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[The role of home pressure monitoring in the treatment hypertension in the practice of general medicine].

AIM OF THE STUDY: The aim of the study was to evaluate home blood pressure (BP) measurement using an OMRON HEM 706 device (including printout values) for the treatment of essential hypertension by a greater number of general practitioners and to establish the incidence of "white coat hypertension". METHODS: We compared home BP values, taken by the portable digital Omron HEM 706 device with casual BP values, measured during the course of a 6-month treatment of essential hypertension by the ACE inhibitor perindopril or a combination of perindopril and a diuretic (most frequently a low dose of hydrochlorothiazide) in 503 patients with mild to moderate essential hypertension. Czech and Slovak general practitioners participated in the study. Home BP measurement was performed by the patients always during the 4 days preceding the visit by the general practitioner. Home BP was measured twice daily, "trough" and "peak" values (in the morning before the use of drug and then between noon and 2.00 p.m.), each time twice. The OMRON device enables to print out the measured values. Casual hypertension was defined as casual BP 140/90 mmHg and higher, "home hypertension" was defined as a mean BP higher than 130/85 mm Hg from 8 home BP measurements performed during the last 2 days before the visit by the general practitioner higher than 130/85 mmHg. RESULTS: A significant decrease in both systolic and diastolic BP occurred during the treatment by perindopril or the combination of perindopril and a diuretic. The decrease in BP was observed both in the casual BP values and in the home BP values. Normalisation of the casual diastolic BP (diastolic BP lower than 90 mmHg) occurred in 59.3% of the patients after the first month of treatment, in 75.4% of the patients after 3 months of treatment, and in 78.5% of patients after 6 months of treatment. Only 2.1% of patients dropped out from the study due to side effects. These data demonstrated a very good efficacy and tolerance of perindopril. Only 62.6% of general practitioners showing interest in home BP measurement at the informative meetings joined the study and 14-19% of patients of the whole studied group did not use home BP at all. In general the interest of general practitioners and their patients observed in this study was less than that observed among the cardiologists in our previous study. The incidence of the "white coat phenomenon" was related to its definition, it increased when using a less strict definition and decreased during the course of therapy, in parallel to the normalisation of BP. Home BP values were significantly higher during the first 2 day of measurement then during the last 2 days of measurement (of the 4-days period). "White coat hypertension" could be observed in 9.4% of the group during the study. Home BP measurement also enabled to disclose "white coat normotension" defined as normal casual BP values and hypertensive home BP values. "White coat normotension" occurred at the end of the study in 26.3% of the patients. This relatively high number of patients with "white coat normotension" could be partly due to a short period of rest at home before taking home BP values. CONCLUSION: Home BP measurement was positively evaluated both by the general practitioners and patients. Home BP measurement provides better information about the efficacy of hypertension treatment and discloses "overtreatment" ("white coat hypertension") as well "undertreatment" ("white coat normotension"). It also increases the adherence of patients to the treatment of essential hypertension. The interest in home BP measuring was, however, less among the general practitioners and their patients than among the cardiologists and their patients (observed in a previous study).

Adolescent↗

[Strategies of hepatitis C screening in general practice. Results of a two-center randomized trial].

OBJECTIVES: To improve the detection of patients infected with hepatitis C virus. METHODS: A study was undertaken in the general medicine setting in two hepatitis C networks. General practitioners volunteered and received training on hepatitis C, then were randomly assigned to one of two screening strategies: group 1: general practitioners prescribed hepatitis C virus testing if the risk factors for HCV hepatitis C virus infection were identified during questioning of patients, group 2: general practitioners were helped in their screening approach by posters and leaflets on the risk factors of hepatitis C virus, available in the waiting room. RESULTS: A total of 184 general practitioners enrolled 90 from group 1 and 94 from group 2. During a 15-month-period, 617 serologies were prescribed, 323 by general practitioners in group 1 (in patients who were an average of 40 year-old) and 294 in group 2 (in patients who were an average of 44 year-old); 489 serologies (79.3%) were actually performed (261 and 228 respectively) and 25 (5.1%) tested positive (15 and 10 respectively). The number of prescribed, performed, and positive serologies did not differ from one group to the other. The motive for hepatitis C virus screening was similar in both groups and included a history of transfusion in 27% of cases, intravenous drug use in 6%, increased ALT or symptoms compatible with hepatitis in 13%, nosocomial exposure in 22%. Risk factors in the 25 patients who were hepatitis C virus positive were drug use (44%), history of transfusion before 1991 (16%), elevated ALT or symptoms (12%), others (28%). CONCLUSION: This study comparing screening strategies in general medicine, resulted in the diagnosis of hepatitis C virus infection in 5% of tested patients, regardless of the strategy. However, the fewer serologies prescribed by general practitioners (an average of 3 tests in a 15-month-period) suggests a low rate of identified risk factors in general practice, and emphasizes that other types of screening procedures should be implemented and evaluated.

