Showing papers in "Family Practice in 1996"

Sampling for qualitative research

Abstract: The probability sampling techniques used for quantitative studies are rarely appropriate when conducting qualitative research. This article considers and explains the differences between the two approaches and describes three broad categories of naturalistic sampling: convenience, judgement and theoretical models. The principles are illustrated with practical examples from the author's own research.

The key informant technique

Abstract: Background and objective This article considers the role of the key informant technique as a qualitative research method and examines the potential contribution of the approach to health care research. Method The principles underlying the technique and the advantages and disadvantages are considered, illustrated with examples from a range of social science studies. Results and conclusion An example of the author's own use of key informants in a study of the professional relationship between general practitioners and specialists is described.

Why do people consult the doctor

Abstract: Background Symptoms are an everyday part of most peoples' lives and many people with illness do not consult their doctor. The decision to consult is not based simply on the presence or absence of medical problems. Rather it is based on a complex mix of social and psychological factors. Objectives This literature review seeks to explore some of the pathways to care and those factors associated with low and high rates of consultation. Methods The paper examines the impact of socioeconomic and demographic factors on consultation rates and, using a revised version of the Health Belief Model, it highlights the psychological factors which influence decisions to seek medical care. Barriers which can inhibit consultation are discussed, as the decision to seek care will only result in a consultation if there is adequate access to care. Results and conclusions Whilst poor health status and social disadvantage increase both "objective" medical need and in turn, consultation rates, a range of other social and psychological factors have been shown to influence consulting behaviour.

Shared care: a review of the literature

Abstract: This review examines broad issues of concern regarding the primary/secondary care interface. The main purpose was to identify areas of good practice which could be adapted for more general use. One of the most fundamental aspects identified was communication, which is discussed in some detail. Also covered are shared prescribing and disease management. The data suggest that the most effective system(s) of shared care has yet to be established. Further qualitative and economic evaluations are required, taking into account patient preferences. Although the literature does describe certain practice exemplars, it is clear that inter- and intra-professional communication continues to be a problem. Whilst information technology may provide some of the solutions, it is concluded that a culture change, which compels health professionals to make sharing of patient information a much higher priority, is required.

A comparison of methods for measuring patient satisfaction with consultations in primary care.

Abstract: the questionnaires immediately after the consultation in the general practitioners' surgeries with those completing the questionnaires later at home. Methods. The two questionnaires were bound as a single instrument with order determined at random. This was given to patients immediately after their consultations in eight practices in South Glamorgan. Results. One hundred and ninety-eight of 316 (63%) patients completed and returned questionnaires. The distributions of patient satisfaction scores for the two questionnaires were very similar. For the MISS: mean 76.7% (SD 11.4); for the CSQ mean 77.2% (SD 12.6). Correlations between sub-scales ranged from 0.58-0.84 for the MISS and from 0.40-0.79 for the CSQ. The correlation between the overall scales was 0.82. Levels of reliability for the scales and sub-scales were fair to good ranging from 0.78-0.96 for the MISS and from 0.73-0.94 for the CSQ. Conclusions. The study does not identify one scale as being superior in pyschometric terms, however by demonstrating consistency of responses it provides support for the scales as measures of patient satisfaction for use in primary care. The level of inter-correlation suggests that the sub-scales may not be clearly independent of each other and suggests that total scores may be preferred. Lower levels of satisfaction are expressed if patients complete questionnaires at home rather than in general practitioners' surgeries.

The International Classification of Primary Care (ICPC): new applications in research and computer-based patient records in family practice

Abstract: The international Classification of Primary Care (ICPC) has now been available to the family medicine community for a decade as the main ordering principle of its domain. Research data and practical experiences with ICPC, as well as the development of new concepts in family medicine, have resulted in new applications. The structure of episodes of care to be included in a computer-based patient record has been further developed and refined. ICPC as the ordering principle of patient data is now available in 19 languages. Its conversion structure with the International Classification of Diseases (ICD-10) allows the highest possible level of specificity in a patient's problem list necessary in patient care, while the compatibility of the ICPC drug codes with the Anatomic Therapeutic Chemical Classification Index allows the systematic inclusion of data on prescription.

“I've been crying my way”—qualitative analysis of a group of female patients' consultation experiences

Abstract: Background and objectives What do women patients, sick-listed for biomedically undefined musculoskeletal disorders, expect and experience when they consult a doctor? With the purpose to learn more ...

