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A survey of general practitioners' views on psychiatry and the psychiatric services within an area has shown that considerable problems exist between general practitioners and psychiatrists over the care of patients with mental illness.
Additionally to the training in the hospital and in the practice, the rules for continuing education for general practise, established at the meeting of medical German physicians in 1992 demand the participation in theoretical seminars. The content and duration of these seminars is content and duration of these seminars is laid down in recommendations of the chamber of the physicians of Germany to ensure the quality of the courses. According to this, the first recommendations consists of the Course Book for General Medical Practise regarding a course of 240 hours duration. This is a nation-wide standardized curriculum which was accepted from all German chambers of physicians as the basis of the further education in family medicine. The standardization and the structuring of the content, goals, and methods of teaching and learning as well as the organization of the seminars, the working materials for the teachers, regular training for the presenters and teachers, methods for a nation-wide evaluation of the seminars, and independence from commercial interests are the features to ensure the quality of the courses.
We interviewed 51 Norwegian general practitioners selected at random about their knowledge and practice of medical genetics. Of these doctors, 29 worked in Oslo and 22 in Oppland county. About 90% of the doctors working in Oslo knew where to refer patients for genetic counselling, while 55% of the doctors working in the area outside Oslo had this knowledge. We believe that this difference is because Oslo has a municipal genetic clinic and is the only area in Norway with an adequate genetic counselling service according to WHO standards. This article presents the results from this survey, and discusses genetic diseases in general practice and the organisation of medical genetic services in Norway.
UNLABELLED: The present paper describes the institutionalization of a general practitioners' quality circle and the development of management guidelines for the treatment of patients with sore throat. Doctors participating: An invitation to attend an "information meeting" on the subject quality control and a quality circle sent to 200 general practitioners and internists, evoked a response by 18 physicians, ten of whom participated in the first meeting of the quality circle. Practical procedure: Stocktaking of the procedure in the doctor's office on the basis of a documentation questionnaire, the discussion of a video of the counselling of a patient with a sore throat, interviews with patients and the personal experience of the participating physicians was compared with a current analysis of the literature. The results of the comparison were taken as a basis for the development of management guidelines following the Dutch NHG Standard (Nederlands-Huisartsen-Genootschap-Standarden). RESULTS AND CONCLUSIONS: A wide variation was found in the treatment offered to patients with sore throats in the doctor's office. Deviation from text book information does not indicate a priori any quality deficit in the GP's practice. With respect to the management guideline worked out, it was agreed that in the individual case, a wellfounded deviation can be justified.
Postal surveys were conducted among samples of patients in four practices to determine accessibility of surgeries and general practitioners by telephone. Over half of the respondents reported being unable to get through to the surgery on their first attempt. Significant differences between practices were related to the number of patients served by each incoming line. Although all of the general practitioners involved were accessible to patients by telephone, only half of the respondents knew this. Significant differences in awareness levels between practices were related to policies and methods of disseminating this information. Satisfaction with the help received from doctors by telephone was uniformly high, but patients were less satisfied with the process of contacting a doctor, particularly where receptionists questioned callers about their problem. It is suggested that practices review the adequacy of their telephone systems against a recommended standard of one incoming line per 2500 patients and consider how information about their telephone policies and services can be effectively communicated to patients. Reception staff may need additional guidance on managing telephone contacts with patients.
Thirty eight specialists in one district health authority were asked to take part in a questionnaire survey to assess the appropriateness of referral and the quality of the referral letter for 20 consecutive new patients each. A total of 705 new patient referrals to 13 specialties were included in the study. Twelve of the 38 specialists were randomly selected and their 234 new patient referral letters were independently assessed by a general practitioner for the appropriateness of the referral decision. The study revealed errors and omissions in between 5% and 28% of referral letters according to the category of information. Thirteen per cent of the new patient referrals were assessed by specialists to be inappropriate and 4% of patients had been referred to an inappropriate specialty. Significantly more of the referrals to medical specialties were inappropriate (20%) than to surgical specialties (9%) (P < 0.01). There were more than three times the number of errors and omissions in the referral letters of referrals assessed as inappropriate than in the referral letters of referrals assessed as appropriate (P < 0.01). The referral letters of referrals assessed as inappropriate were more than nine times as likely to omit the reasons for or objectives of the referral compared with letters for those referrals assessed as appropriate (P < 0.01). There was a good overall agreement between the specialists and general practitioner in their assessment of the appropriateness of the clinical referrals (kappa = 0.614, P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
The incident Monitoring in General Practice Project began as an initiative of the Professional Indemnity Review. Anonymous data from general practitioners about unintended, and possibly adverse events were collected in order to develop preventive strategies that might ultimately increase patient safety and therefore reduce litigation. Feedback and sharing of experiences and ideas about these events, possible management strategies or the project as a whole are invited from readers.