Adolescent↗

Good Medical Practice: comparing the views of doctors and the general population.

OBJECTIVES: To assess the views of the general public and general practitioners (GPs) on the General Medical Council's Good Medical Practice. METHODS: A large national consumer survey organization (MORI) was commissioned to conduct a survey of a representative sample of the general public using quota sampling methods with randomly selected sampling points across Great Britain. A similar survey was carried out of GPs across Great Britain. Questions were asked of the general public about their perceptions on medical practitioners keeping their knowledge sufficiently up to date to do their job, on complaints being properly investigated, and about doctors being removed from the General Medical Council register if they failed to perform a specifically defined duty. The GPs were asked the same questions about duties. The general public was also asked whether they worked in the National Health Service (NHS), about any recent experiences as a patient in the NHS and whether they had ever complained about a doctor. RESULTS: A total of 1949 people were interviewed in their homes along with 199 GPs. Over one-third either worked in the NHS or had friends or relatives who worked in the NHS. Eleven per cent felt they had reason to complain about a doctor although only 6% had made a formal or informal written or verbal complaint. The general public and GPs held similar views on reasons for doctors being removed from the register, although the public's threshold was somewhat lower than the doctors. CONCLUSIONS: GPs and the general public have similar views on good medical practice, although the degree of concern shown by the public is greater than that registered by doctors. Both groups show similar patterns of variation in their perception of the importance of some duties compared with others.

Adolescent↗

[Factors related to screening of hepatitis C virus in general medicine].

UNLABELLED: Despite the high prevalence of hepatitis C in France ( approximately 1.2%), a large proportion of people infected with hepatitis C virus (HCV) are not known aware of their status. The objective of this study was to investigate the factors related to screening in general medicine. MATERIAL AND METHODS: Three hundred and one general practitioners were interviewed by phone in South-Eastern France about their HCV screening practices, knowledge of the epidemic, of the natural course of the disease, and opinions about health care for people infected with HCV. RESULTS: While general practitioners often offered HCV screening to intravenous drug users, screening for people who had received blood transfusion, and identification of risk factors among patients were not satisfactory. Multivariate analysis showed that certain characteristics in general practitioners were negatively and independently related to the frequency of HCV screening, especially: general practitioners older than 40 (odds-ratio: 3.12), general practitioners who did not care for intravenous drug users (odds-ratio: 2.24) and did not prescribe human immunodeficiency virus tests (odds-ratio: 5.55). Other characteristics such as awareness of the course of hepatitis C and health care were also associated with HCV screening. Conversely knowledge of the size of the epidemic was not related to better HCV screening practices. CONCLUSION: Our study shows that knowledge about the size of the epidemic and the natural history of hepatitis C, HCV screening practices and investigation of risk factors among patients are not satisfactory among South-eastern French general practitioners. Although HCV screening and health care must be improved among intravenous drug users, hepatitis C should not be considered as a disease of injecting drug users only by general practitioners and the population. Efforts should be made so that hepatitis C is recognized as a global public health issue, and training of general practitioners should be improved to investigate risk factors and offer HCV screening instead of merely dramatizing the situation.

Adult↗

[Screening and hepatitis C management survey in general medicine in the Alpes-Maritimes and east Var area].

