Showing papers in "Family Practice in 2002"

Ethics of qualitative research: are there special issues for health services research?

Abstract: Background An increasing volume of qualitative research and articles about qualitative methods has been published recently in medical journals. However, compared with the extensive debate in social sciences literature, there has been little consideration in medical journals of the ethical issues surrounding qualitative research. A possible explanation for this lack of discussion is that it is assumed commonly that qualitative research is unlikely to cause significant harm to participants. There are no agreed guidelines for judging the ethics of qualitative research proposals and there is some evidence that medical research ethics committees have difficulty making these judgements. Objectives Our aim was to consider the ethical issues which arise when planning and carrying out qualitative research into health and health care, and to offer a framework within which health services researchers can consider these issues. Results Four potential risks to research participants are discussed: anxiety and distress; exploitation; misrepresentation; and identification of the participant in published papers, by themselves or others. Recommended strategies for reducing the risk of harm include ensuring scientific soundness, organizing follow-up care where appropriate, considering obtaining consent as a process, ensuring confidentiality and taking a reflexive stance towards analysis. Conclusions While recognizing the reservations held about strict ethical guidelines for qualitative research, we argue for further debate of these issues so that the health services research community can move towards the adoption of agreed standards of good practice. In addition, we suggest that empirical research is desirable in order to quantify the actual risks to participants in qualitative studies.

Not another questionnaire! Maximizing the response rate, predicting non-response and assessing non-response bias in postal questionnaire studies of GPs

Abstract: Background. Non-response is an important potential source of bias in survey research. With evidence of falling response rates from GPs, it is of increasing importance when undertaking postal questionnaire surveys of GPs to seek to maximize response rates and evaluate the potential for non-response bias. Objectives. Our aim was to investigate the effectiveness of follow-up procedures when undertaking a postal questionnaire study of GPs, the use of publicly available data in assessing non-response bias and the development of regression models predicting responder behaviour. Method. A postal questionnaire study was carried out of a random sample of 600 GPs in Wales concerning their training and knowledge in palliative care. Results. A cumulative response rate graph permitted optimal timing of follow-up mailings: a final response rate of 67.6% was achieved. Differences were found between responders and non-responders on several parameters and between sample and population on some parameters: some of these may bias the sample data. Logistic regression analysis indicated medical school of qualification and current membership of the Royal College of General Practitioners to be the only significant predictors of responders. Late responders were significantly more likely to have been qualified for longer. Conclusions. This study has several implications for future postal questionnaire studies of GPs. The optimal timing of reminders may be judged from plotting the cumulative response rate: it is worth sending at least three reminders. There are few parameters that significantly predict GPs who are unlikely to respond; more of these may be included in the sample, or they may be targeted for special attention. Publicly available data may be used readily in the analysis of non-response bias and generalizability.

Patient trust in the physician: relationship to patient requests

Abstract: BACKGROUND Patient trust is a key component of the patient-physician relationship. A previous qualitative study has suggested that a low level of trust is associated with unfulfilled requests. OBJECTIVE Our aim was to test the hypothesis that patients with a low level of trust will be more likely to report that requested or needed services were not provided during an office visit. METHODS An observational study was carried out of office visits by 732 patients of 45 physicians (16 family physicians, 18 general internists and 11 cardiologists), within two managed care settings. Participants were consecutive, English-speaking patients, age 18 and older who had a significant health concern. Visit questionnaires were completed by 68% of patients known to be eligible. Post-visit measures included services requested (information, examination, prescription, test or referral); services provided; and requested or needed services not provided during the visit. Measures at 2-week follow-up included patient satisfaction, intended adherence to advice, interval contacts with the health system and symptom improvement. RESULTS After adjustment for patient and physician characteristics, patient trust in the physician was not associated with the likelihood that a service was requested or provided during the visit, with the exception that prescription of a new medication was more frequent among patients with higher trust. In contrast, patients with low trust prior to the visit consistently were more likely to report that a needed or requested service was not provided (P < 0.001 for all services). Patients with a low level of trust were less satisfied with their care (P < 0.001), were less likely to intend to follow the doctor's advice (P < 0.001) and were less likely to report symptom improvement at 2 weeks (P = 0.03). CONCLUSIONS Patients with a lower level of trust in their physician are more likely to report that requested or needed services are not provided. Understanding this relationship may lead to better ways of responding to patient requests that preserve or enhance patient trust, leading to better outcomes.