Sampling for qualitative research using quantitative methods. 1. Measuring GPs' attitudes towards discussing smoking with patients

Abstract: Method. Thirteen attitude statements with an accompanying Likert-type scale were completed by 327 GPs in one FHSA area. Factor analysis of responses produced two subscales: 'perceived efficacy' and 'enthusiasm'. Reliability and validity of these were examined. Results. Each subscale had good internal reliability and preliminary exploration of construct validity supported the notion that the subscales were valid. Conclusion. The use of this type of instrument in sampling GPs for qualitative studies could be effective for selecting subjects with a diversity of views towards the research topic.

Constipation: a different entity for patients and doctors

Abstract: Results. The present survey showed that constipation is more common in women and in the older (> 40 years) age group. The most important finding of this investigation was the wide discrepancy in the criteria used by doctors and patients to diagnose constipation. Fifty per cent of the patients defined constipation differently from accepted medical definitions—27% of the patients defined it as defecation every 2 days or less and 25% as hard stool alone. All 57 doctors who were asked the same question defined constipation as defecation every 3 or 4 days or less, sometimes in combination with hard stool. Conclusions. This study suggests that patients and doctors refer to different entities when they talk of 'constipation'. It is the doctor's responsibility to ensure that this misunderstanding is avoided so that unnecessary tests and treatment are not undertaken and, patient-doctor acrimony is avoided.

Treatments for postherpetic neuralgia--a systematic review of randomized controlled trials.

Abstract: BACKGROUND A number of different therapies have been used for postherpetic neuralgia. We decided to conduct a systematic review of existing randomized controlled trials. OBJECTIVE To determine the efficacy of available therapies for relieving the pain of established postherpetic neuralgia. METHODS We performed a systematic review, including meta-analysis, of existing randomized controlled trials. Eleven published trials and one unpublished trial were identified which met the inclusion criteria and were included in the current review. RESULTS Pooled analysis of the effect of tricyclic antidepressants demonstrate statistically significant pain relief (OR 0.15, CI 0.08-0.27). Pooling of the results of the three trials comparing the effects of capsaicin and placebo could not be done due to heterogeneity. This heterogeneity was mainly attributable to an unpublished trial which differed in terms of the dose and duration of treatment. When this study was omitted, no heterogeneity was found and the pooled analysis revealed a statistically significant benefit (OR 0.29, 95% CI 0.16-0.54). However, problems with blinding in patients using capsaicin may have accounted for the positive effect. One small study of vincristine iontophoresis compared to placebo also yielded a favourable result (OR 0.05, 95% CI 0.01-0.26). Other treatment evaluated include lorazepam, acyclovir, topical benzydamine, and acupuncture. We found no evidence that these are effective in relieving pain associated with postherpetic neuralgia. CONCLUSION Based on evidence from randomized trials, tricyclic anti-depressants appear to be the only agents of proven benefit for established postherpetic neuralgia.

The uses and abuses of meta-analysis.

Abstract: Meta-analysis is a quantitative process of summary and interpretation which involves pooling information from independent studies concerning a single theme in order to draw conclusions. Greatly increased employment of meta-analysis is currently being advocated for clinical and policy decision making. However, the prestige of meta-analysis is based upon a false model of scientific practice. Interpreting empirical research is an extremely complex activity requiring clinical and scientific knowledge of the field in question; and teams of professional 'meta-analysts' with a primary skill base in information technology and biostatistics cannot take over this role. Meta-analysis is not a hypothesis-testing activity, and cannot legitimately be used to establish the reality of a putative hazard or therapy. The proper use of meta-analysis is to increase the precision of quantitative estimates of health states in populations. If used to estimate an effect, the reality of that effect should have been established by previous scientific studies. But the summary estimate from a meta-analysis can only be directly applied to a target population when the 'meta-protocol' and 'meta-population' match the target situation in all relevant particulars. These constraints can rarely be satisfied in practice, so the results of meta-analysis typically require adjustment--which is a complex, assumption-laden process that negates many of the statistical power advantages of a meta-analysis. Lacking any understanding or acknowledgement of the need for adjustment, most meta-analyses must be regarded as abuses of the technique.