BACKGROUND: This study was performed to assess screening and management of hepatitis C by community-based practitioners in the Alpes Maritimes district in the South of France and to compare their practices with the recommendations issued by the consensus conferences in 1997 and 1999. This information was to be used to adapt continuing medical education to the needs of practitioners in the area. METHOD: Two hundred and nineteen general practitioners who were members of eighteen continuing medical education associations accepted to complete a questionnaire containing eighteen closed questions. It was issued late 1999 during one of the monthly meetings and completed by all the participating physicians. RESULTS: Only 32% of general practitioners knew the conclusions of one of the two French and European consensus conferences concerning hepatitis C. General practitioner practices were in accordance with recommendations for targeted screening in case of transfusion before 1991 (88%), intra-venous drug use (94%) and increased ALT (91%); however intra nasal drug use (35%) and imprisonment (46%) were underestimated risk factors. Frequency of screening was correlated to duration of practice (P<0.01), size of practice (P<0.02) and follow-up of hepatitis C infected patients, regardless of treatment (P<0.03). Upon discovery of a positive HCV status, 80% of general practitioners prescribed initial investigations but these included costly and needless procedures such as hepatic imaging (56%), RNA quantification (39%) and viral genotype (6%). On the other hand, 79% general practitioners recommended a liver biopsy for patients with elevated transaminase levels. When transaminase levels were normal, only 13% requested qualitative detection of viral RNA. Generally, general practitioners were confused concerning the indications for qualitative or quantitative viral RNA investigations. Few general practitioners followed treated HCV-infected patients and renewed interferon therapy prescriptions. Condom use was advised by 56% of GPs for couples in which one of the partners had a positive HCV status. CONCLUSIONS: This study demonstrates the weak impact of consensus conferences on hepatitis C management for general practitioners in the Alpes Maritimes. It provides an opportunity to identify the need for specific training which will be developed within the Côte d'Azur Hepatitis C Network.

Biopsy↗

[Medical education and surgical residency program for general thoracic surgery].

We introduced medical education for general thoracic surgery to medical students and a new surgical residency program to instruct residents who aspire to become general thoracic surgeons. It is important to understand the etiology of thoracic diseases, methods of diagnosis for tumorous lesions, anatomy of the interior thorax, surgical therapies and indications for thoracic diseases, and management of perioperative periods in the medical education of general thoracic surgery. According to the new residency program, a surgical resident must complete a super rotating system that consists of the subjects of internal medicine, general surgery, emergency and critical care medicine, anesthesiology, pediatrics, gynecology, and local healthcare for several months each in the first two years. On the other hand, a surgical residency program includes core surgical residencies to train clinical patient-care oriented surgeons and advanced residencies in such areas as thoracic surgery, cardiovascular surgery, pediatric surgery, and digestive organ surgery. Residents who want to become general thoracic surgeons must complete 350 cases of general surgery including at least 120 cases for an operator in the first 4 or more years in core programs. After passing the board for general surgery, they can advance to a subspecialty program for thoracic surgery in the final 3 or more years to pass the board for general thoracic surgery. It is essential to train the general thoracic surgeons who empathize with patients with thoracic diseases and can contribute to overcoming thoracic diseases by practicing evidence- or science-based medicine.

Curriculum↗

[Research in general medicine, role of the medical thesis].

General practice doctors are naturally presented as being actors on the front lines of public health. The ability of general practitioners to be aware of and deal with public health questions largely depends upon their training. Perhaps one could consider the general practitioner's thesis as a preparatory analytical work within the area of their future field of practice. Do these theses serve to provide food for thought on general practice and its contribution to public health, and if not, could they? An analysis conducted within four medical schools in western France demonstrates that the work produced for general medicine identified as such only constitutes a fraction of the overall number of medical (non-university) theses (approximately 5%). Two possible explanations may be put forward. First, on the one hand, the theses highly depend on the context of the training and the work produced is a direct result of this. Second, on the other hand, the current methods of indexing notes in the university databases does not enable general medicine to be clearly seen and visibly recognised as an academic discipline. Two questions then remain: Can medical theses be considered as research? Should research in general medicine be carried out solely by general practitioners? It is vital that resources from outside the medical field be raised and mobilised for general practice research, whose themes are multi-disciplinary and not only clinical.

Academic Dissertations as Topic↗

General practitioners' views on the role of the community pharmacist.