Acceptance of guideline recommendations and perceived implementation of coronary heart disease prevention among primary care physicians in five European countries: the Reassessing European Attitudes about Cardiovascular Treatment (REACT) survey.

Abstract: Background. Although primary care is the major target of coronary heart disease (CHD) clinical recommendations, little is known of how community physicians view guidelines and their implementation. The REACT survey was designed to assess the views, and perceived implementation, of CHD and lipid treatment guidelines among primary care physicians. Methods. Semi-structured validated telephone interviews were conducted, in the relevant native tongue, with 754 randomly selected primary care physicians (GPs and family doctors) in five European countries (France, Germany, Italy, Sweden and the UK). Results. Most physicians (89%) agreed with the content of current guidelines and reported use of them (81%). However, only 18% of physicians believed that guidelines were being implemented to a major extent. Key barriers to greater implementation of guidelines were seen as lack of time (38% of all physicians), prescription costs (30%), and patient compliance (17%). Suggestions for ways to improve implementation centred on more education, both for physicians themselves (29%) and patients (25%); promoting, publicizing or increasing guideline availability (23%); simplifying the guidelines (17%); and making them clearer (12%). Physicians perceived diabetes to be the most important risk factor for CHD, followed by hypertension and raised LDL-C. Most physicians (92%) believe their patients do associate high cholesterol levels with CHD. After establishing that a patient is 'at risk' of CHD, physicians reported spending an average of 16.5 minutes discussing risk factors and lifestyle changes or treatment that is required. Factors preventing this included insufficient time (42%), having too many other patients to see (27%) and feeling that patients did not listen or understand anyway (21%). Conclusions. Primary care physicians need more information and support on the implementation of CHD and cholesterol guideline recommendations. This need is recognized by clinicians.

Qualitative research and the problem of judgement: lessons from interviewing fellow professionals.

Abstract: Background: Qualitative research methods are recognized increasingly as valuable tools for primary care research, and add an extra dimension to quantitative work. Objective. The aim of this study was to illustrate the benefits and problems attending the dual role of clinician/qualitative researcher. Methods: As part of two studies employing semi-structured interviews of GPs in a North-West conurbation, about the topics of consultations on chronic low back pain and drug misuse in primary care, respondents' views on their interaction with a GP researcher were explored. Results: Access to the GP by the interviewing GP was easier when the GP researcher was known to the respondent. Such prior knowledge, however, may then influence the content of the data and the manner in which the GP researcher is perceived. During the interview itself, where respondents recognized the researcher as a clinician, interviews were broader in scope and provided richer and more personal accounts of attitudes and behaviour in clinical practice. The GP was also identified as an expert and judge, not just of clinical decision making but also about moral judgements made by GPs in their work. This will impact on the data obtained at interview and must be taken into consideration when the data are interpreted and analysed. Conclusion: Qualitative research techniques increasingly are advocated as appropriate for research on and in general practice. The professional identity of the researcher plays an important part in constructing the kind of data obtained in such studies, and this must be made apparent in reporting and discussions of such qualitative work.

Herpes zoster and postherpetic neuralgia: incidence and risk indicators using a general practice research database

Abstract: Background Postherpetic neuralgia (PHN) is a frequent complication of herpes zoster (HZ). Treatment results of this severe and long-lasting pain syndrome are often disappointing. From the point of view of possible prevention and early treatment, it is important to identify HZ patients who have an increased risk of developing PHN. Objectives Our goals were to determine the incidence of HZ and PHN in a primary care population and to identify risk indicators for the occurrence of PHN. Methods A search for HZ and PHN was conducted in a general practice research database, comprising 22 general practices and representing 49 000 people, over a 5-year period. Potential risk indicators were analysed using multivariate logistic regression. Results A total of 837 patients had been diagnosed with HZ [incidence 3.4/1000 patients/year, 95% confidence interval (CI) 2.9-3.9]. The risk of developing PHN 1 month after the start of the zoster rash was 6.5% (95% CI 4.9-8.3). This risk was 11.7% (95% CI 8.5-14.9) for patients aged > or =55 years. Independent risk indicators for the occurrence of PHN were age [55-74 years, adjusted odds ratio (OR) 4.2, 95% CI 1.8-9.7; >75 years, OR 10.7, 95% CI 4.6-25.1] and ophthalmic localization (OR 2.3, 95% CI 1.0-4.6). Conclusions The risk of developing PHN increases with age. Preventive strategies should focus on patients with herpes zoster aged >55 years and with ophthalmic localization.