Computerized assessment of common mental disorders in primary care: effect on clinical outcome

Abstract: Method. Attenders at a general practice in a deprived inner city area of South London were identified using case finding questionnaires. Six hundred and eighty-one subjects were randomly allocated to three groups which differed in the information provided to the GP: 1) no additional information was given to the GP; 2) the results of the 12 item General Health Questionnaire (GHQ) were given to the GP (the GHQ is a paper and pencil questionnaire that assesses common mental disorders); 3) the results of a self-administered computerized assessment (PROQSY) of common mental disorders were provided for the GP. Results. Clinical outcome was assessed using the 12-item GHQ. Consultations with the GP, prescriptions and referrals within and outside the practice were also recorded. The group in whom the GP received the results of the computerized assessment showed a modest clinical improvement, relative to the other two groups after 6 weeks. There was no difference in clinical outcome between the groups at 6 months. There appeared to be no increase in consultations or prescriptions in the computerized assessment group. Conclusions. Self-administered computerized assessments for psychiatric disorder have potential as a means of improving the clinical outcome of patients in primary care. It is likely that the effectiveness of the approach would be greatly increased by linking the results of computerized assessments to clinical practice guidelines, tailored to the individual patient by means of computerized technology.

ICPC as a standard classification in Norway

Abstract: Results. In 1994, the underlying medical diagnosis was coded in 98% of the sickness absence episodes lasting more than 2 weeks. Component 1 codes (symptom codes) were used in 23% of episodes, compared with 26-31 % in practice studies. Conclusions. ICPC-coded data in a large Norwegian register appear promising. Most doctors do accurate and careful work in coding, and data appear to be of acceptable quality for further analysis. It is a matter of concern, however, that as many as 23% of episodes had component 1 codes, since these certificates were issued during follow-up encounters. The

The long-term use of benzodiazepines: patients' views, accounts and experiences

Abstract: Background Although a decrease in new prescribing has occurred for anxiolytic benzodiazepines, concerns have been raised that a 'core' of long-term users has been left behind. Typically, elderly people represent this 'core', using the benzodiazepines as hypnotics. Objective The present study focuses on the reasons why hypnotic benzodiazepines are used for protracted lengths of time. By examining patient experiences and cognitions, a deeper understanding may be gained of why patients continue to use benzodiazepines. Methods Elderly, long-term users of benzodiazepine hypnotics were interviewed using a semi-structured interview procedure. A comparison group of non-users of the drugs were given a brief interview to collect comparative data. Interview data were analysed from transcripts using qualitative methodology; statistical comparisons between the groups were made using non-parametric statistics. Results The long-term users had significantly fewer hours of sleep per night than the non-users. There was some evidence of tolerance and a suggestion that symptoms of withdrawal were maintaining continual use. None of the long-term users had clean knowledge of what their doctors thought of their use of benzodiazepines. Conclusions The data suggest that the power of the doctor may not be utilized to its full potential in the prevention of long-term use, that at least 50% of elderly benzodiazepine users would like to discontinue use, and that patients need information and advice on how to discontinue these drugs.

Sore throat management in general practice.

Abstract: This paper discusses primary care management of sore throat in the context of recent national 'consensus' guidelines from the Drugs and Therapeutics Bulletin The guidelines advise taking a throat swab, using typical clinical features where swabs are not available, and suggest that antibiotics shorten the duration of symptoms and prevent complications Systematic reviews and individual studies indicate that the evidence for prescribing antibiotics for most presentations of sore throat in general practice is marginal, and the benefits are probably outweighed by the likely costs of antibiotics Using clinical scorecards or symptom clusters to identify individuals who would benefit from treatment is insensitive with low predictive value, although inexpensive Using throat swabs as a gold standard for diagnosis is inappropriate since they are neither very specific nor sensitive, and will greatly increase costs of management The relative lack of evidence for the efficacy of antibiotics and for the use of throat swabs from primary care research, and also an unbalanced perspective of dangers and complications related predominantly to a secondary care setting, underlines the problem of achieving valid consensus guidelines Guidelines not firmly based on evidence appropriate to the intended setting are more likely to be received sceptically and hinder getting research into practice

Methods for quality assessment in general practice

Abstract: Background and objectives. There is now a wide variety of methods available to general practitioners who want to engage in quality assessment, quality assurance, or quality improvement activities in their practices. These methods require some kind of performance review, or at least the collection of some performance-related data. As in traditional research, the choice of methods depends on what research questions one wants to address. This paper elaborates on some key concepts related to the choice of methods, making a distinction between whether any method actually covers performance (what a doctor does in daily practice) or competence (what a doctor is capable of doing) as well as a distinction between whether a method is direct (patient-doctor contact is observable) or is indirect. Methods. An overview frame will be presented of the methods most commonly used for data collection within quality assessment. These methods are discussed on their validity, reliability, feasibility and acceptability. Direct methods aimed at recording performance are assumed to hold the highest validity, but practical, economic and logistic factors may favour less ambitious methods for audit or quality improvement activities. Conclusions. One crucial element in all methods is creating a set of empirical data, as a basis for comparisons, reflection, dialogue and discussions among colleagues.