AIM: to determine the views of general practitioners on the roles and activities of community pharmacists. METHOD: the views of 137 general practitioners in Otago and Southland were canvassed by postal questionnaire. RESULTS: one hundred and three completed questionnaires were returned. All of the general practitioners reported that their professional contact with pharmacists was useful. Seventy-five percent expressed a desire for greater cooperation. Nearly all respondents (99%) accepted that pharmacists have a role in screening prescriptions for possible problems and preparing and dispensing medicines. They also accepted that pharmacists were capable of treating and advising in the management of minor illnesses. Providing drug information to general practitioners, information about previously diagnosed conditions to patients, and advice on personal and home hygiene were less widely accepted activities. The majority indicated that they considered it inappropriate for pharmacists to undertake screening programmes (blood pressure (70.6%), cholesterol (70.6%), glucose (60.8%), haemoglobin (72.5%)). Younger general practitioners objected more often than older general practitioners to reclassification of Acetopt eye drops from prescription only to availability through pharmacies (p < 0.05). Female general practitioners were more often in favour of reclassification of Gyno-Daktarin than their male colleagues (p < 0.05). CONCLUSION: this study shows that general practitioners accept several aspects of the current role of pharmacists in providing primary health care. However, there is room for improved communication between general practitioners and pharmacists to ensure optimum patient care.

Adult↗

[What does the higher concentration of general practitioners mean for fee-for-service reimbursement].

The density of general practitioners has increased steadily in Norway. By the end of 1989, there were 1,339 inhabitants per general practitioner. General practitioners are partly remunerated per item of service, i.e., by reimbursement from the National Insurance Fund and partly by patient co-payment. The article analyses the connection between density of general practitioner and level of fee-for-service reimbursement. The average general practitioner received about 60% higher fee-for-service reimbursement in 1989 than in 1985. This increase is markedly higher than the nominal changes in the tariff. The increase was somewhat higher in areas with a relatively low density of general practitioners. Also, in each of the years 1985-1989, the average fee-for-service reimbursement was slightly higher in areas with a low density of general practitioners. The variations have only a slight impact on the gross revenues of general practitioners. Three models explaining the use of general medical services are outlined. The results can be interpreted in the light of changes in health, changes in health-related behaviour, and supplier-induced demand. Since only aggregate data are available, it is difficult to further explore possible explanations.

Fees, Medical↗

General practitioners' confidence in diagnosing and managing eye conditions: a survey in south Devon.

In order to open dialogue aimed at increasing eye care in general practice and reduce waiting times for ophthalmic outpatient appointments general practitioners in the Torbay health district were asked about their levels of confidence in ophthalmology as a subject, and in the diagnosis and management of specific eye conditions. They were also asked about ophthalmic equipment available to them, their management policies for 34 specific eye conditions, and their perceived need for further training in this subject. A total of 75% of the general practitioners responded to the questionnaire. Despite more than half of the general practitioners indicating that they did not feel confident with ophthalmology generally, most expressed confidence in diagnosing and managing common eye conditions. Basic equipment for examining the eye was available to most doctors. Referral policies varied considerably, and these have resource implications. Seventy eight per cent of respondents were prepared to take on more eye care in general practice, and over 80% of general practitioners requested informal teaching sessions in ophthalmology. Support must be forthcoming if general practitioners are to provide eye care in general practice.

Clinical Competence↗

Self-reported health care over the past 10 years: a survey of general practitioners.

To investigate how and where doctors receive their health care, 275 general practitioners were given a questionnaire about their health care in the previous 10 years; responses were received from 247 doctors (90%). Thirty nine per cent of the subjects were registered with a general practitioner who was independent of them. All but one of the remainder were registered with a practice partner, close friend or relative. Whatever the relationship of the subjects with their own general practitioner, personal health problems were managed to a great extent by themselves. Most (84%) of the medication taken in the previous five years had been self-prescribed and one third of medical investigations had been self-initiated. Over half of the general practitioners studied had seen a specialist about their health in the preceding 10 years; 51% had referred themselves. A 'jury' of seven general practitioners compared the subjects' referrals to a specialist with the care that would be expected for a non-general practitioner patient. Where the jury reached agreement, 68% of referrals were thought to have been appropriate; self-referrals were significantly more likely to be thought inappropriate (P less than 0.05); and self-treatment prior to self-referral to a specialist was considered inappropriate in 78% of cases. The amount of self-prescribed medication and frequency of consultation was the same, whatever relationship the subject held with the general practitioner. This study shows that most general practitioners manage their own health care. The question of whether this is always appropriate is raised and the provision of an occupational health service for general practitioners is discussed.