General practitioners' criteria for good clinical practice vary, and it is unknown whether systematic education by specialists could be expected to reduce variation. The aim of this was to describe general practitioners', microbiologists' and urologists' criteria for diagnosis, treatment, and follow-up of women with symptoms of urinary tract infection. Based on these examples, advantages and disadvantages of using specialists as consultants in GPs' peer-group-based CME (continued medical education) are discussed. Three short case vignettes were presented in a questionnaire to GPs, microbiologists and urologists with prechosen choice of diagnostic, treatment, and follow-up strategy. A total of 154 (77%) GPs, 45 (51%) microbiologists, and 54 (61%) urologists answered the questionnaires. There was considerable variation in proposed strategy both within each specialty and between the specialties. Microbiologists, and to some extent urologists, would more often than the GPs treat a 30-year-old woman via telephone advice and prescription, while they more often tended to ask a 10- and 60-year-old woman to come to the clinic for examination. The GPs, more than the other doctor groups, would ask the patients to return for follow-up. Continuous medical education of GPs based on small-group peer discussions and with specialists as consultants in the groups cannot be expected to lead to less variation in choice of medical strategy.
BACKGROUND: The primary care setting has been regarded in government policy and the scientific literature as an ideal setting for the work needed to meet the Health of the Nation drug and alcohol targets. Although studies have pointed to the negative attitudes held by general practitioners (GPs) towards alcohol- and drug-misusing patients, there has been no direct comparison of the work and attitudes of the GP towards these patients. AIM: To compare the work and attitudes of GPs towards alcohol- and drug-misusing patients. METHOD: All GPs in an outer London area (157 doctors) were surveyed, using an eight-page postal questionnaire, collecting clinical and attitudinal data alongside demographics and practice information. A response rate of 52% was achieved. RESULTS: General practitioners reported working with only 3.5 patients drinking above recommended guidelines in the previous four working weeks, and even fewer drug-using patients (0.75). While they viewed the alcohol-misusing patients negatively, the drug misuser elicited substantially more negative attitudes. The primary care setting was seen as appropriate to work with the alcohol-misusing patient but not with drug users. Training and support from local services would encourage substantially more GPs to work with alcohol misusers but not with drug misusers. CONCLUSIONS: Our findings indicate that there are some cautious grounds for optimism that GPs are willing to work with alcohol misusers; however, with regard to drug misusers, we find a GP workforce that is only minimally involved with this group and would not be greatly encouraged by the provision of additional training, support, or incentives. The Health of the Nation targets are not being met, and GPs are not detecting adequate numbers of the patients at whom these targets are aimed. Emphasis has been placed on the role of primary care, but the real achievements that can be made require detection of the less severe drinkers and injecting drug misusers.
BACKGROUND: The improvement of general practitioner (GP) availability has been suggested as a factor influencing the rise in attendance rates at accident and emergency departments (AEDs) in the United Kingdom, particularly in innercity areas. However, previous studies suggest that only 3-6% of patients attempt to contact their GP before attending the AED, and measures of the availability of appointments in the surgery are not associated with AED self-referral rates. AIM: To examine the overlap of services between general practice and AEDs, and the characteristics of patients who attend at both sites. METHOD: A prospective observational study, set in east London, of all AED attendances from two group practices located within two kilometers of the Royal London Hospital, over a seven month period in 1994. RESULTS: Of 1785 attendances analysed, 80% were self referrals. Rates of hospital admission (18.1%) and outpatient referral (9.5%) reflect national figures. There was a significantly higher proportion of attendance from those of white ethnicity among children under 16. Using the Sheffield process-based classification, 43% of adult attendances were categorized as primary care attendances. Within this category the rate of attendance declined with age. Twenty-five point eight per cent of primary care attendances occurred between 10.00 pm and 8.00 am. Among self-referrals to the AED, 16% were seen by their GP in the previous two weeks for a similar problem. Frequent attendance at the AED was associated with a significantly higher consultation rate at the GP surgery (F = 19.6, df = 5, P < 0.0001). Less than 2% of attendances were recalled to the AED for follow-up. A minority (14%) of attendances resulted in a communication with the GP. The seven-month AED attendance rates for the two practices were significantly different (72 per 1000 (95% CI 67-78) and 111 per 1000 (95% CI 105-116), despite similar practice organization and markers of social deprivation. CONCLUSIONS: AED attendance rates were below the national average. GP referral and admission rates to AEDs from inner urban practices mirror national rates. High rates of primary care attendance occurred in younger age groups, with more than expected occurring out of hours. The reduction in case follow-up within the AED must be supported by improvements in communication with GPs, and an expansion of practice-based nursing. Practices that are geographically close, and with similar sociodemographic features, may have different AED attendance rates. This has important implications for resource allocation in primary care.