Anxiety and depression in general practitioners: associations with type of practice, fundholding, gender and other personal characteristics

Abstract: Background. There is evidence both that a doctor's own well-being is closely associated with efficiency and positive attitude to patients, and that levels of stress, anxiety and depression in doctors are rising. Objective. This postal survey aimed to measure anxiety and depression levels in general practitioners in 1994 and identify any associations with personal and practice characteristics. Method. All general practitioners with patients in Staffordshire were invited to complete the Hospital Anxiety and Depression (HAD) scale. Results. Six hundred and twenty of 896 general practitioners replied (response rate 69%). No gender differences were found in rates of anxiety and depression; overall, 19% of respondents were 'cases' of depression and 16% others had borderline depression scores. Anxiety 'caseness' was associated with living alone, amount of on-call duties undertaken, and being fourth/fifth wave fundholders. Depression 'caseness' was associated with having little free time from practice work, amount of on-call, being single handed, and working in a non-training practice. Conclusions. The authors concluded that the level of mental ill-health in general practitioners is a matter of concern and is associated with workload. Keywords. Anxiety, depression, general practitioners, personal characteristics, practice characteristics.

Colorectal cancer and polyps in patients aged 40 years and over who consult a GP with rectal bleeding.

Abstract: BACKGROUND Rectal bleeding is common in the community and in general practice, but few studies have examined the causes of rectal bleeding in patients presenting to general practitioners. OBJECTIVE To determine the frequency of neoplastic conditions in patients with rectal bleeding presenting in general practice and to explain the associations between presenting symptoms and final diagnoses. METHODS We conducted two studies, the first in 1989, the second in 1991, in which we invited Danish general practitioners to register 3-4 patients aged 40 and over presenting with rectal bleeding. RESULTS In Study 1 among 208 patients aged 40 and over and presenting with a first episode of rectal bleeding, colorectal cancer and polyps were present in 15.4 and 7.7%, respectively. In Study 2 among 209 patients aged 40 and over and presenting with overt rectal bleeding, 156 reported a first bleeding episode or a change in their usual bleeding pattern, and in this group colorectal cancer and polyps were diagnosed in 14.1 and 11.5%, respectively. In the group with unchanged bleeding the cancer polyp prevalence was 6.7% (P < 0.05). The patients in both studies were followed through a yearly letter to the GP for at least 32 and 22 months, respectively. CONCLUSIONS A joint analysis of the two study populations showed that only age and change in bowel habit contributed to differentiating the cancer from the non-cancer patients.

A troubled youth: Relations with somatization, depression and anxiety in adulthood

Abstract: BACKGROUND: Childhood experiences profoundly affect later functioning as an adult. Family practitioners are well-placed to discover the links between childhood troubles and later somatization, depression or anxiety. OBJECTIVES: We aimed to study the interrelation of somatization, depressive and anxiety disorders in frequently attending patients in general practice; to investigate whether these problems are related to a childhood history of illness experiences, deprivation, life events and abuse; and to determine the independent contributions of these childhood factors to the prediction of adult somatization, depressive and anxiety disorders. METHODS: One hundred and six adult general practice patients with high consultation frequency were studied. Somatization was operationalized as a more comprehensive version of DSM-III-R somatization disorder (5 complaints; SSI 5/5). For depression (ever depressive and/or dysthymic) and anxiety (panic, phobias and/or generalized anxiety) DSM-III-R criteria were used. Using a structured questionnaire we assessed illness experiences, deprivation of parental care, abuse (sexual/physical) and other life events before age 19. RESULTS: The overlap between somatization, depression and anxiety was largely accounted for by 16 patients with a triple problem: somatization and depression and anxiety. Somatization was specifically related to deprivation, depression to other life events. Abuse (prevalence 16%) independently predicted psychiatric problems in general. Youth experiences before age 12 were most important. CONCLUSIONS: The high prevalence of triple problems suggests a need to reconsider concepts like somatic anxiety and anxious depression. The specificity of the relation between deprivation and somatization and of the relation between other life events and depression indicates that distinct causal mechanisms (in youth) contribute to these problems. Language: en

A prospective controlled trial of computerized decision support for lipid management in primary care.