Humans↗

[General practitioners' attitude to prescription of psychopharmaceuticals. Autonomy versus paternalism, education and understanding of disease].

The object of this investigation was to illustrate the attitudes of general practitioners to prescription of psychotropic drugs and to mental illness. The qualitative research interview method was chosen as the method employed here. Fourteen general practitioners were interviewed while one did not wish to participate. A marked difference was found between the attitudes of the general practitioners to respect the autonomy of the patients or to act paternally. The paternal general practitioner could either prescribe psychotropic drugs on his own initiative or refuse prescription. General practitioners who respected autonomy were relatively restrictive in their prescribing habits so that respect for autonomy was by no means expression for free prescription of psychotropic drugs. Their goal was that the patient should be placed in a situation where he/she could choose and determine personally. The general practitioners considered that their undergraduate and postgraduate training in treating patients with mental illness was inadequate. Taking into consideration how frequently patients with conditions of this nature are seen in general practice, this must be regarded as a serious deficit in medical training. A number of general practitioners have, however, received postgraduate training in this subject. General practitioners did not consider patients who consulted them with mental conditions as mentally ill but they did not have an alternative disease model by which they could classify the problems and complaints of these patients.

Attitude of Health Personnel↗

Abortive generalized spike and waves in children: a review.

Full-blown generalized spike and wave patterns in electroencephalogram lasting more than 3 seconds are diagnostically significant, suggesting one of the generalized epileptic syndromes. However, brief (less than 3 seconds) bursts of generalized spike waves activity are often difficult to evaluate the clinical correlations when such bursts are the only remarkable finding in a record which is otherwise within broad limits of normality. After reviewing the literature about the classification and genetic aspects of generalized spike and waves, we concluded that one or more of the following conditions will be the most possible to correlate with abortive generalized spike and waves: 1. as a interictal pattern of generalized tonic-clonic seizures. 2. simple or complex partial seizures. 3. generalized epilepsy under effective anticonvulsant treatment. 4. withdrawal from anticonvulsant therapy. 5. natural evolution of generalized spike waves. 6. drug induced. 7. a genetic trait of relatives of generalized epilepsy. 8. normal pattern.

Electroencephalography↗

A survey of doctorates by thesis among general practitioners in the British Isles from 1973 to 1988.

Doctors who were general practitioners in the period 1973-88 and had written a successful MD or PhD thesis were identified. Of 96 doctorates, 64 were MDs and 32 PhDs. Fourteen doctors had obtained their MD before becoming general practitioners and the remaining 50 after becoming general practitioners. Twenty of the 64 doctors were full time or part time members of a university department of general practice; six of these were professors. In this 16 year study the mean annual number of MDs written by doctors while in general practice was three, compared with five in the previous 15 years. Of the PhDs, 11 were obtained before starting a medical course, six during the pre-clinical period, three after qualifying but before entry into general practice and 12 after entry into general practice. Ninety two per cent of the 50 doctors who obtained their MDs while in general practice and 84% of all the doctors with MDs continued to do research afterwards. Further research was carried out by 81% of doctors with a PhD. The best way of producing good researchers in general practice is to encourage doctors to accept the challenge of writing a PhD or an MD thesis. This study has shown that writing such a thesis encourages rather than discourages a doctor to undertake further research.

Academic Dissertations as Topic↗

Estimates of general practitioner workload: a review.

This paper reviews four studies sponsored by the Department of Health which have attempted to measure workload in general practice and compares these with data from the general household survey. Despite the considerable differences in the objectives and methods employed by the four studies, they were found to contain remarkably consistent measurements of general practitioner workload. In a 'normal working week' general practitioners spend 38 hours on general medical service duties (including 24 hours of patient contact and five hours of travel to home visits), they see 150 patients or their representatives in surgery, and make 26 home visits. In an 'annual average week', taking into account holidays and sick leave, general practitioners undertake 90% of this workload. The studies show consistently large variations in the workload of general practitioners measured in this way, but fail to identify the key determinants of such variations. The reasons underlying the variation in general practitioner workload will remain unclear until we can distinguish between the expected, measurable variation and the residual, unexplained variation which may be due to the personal preferences of general practitioners.