AIM: General practitioners in the central Sydney area were surveyed to quantify the extent of, and attitudes towards, computerisation in Australian general practice. METHOD: Two surveys were mailed to all GPs in the central Sydney area, first in 1994, and again in 1996. The majority of questions in both surveys were identical. The results were collated and descriptive and comparative statistics calculated. RESULTS: There was an increase in the use of computers for clinical tasks and, GPs' attitudes towards computerised prescribing systems became more positive. There was a persistent negative attitude towards the actual costs of computerisation. CONCLUSION: Methods are now required to transform the increased use of computers by GPs into improved outcomes for them and their patients.
General practice research focusing on patients may involve risk factors, morbidity, medication use or patient satisfaction. When collecting information about patients it is often easier, cheaper and more appropriate to enlist the support of a number of general practitioners (GPs) who provide access to a number of patients. Such studies utilise a 'cluster sampling' (CS) design, as clusters or groups of patients around a GP are used for the investigation. In analysing data from these studies it is necessary to consider the impact that the study design will have on the variance structure of data collected.
An attempt was made to improve the validity of the 30-item General Health Questionnaire by excluding items. This exclusion was performed by using correlations of sum-scores with an external case criterion. This hierarchical approach based on subsets of items (stepwise hierarchical variable selection) resulted in a 9-item questionnaire whose discriminating performance was significantly better than that of the original version.
BACKGROUND: The fact that a high prevalence of asymptomatic peripheral arterial disease (PAD) in the population has repeatedly been noted in recent years, without there being data as to how often asymptomatic PAD has to be anticipated in inpatients treated for divergent internal diseases led us now to performing a screening study in a general-care hospital. PATIENTS AND METHODS: The study population consisted of 990 patients (51.8% women, 48.2% men) with a mean age of 65.2 years (40-93 years) who had to be treated in a hospital for various internal diseases in the period from January 1994 to January 1995. Their case histories were taken, and their clinical findings and the ankle/brachial indices as calculated from Doppler ultrasonographic measurements of the systolic pressures in the malleolar and brachial arteries were used to ascertain how many of the patients presented with asymptomatic and symptomatic PAD. Further the frequency of risk factors (smoking, hypertension, diabetes mellitus, lipid disorders) was recorded for either patient group. RESULTS: The study showed that 6% of the 990 patients suffered from symptomatic PAD and that of the remaining 931 patients, 43.7% were diagnosed, on the basis of the ankle/brachial index (ABI) (< or = 0.9), to have asymptomatic PAD, while 56.3% showed no indication of PAD. CONCLUSIONS: The high number of cases of asymptomatic PAD among inpatients who underwent internal treatment--a percentage well above the figures published so far for outpatients--allows the conclusion that the determination of the ABI is well suited to screen patients older than 50 years even in a hospital setting so that early secondary prophylaxis can be initiated.
OBJECTIVE: To describe the working patterns, training experiences, estimated size, and future training needs of the workforce of professionals complementary to dentistry in the general dental service in an English region. METHODS: Postal questionnaire of NHS dental practices in the South West of England. RESULTS: The response rate was 65%. There was an average of two whole time equivalent (wte) dentists working per practice. Dentists work a mean 0.8 wte per practice. Sixty per cent of practice time is NHS. Vacancies existed for 120 dentists (98 wte) with reported difficulties in recruitment. There was an average of 1.25 wte dental nurses per dentist with 44% of nurses working part-time. A quarter of nurses' time is on non-clinical duties. The turnover rate for nurses was between 13% and 26%, with recruitment difficulties. Approximately 50% of nurses do not have a professional qualification. There is variation between health authorities in proportions of qualified nurses. Hygienists are employed in 72% of practices, but only 20% of their work is NHS. Dentists have favourable attitudes to an expansion in the employment and training of professionals complementary to dentistry. CONCLUSIONS: There are problems with recruitment and retention of all categories of the dental workforce in the GDS, particularly in rural areas. There is a large unmet need for pre- and post-qualification training for professionals complementary to dentistry compounded by marked inequalities in access to training.