Abstract: Objectives. This study aimed to assess the uptake and effect in primary care of a computerized decision support system (DSS) for the management of hyperlipidaemia. Method. A prospective controlled trial was conducted in 25 practices covering a population of 150,000 in the city of Birmingham. The Primed system, a specialist developed, rule based DSS for general practice, was introduced prospectively after a 3-month baseline data collection. The main outcome measures were nine months' data on prescribing of lipid lowering agents; use of laboratory tests; and referrals to secondary care for the investigation of hyperlipidaemia. Results. System use was lower than expected. A shift was observed towards requests for appropriate follow-up of previously abnormal lipid results and a greater emphasis on full lipid profiles, in line with the DSS guidelines. Referrals showed a 55% decrease on those expected (NS). The prescribing evaluation revealed a large variation between practices, but no significant alteration following system use. Views of users favoured decision support as a concept, but criticised technical problems with the system. Conclusions. Greater integration of DSS software and practice based data handling systems is needed. The mode of data capture, and hence both the content and form of knowledge representation, in DSS must take greater account of the primary care consultation process if such systems are to be of use to practitioners.

The effect of a computer-generated patient-held medical record summary and/or a written personal health record on patients' attitudes, knowledge and behaviour concerning health promotion

Abstract: Objective The aim of the study was to examine the effect of a computer-generated patient-held medical record summary (CHR) and/or a written personal health record (PHR) on patients' attitudes, knowledge and behaviour concerning health promotion. Method It was conducted in five general practices in Oxfordshire. Patients aged 25-65 years in each practice were randomly assigned to receive either a CHR plus PHR, CHR only, PHR only, or no personal record. Patients were recruited by mail (one practice) or opportunistically by nurses (four practices). Health checks were carried out using the randomly assigned record, which the patient retained. Attitudes to patient-held records, and pre- and post-intervention knowledge and behaviour concerning health promotion, were assessed using questionnaires. Only those who responded to 'before' and 'after' questionnaires were included in the analysis. Results A sample of 261 patients was obtained from mail recruitment and 103 from opportunistic nurse recruitment. Patients receiving a CHR as part of mail recruitment were significantly more likely to attend for a health check (P = 0.016). Those receiving both PHR and CHR were more likely to keep (P = 0.014) and use (P = 0.029) the record. Those receiving PHR as part of the package improved their knowledge of health promotion and became more aware of and more likely to change their life-style (P = 0.022). Conclusions The effectiveness of a computer-generated patient-held health summary and an explanatory booklet together is greater than either separately in changing patients' knowledge attitudes and behaviour concerning health promotion.

The relationship between complaint-related cognitions in referred patients with irritable bowel syndrome and subsequent health care seeking behaviour in primary care

Abstract: BACKGROUND. It is generally accepted that it is important to explore patients' beliefs and fears about the meaning of their symptoms during medical consultations. OBJECTIVE. To discover how referral behaviour of GPs and attention to dysfunctional cognitions of medical specialists affect the subsequent health care seeking behaviour of patients with irritable bowel syndrome. METHOD. Questionnaires were distributed to GPs and to doctors and patients at an outpatient clinic in the University Hospital of Nijmegen. RESULTS. The results of the present study indicate that doctors' attention to the complaint-related cognitions of IBS-patients is also related to a reduced use of medical health services in primary care. On the other hand, when referred IBS-patients continue to attribute their complaints to a somatic abnormality even after such an abnormality has been ruled out through extensive physical examinations, the subsequent use of medical health services in primary care is likely to increase. Moreover, GPs' referral behaviour appears to strengthen these dysfunctional somatic attributions in IBS-patients. CONCLUSION. These unfavorable consequences might be avoided by handling cognitions and anxiety more specifically during medical consultations in primary as well as secondary care. (aut. ref.)

Improving patient-doctor concordance: an intervention study in general practice.