Appointments and Schedules↗

Training for general practice: a look to Norway.

In the 1960s general practitioners were a dying race in Norway. Today general practice is a highly approved specialty among doctors as well as patients. Better education is one of the revitalizing factors. General practice is currently taught as a mandatory subject at all four universities in Norway. The practice apprenticeship is the essential element in our undergraduate curricula. In their fifth year, the students spend three to eight weeks in a structured training program supervised by general practice faculty. Approximately 500 general practitioners take part in this decentralized training network. In 1985 general practice was recognized as a specialty in Norway. The obligatory requirements in the five-year educational program are: -courses, 400 hours -hospital training, one year -general practice training, four years -group-based training program, two years The last element is based on a decentralized concept where a group of two to 10 trainees meet for three hours every two weeks during a two-year period. The group is headed by an appointed and qualified trainer. Besides being in accordance with the geography and demography of Norway, this model gives substance to the slogan "general practice can only be learnt in general practice."

Curriculum↗

Fibromyalgia: generalized pain intolerance and manifold symptom reporting.

We tested the current criteria for fibromyalgia. Pain tolerance was measured at tender point and control point sites using a pressure algometer, and responses to 6 standard psychological self-reports were obtained from 125 patients with generalized nonarticular rheumatism, rheumatoid arthritis, or osteoarthritis. Among patients with generalized nonarticular rheumatism, published symptom criteria for fibromyalgia did not correlate significantly with the number of tender points. Only lower generalized pressure point pain tolerance distinguished fibromyalgia from other generalized nonarticular rheumatism. Generalized nonarticular rheumatism mean scores were much higher than controls on tests measuring the tendency to report physical symptoms, including headaches and functional bowel syndrome. It is probable that patients with fibromyalgia do not differ in any important physical or psychological respect from other patients with generalized nonarticular rheumatism except for the presence of tender points. However, the presence of tender points is merely a reflection of the patient's general pressure pain sensitivity and is not indicative of any special localized pathological phenomenon. The concept of fibromyalgia as an entity separate from the rest of generalized nonarticular rheumatism may be an artifact of a physician's approach to the patient. Most patients with generalized nonarticular rheumatism demonstrate an abnormally high frequency of reporting manifold disagreeable symptoms and probably come to the attention of many medical disciplines.

Arthritis, Rheumatoid↗

General practitioners and postgraduate education in the Northern Region.

We describe a survey of general practitioners in the Northern Region which was carried out during the summer of 1977 as the result of a commission from the Education Committee of the North of England Faculty of the Royal College of General Practitioners. Seventy-five per cent of a one in two random sample of general practitioner principals returned a postal questionnaire in which their perceptions of postgraduate education were sought and their behaviour measured by the number of sessions they attended during the previous year at their 'usual' and other postgraduate centres. Almost half the respondents had more than a basic qualification and all but three per cent had held full-time hospital appointments, two thirds of them at the level of senior house officer or above. Their experience as general practitioner principals averaged 15 years and 57 per cent held part-time appointments outside their practices. Only four per cent had not attended any postgraduate events during the previous year but the remaining respondents had attended eight sessions on average, six of which were at their usual centres. Those attending more than the average number of sessions tended to have registered between 1950 and 1969, to work in larger practices, to hold additional appointments, or to be trainers or College tutors. Most of the respondents were conservative in their perceptions of teaching methods, the topics discussed at meetings, and the contributors to postgraduate education but the younger general practitioners and a group of established general practitioners affiliated to the Royal College of General Practitioners held more radical views. They agreed about the primacy of traditional clinical topics but were sceptical of the value of ward rounds and formal lectures and favoured the seminar and clinical attachments. They saw a need for more material about practice management and wanted experienced general practitioners and community paramedical staff as teachers in addition to hospital consultants. Most of the respondents believed that their usual centres were well organized and managed but failed to cater for the special requirements of general practitioners in non-clinical aspects of practice. Lunchtime and evenings were seen as the most convenient for weekday meetings and Sunday as the most convenient day of the week. A majority of respondents believed that post-graduate education had altered their practice of clinical medicine but only 15 per cent believed it had caused changes in their practice organization.

Education, Medical, Continuing↗