OBJECTIVE: This study compared general anesthesia (GA), combined GA plus thoracic epidural anesthesia (TEA), and TEA alone in patients scheduled for off-pump coronary artery bypass grafting. DESIGN: Prospective, nonrandomized clinical study SETTING: University hospital. PARTICIPANTS: Ninety consenting patients undergoing beating-heart coronary artery revascularization with comparable coronary status and left ventricular function. INTERVENTIONS: GA (n=30) was conducted with propofol, remifentanil, and cisatracurium or combined with TEA (GA+TEA, n=30) or TEA as the sole anesthetic with ropivacaine plus sufentanil (TEA, n=30). MEASUREMENTS AND MAIN RESULTS: Groups were comparable regarding the surgical approaches and the number of anastomoses. Four patients (GA, n=2; GA+TEA, n=2) who required unplanned cardiopulmonary bypass, and 4 patients in the TEA group who underwent unexpected intubation because of pneumothorax (n=2), phrenic nerve palsy, or incomplete analgesia were excluded from further analysis. Intraoperative heart rate decreased significantly with both GA+TEA and TEA. None of the patients with TEA alone was admitted to the intensive care unit, they all were monitored on average for 6 hours postoperatively in the intermediate care unit and allowed to eat and drink as desired on admission. Postoperative pain scores were lower in both groups with TEA. There were no differences among groups in patients overall satisfaction. CONCLUSION: Based on the authors data, all anesthetic techniques were equally safe from the clinicians standpoint. However, GA+TEA appeared to be most comprehensive, allowing for revascularization of any coronary artery, providing good hemodynamic stability and reliable postoperative pain relief. Nonetheless, the actual and potential risks of TEA during cardiac surgery should not be underestimated.
Both the surgical and the prosthodontic procedures will be performed by one and the same general practitioner (GP) for many implant patients, as access to specialists is limited or non-existent in a large number of places. However, treatment by GPs has not been documented to the same extent as treatment performed by specialists. This lack of knowledge was the reason for the present study, in which four GPs performed both the surgery and the prosthodontics on patients requiring single tooth implant replacements. The treatments were performed after an initial training of the GP and his/her dental assistant for 8 days. The treatments by the GPs exhibited clinical results corresponding to those achieved at a specialist clinic. The outcome indicates that complete single tooth implant treatments might be performed by GPs who have passed an initial training and demonstrated an interest in a close co-operation with specialists in oral surgery/periodontics and prosthodontics. Such a co-operation should be based on the distribution of complicated cases to the specialists and of non-complicated cases to the GPs.
Our hypothesis was that, due to its sympatholytic action, epidural anesthesia (EA) administered as part of anesthesia in abdominal surgery would generate a marked venous leg flow enhancement, thus aiding in the prevention of peroperative venous stasis. We studied, and comprehensively quantified the venous haemodynamic changes in the lower limb during and immediately after abdominal surgery performed under EA and general (GA) anesthesia combined, in comparison to GA alone. This is a prospective, randomized, controlled study, stratified for hypertension and smoking, comprising ASA 1-2 patients undergoing elective total abdominal hysterectomy. Those with peripheral vascular or chronic venous disease, prior DVT or BMI>35 were excluded. Eligible recruits received either GA (Group GA) (n = 10; age 36-65, median 50) alone or epidural anesthesia (EA) and GA combined (Group EA/GA) (n = 9; age 32-58, median 46). EA (L(1-2)) was administered using lignocaine 2%. Both groups had GA induced with fentanyl and propofol, maintained with N(2)O and isoflurane; larygoscopy was facilitated with vecuronium; analgesia was provided either with morphine (Group GA) or epidurally with 2% lignocaine boli (Group EA/GA). Hemodynamics were determined at the popliteal vein in the horizontal supine position at baseline (resting prior to anesthesia), post epidural (20 min after delivery of EA), post induction (15 min after laryngeal intubation), surgery (upon uterus removal) and recovery (30 min after extubation). There was no difference in the mean velocity[V(mean)] between the 2 groups at baseline (p = 0.35([Mann-Whitney])), and post induction (p = 0.5([Mann-Whitney])). However V(mean) was significantly higher in Group EA/GA than Group GA, both at surgery (point estimate[PE]: 1.8 cm/s; 95% CI: 0.01, 6.3 cm/s; p <0.05([Mann-Whitney])) and recovery (PE: 2.6 cm/s; 95% CI: 0.4, 5.1 cm/s; p = 0.02([Mann-Whitney])). Volume flow[V(Q)] was similar in the 2 groups at baseline and post induction (both, p >0.1([Mann-Whitney])), but was significantly higher in Group EA/GA at surgery (PE: 54 ml/min; 95% CI: 18, 159 ml/min; p = 0.045([Mann-Whitney])) and recovery (PE: 49 ml/min; 95% CI: 16, 129 ml/min; p=0.0037([Mann-Whitney])). Peak velocity, V(mean) and V(Q) increased significantly post epidural in Group EA/GA. Contrary to the venous leg flow attenuation in elective abdominal surgery under GA and upon its recovery, EA administered as part of GA is associated with a significant enhancement of both V(mean) and V(Q). This beneficial hemodynamic effect of EA at the vulnerable stage of recovery may be critically essential in light of enhanced blood viscosity, fibrinolytic shut-down, endothelial/platelet activation and immobility, acting in synergy with putative cardiorespiratory protection. The results of this study lend support to the preferential selection of combined EA/GA in subjects at high risk for venous thromboembolism, particularly when optimal DVT prophylaxis is practically unattainable due to limitations pertaining to the nature of surgery.