Abstract: Results. The pre-intervention sample (n = 197) was young (mean age 33 years), evenly divided into English-speaking (48%) and non-English-speaking (52%), and low SES (66%). The post-intervention samples (n = 95) was similar except for a lower proportion of persons from a low SES (27%). Main body systems reported were musculoskeletal, skin, respiratory, digestive, urological and gynaecological. Post-intervention, PDC on health problems improved significantly from 31% to 63% at the problem level (P = 0.001) and from 65% to 79% at the body system level (P = 0.02). PDC on treatments received also improved significantly from 5.5 to 6 out of 7 treatment options (P = 0.003). There were no significant differences due to gender, SES and non-English-speaking background status. Conclusion. PDC is a practical, useful and relevant indicator of effective patient-doctor communication. A well-presented summary of existing levels of PDC is an effective intervention to improve PDC and, by inference, patient-doctor communication on health problems and treatments. PDC should also be examined and reported in prevalence and incidence studies based on patient's reports and doctor's records.

What do patients expect from consultations for upper respiratory tract infections

Abstract: Background and objective A cross-sectional survey was conducted amongst patients who consulted for upper respiratory tract infections (URTI) at 22 private practitioners' offices. Method A total of 505 adult patients and 504 guardians (parents or grandparents of child patients) completed a self-administered questionnaire. Results The majority thought that URTI would not resolve on its own, while half thought that injections would speed recovery. But 78% disagreed with the statement that "taking multiple medications means faster recovery". Although 91% consulted for medicines, only 36% went specifically for antibiotics and 20% for injections. More than half would accept it if the doctor advised no medicine. More guardians (85%) than adult patients (69%) went for reassurance and to exclude complications. Using logistic regression analysis, the more educated respondents and the working guardians had higher knowledge scores, while the working guardians and respondents who knew the viral cause were less likely to worry and to demand antibiotics and injections. Conclusion Much patient education and a change in doctors' prescribing habits in the management of URTI are needed in Hong Kong.

Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. A controlled randomized videotaped intervention study

Abstract: BACKGROUND:Many patients with asthma or chronic obstructive pulmonary disease use their medication inhalers incorrectly. General practitioners, pharmacists and other health care providers do not always have the opportunity to instruct patients in correct inhaler technique. OBJECTIVE:To find out whether the inhaler technique and respiratory symptoms of patients can be improved after instruction by practice assistants. METHODS:Single blind, randomized intervention study in which 48 patients who had been using a dry powder inhaler for at least one month took part. Their inhaler technique was videotaped on two visits with a two-week interval between visits. The inhaler technique on the videos was subsequently scored by two experts on nine criteria. At both visits the patients completed a questionnaire about their respiratory symptoms. After the first video, 25 patients were randomly chosen to receive instruction from one of six practice assistants who had followed a one evening course about inhaler instruction, and who had been issued an instruction-set. RESULTS:The patients who received instruction had a significantly greater reduction in number of mistakes at the second visit than the patients who did not (P = 0.01). The instructed patients also reported less dyspnoea at the second visit (P = 0.03). No effect of instruction was found on wheezing, cough and sputum production. CONCLUSION:The inhaler technique of patients can be improved significantly by the instruction of patients by trained practice assistants, possibly resulting in less dyspnoea.

A randomized controlled trial of electromagnetic therapy in the primary care management of venous leg ulceration

Abstract: Objective. The aim was to establish the potential efficacy, tolerability and side-effect profile of electromagnetic therapy as an adjunct to conventional dressings in the treatment of venous leg ulcers. Method. A prospective, randomized, double blind controlled clinical trial was carried out in a dedicated leg ulcer clinic based in one urban general practice. Nineteen patients with leg ulcers of confirmed venous aetiology were assessed. The main outcome measures were rate and scale of venous leg ulcer healing, changes in patient-reported pain levels, quality of life, degree of mobility, side effect profile and acceptability to patients and staff. Results. Sixty-eight per cent of patients attending this dedicated clinic achieved improvements in the size of their ulcer (4, 21%, healed fully) and in reduced pain levels (P < 0.05) during the trial, despite the chronicity of ulcer histories. Patients treated with electromagnetic therapy at 800 Hz were found at day 50 to have significantly greater healing (P < 0.05) and pain control (P < 0.05) than placebo therapy or treatment with 600 Hz. All patients reported improved mobility at the end of the study. The electromagnetic therapy was well tolerated by patients, with no differences between groups in reporting adverse events, and proved acceptable to staff. Conclusions. Despite the small numbers in this pilot study, electromagnetic therapy provided significant gains in the healing of venous leg ulcers and reduction in pain.

