBJECTIVE: To determine the views of general practitioners about professional reaccreditation. DESIGN: Postal questionnaire. SUBJECTS: All 278 general practitioner principals working in Cleveland. MAIN OUTCOME MEASURES: General practitioner characteristics; attitudes to reaccreditation; and views on the development, conduct, content, and format of reaccreditation. RESULTS: 210 out of 278 (76%) general practitioners responded to the questionnaire. 128 (61%) agreed that general practitioners should undergo reaccreditation. 149 (72%) thought the General Medical Services Committee and local medical committees were appropriate bodies to lead its development. 120 respondents suggested that reaccreditation should be carried out by assessors appointed by the doctor's own local medical committee. The most favoured interval between reaccreditation episodes was 10 or more years. 152 doctors thought that doctors who failed reaccreditation should be advised on education and reassessed soon afterwards. Clinical knowledge (82%), clinical skill (82%), prescribing practices (67%), standards of medical record keeping (60%), and consultation behaviour (58%) were the most popular subjects for scrutiny. 138 (67%) respondents felt that reaccreditation should be part of continuing medical education. CONCLUSION: Most general practitioners support professional reaccreditation. They believe the process should be led by the profession, be educational, and take account of a range of professional activities.
OBJECTIVE: To measure general practitioners' knowledge of, confidence with and attitudes to the diagnosis and management of dementia in primary care. SETTING: 20 general practices of varying size and prior research experience in Central Scotland, and 16 similarly varied practices in north London. PARTICIPANTS: 127 general practitioners who had volunteered to join a randomised controlled trial of educational interventions about dementia diagnosis and management. METHODS: Self-completion questionnaires covering knowledge, confidence and attitudes were retrieved from practitioners prior to the educational interventions. RESULTS: General practitioners' knowledge of dementia diagnosis and management is good, but poor awareness of its epidemiology leads to an over-estimate of caseload. Knowledge of local diagnostic and support services is less good, and one third of general practitioners expressed limited confidence in their diagnostic skills, whilst two-thirds lacked confidence in management of behaviour and other problems in dementia. The main difficulties identified by general practitioners were talking with patients about the diagnosis, responding to behaviour problems and coordinating support services. General practitioners perceived lack of time and lack of social services support as the major obstacles to good quality care more often than they identified their own unfamiliarity with current management or with local resources. Attitudes to the disclosure of the diagnosis, and to the potential for improving the quality of life of patients and carers varied, but a third of general practitioners believed that dementia care is within a specialist's domain, not that of general practice. More experienced and male general practitioners were more pessimistic about dementia care, as were general practitioners with lower knowledge about dementia. Those reporting greater difficulty with dementia diagnosis and management and those with lower knowledge scores were also less likely to express attitudes endorsing open communication with patient and carer. CONCLUSION: Educational support for general practitioners should concentrate on epidemiological knowledge, disclosure of the diagnosis and management of behaviour problems in dementia. The availability and profile of support services, particularly social care, need to be enhanced, if earlier diagnosis is to be pursued as a policy objective in primary care.
PURPOSE: To compare the self-reported management of diabetic retinopathy by general practitioners to the National Health and Medical Research Council of Australia (NHMRC) Guidelines for the Management of Diabetic Retinopathy. METHODS: In 1994, a stratified (by urban/rural practice location) sample of 500 general practitioners in Victoria was surveyed in regard to their management of diabetic retinopathy. Following the release of the NHMRC Guidelines for the Management of Diabetic Retinopathy in 1997, these same general practitioners were sent a two-page questionnaire related to their management of diabetic retinopathy. RESULTS: Completed questionnaires were received from 228 general practitioners (59% of original participants). Only 37% (79/216) of the general practitioners reported that they had received a copy of the guidelines. Of the general practitioners who had received the guidelines, 18% (14/79) said that they had not read them at all, while 65% (51/79) had read them partially and 18% (14/79) had read them in their entirety. At follow up, less than half (98/214) of general practitioners reported examining 50% or more of their patients for diabetic retinopathy, compared with 104/214 at baseline. General practitioners who had read the guidelines were more likely to report that not being sure what to do when changes were detected was a minor barrier or was not a barrier to them performing dilated ophthalmoscopy (93% vs 83%, chi2(1) = 3.67, P = 0.055). Nearly all of the general practitioners reported that they refer their patients with diabetes to an ophthalmologist or optometrist at least every 2 years as recommended. Seventy-six per cent (170/224) of the general practitioners felt that 70% or more of their patients complied with their instructions to visit an ophthalmologist or optometrist. CONCLUSION: The NHMRC guidelines for diabetic retinopathy appear to have had a positive effect on some of the attitudes of general practitioners who have read them, but more effort is needed to disseminate the guidelines to all general practitioners and to increase their uptake.
The performance of skin biopsies by general practitioners has been examined in several recent studies. The aim of this study was to examine the difference between skin biopsies of pigmented skin lesions taken by general practitioners and those taken by hospital specialists. Reviewing all histopathology records at one hospital over a five year period revealed that there were 1000 patients who had had skin biopsies. General practitioners had carried out skin biopsies for 55% of these patients. Hospital specialists excised significantly more lesions that had increased in size (P < 0.001) or changed in colour (P < 0.001). General practitioners excised more lesions that had bled (P < 0.001). Hospital specialists excised more of the 15 melanomas diagnosed (80%) (P < 0.05), and general practitioners excised more squamous papillomas (P < 0.01). Forty per cent of melanomas excised were not suspected by the clinician. General practitioners were able to detect the majority of suspicious lesions, but because of the uncertainty of clinical diagnosis, all specimen's should be submitted for histopathological diagnosis. It is important that future general practitioners are trained in both the diagnostic and technical aspects of skin biopsy if they intend to perform this minor operation.