Interruptions during general practice consultations--the patients' view

Abstract: BACKGROUND: Although most aspects of the consultation have been extensively reported there is very little information on the effects of interruptions on the consultation. OBJECTIVE: We wished to discover the patients' view of interruptions. METHODS: In this pilot study the sources and frequency of interruptions to the consultations of a single general practitioner were measured. The effects of interruptions on 102 patients whose consultations were interrupted were then ascertained using a simple questionnaire. RESULTS: The overall interruption rate was found to be 10.2%. The telephone was the commonest source of interruption, accounting for 50% of interruptions. Although most patients did not perceive the interruption as having an important effect on the consultation, 20% of patients did feel that the interruption had a bad effect on the consultation and 40% of patients felt it would have been better not to have been interrupted. A majority of patients (52%) did not feel that the reason for the interruption was important. Although most patients did not feel affected by the interruption, a significant minority (18%) of patients had a strongly negative emotional response to the interruption. CONCLUSIONS: In view of these findings the need for further work has been highlighted.

Pressures on the general practitioner and decisions to prescribe

Abstract: OBJECTIVES This study examined the extent to which four broad areas of concern associated with prescribing are perceived by general practitioners (GPs): their sense of burden in providing health care, their views on financial constraints and incentives, the use of a prescription to cope with clinical workload and their perception of demanding patients. A secondary aim was to relate these concerns to actual measures of prescribing behaviour using PACT data. METHOD A questionnaire covering the four themes was sent to 386 GPs. Using factor analysis, new measures were constructed to reflect the GPs' perception of the four areas of concern. RESULTS A total of 228 GPs (59%) completed the questionnaire. Results indicated a high level of concern among GPs regarding current pressures that could affect prescribing. Only the respondents' concern about the possible adverse effects of financial pressures upon medical decisions was related to prescribing: those concerned about financial pressures prescribed less generically (P < 0.0005), had higher practice costs compared with the Family Health Services Authority average (P = 0.002) and issued more prescriptions overall (P = 0.007). CONCLUSION There is a continuing need to monitor and evaluate the effect of recent changes in primary care for their effect upon prescribing behaviour.

Childhood vulvovaginitis and vaginal discharge in general practice

Abstract: Results. Non-specific vulvovaginitis with mixed bacterial flora, associated with poor hygiene and atrophic vaginal mucosa, was the commonest cause; specific bacteria were found in 10 out of 42 cases, including six of Streptococcus pyogenes. No Candida was isolated. Treatment with topical oestrogen cream was effective only with mixed infection, oral antibiotics were effective in both mixed and single organisms. No evidence of sexual abuse nor foreign body was found. Conclusion. Childhood vulvovaginitis is not uncommon in general practice, is usually associated with mixed growth of faecal organisms, and is seldom due to serious causes such as sexual abuse or foreign body.

Differences in meanings of health: an exploratory study of general practitioners and their patients

Abstract: OBJECTIVES Many health-related behaviours, particularly non-compliance with medical advice, seem irrational to professionals. 'Health' is a planned goal of health care but the extent to which doctors and patients agree about its meaning is unknown. We hypothesized that general practitioners (GPs) construe health as an absence of disease (medical model) to a greater extent than their patients in general and that asthmatic patients construe health in a manner biased to preserve their self-esteem. METHOD Forty-eight patients with asthma, 48 matched well patients and 34 GPs each gave up to six personal definitions of 'health'. Their definitions were classified into nine categories of meaning. RESULTS Results showed significant differences in the ways in which general practitioners and patients defined 'health' (chi-squared between GPs and asthmatics was 98, df = 7, P < 0.0001; chi-squared between GPs and well patients was 85, df = 7, P < 0.0001). As hypothesized, the category of meaning used most by general practitioners was an absence of disease, whereas patients expressed the meaning of health in terms of 'being able', 'taking action' and 'physical well-being'. Support for the second hypothesis, although consistent, was weak. CONCLUSIONS The way in which differences in beliefs provide a basis for understanding apparently irrational patient behaviours is discussed in the context of social identity theory. Implications for doctor-patient communication and the psychological validity of subjective health status and quality of life measures are also noted.