The role of patient, physician and systemic factors in the management of type 2 diabetes mellitus.

Abstract: Background Few studies have explored the contextual dimensions and subsequent interactions that contribute to a lack of adherence in the application of guidelines for diabetes management. Objective The purpose of this qualitative study was to explore family physicians' issues and perceptions regarding the barriers to and facilitators of the management of patients with type 2 diabetes mellitus (DM). Methods Four focus groups composed of family physicians (n= 30) explored the participants' experiences in the management of patients with type 2 DM. A semi-structured interview guide began with questions on family physicians' experience of providing care and included specific probes to stimulate discussion about the various barriers to and facilitators of the management of type 2 DM in family practice. Results Participants clearly identified type 2 DM as a chronic disease most often managed by family physicians. The findings revealed distinct barriers and facilitators in managing patients with type 2 DM which fell into three domains: patient factors; physician factors; and systemic factors. There was a dynamic interplay among the three factors. The important role of education was common to each. Conclusions The interactions of patient, physician and systemic factors have implications for the implementation of a diabetes management model. The care of patients with type 2 DM exemplifies the ongoing challenges of caring for patients with a chronic disease in family practice. The findings, while specific to the management of type 2 DM, have potential transferability to other chronic illnesses managed by family physicians.

Medically unexplained symptoms and the problem of power in the primary care consultation: a qualitative study.

Abstract: Background: Patients presenting in primary care frequently exhibit physical symptoms that may be unrelated to organic pathology. Such symptoms are commonly regarded as products of psychological or emotional problems, and their legitimacy as ‘medical’ matters is often called into question. Objectives: Our aim was to explore GPs' attitudes to the management of patients that present with medically unexplained symptoms in primary care. Methods: Semi-structured interviews were conducted with 15 GPs in North-West England. Interviews were audio-taped and subsequently transcribed and analysed using a constant com-parison technique. Results: Subjects conceptualized patients presenting with medically unexplained symptoms as the presentation of psychological distress. They presented problems of control and authority in the consultation, and difficulties in managing this had a negative impact on the doctor–patient relationship. Such consultations were frustrating for the GP and potentially harmful to the patient. Conclusion: Patients with medically unexplained symptoms were seen to be presenting with inappropriate symptoms that were a manifestation of emotional or social distress. GPs felt ill-equipped to deal with the presentations and the frustrations they felt and may need help in actively and productively managing these patients.

The ‘Medical Interview Satisfaction Scale’ (MISS-21) adapted for British general practice

Abstract: Methods. The study was divided into two phases. The first investigated the properties of the MISS-29 in a UK general practice population and resulted in a modified MISS (MISS-21). The second investigated the properties of the MISS-21 in a wider UK general practice population. In phase 1, 150 patients over 16 years were recruited sequentially from patients attending a large group practice in suburban north London. Patients completed a questionnaire which collected demographic data and the MISS-29. In phase 2, 159 patients with a new problem were recruited from patients over 16 years consulting 18 GPs in north London, Essex and Suffolk. Patients completed a questionnaire while waiting to see the doctor; this collected demographic data and included six separate items, designed by the author, intended to measure patient satisfaction with previous consultations with the doctor. The patients completed the MISS-21 when they left the doctor’s consulting room. Results. The response rates for the phase 1 and phase 2 studies were 76.9 and 72.6%, respectively. Factor analysis, using principal component analysis with a varimax rotation, of the data collected in phase 1 resulted in a 21-item scale with the same four subscales as the original MISS-29. Correlations between subscales range from 0.46 to 0.65. Values of Cronbach’s alpha between 0.67 and 0.92 suggest that the subscales are internally consistent under the conditions of the study. In phase 2, 92.1% completed all the items in the MISS-21 and there were no significant relationships between patients’ demographic variables and the proportion of completed MISS-21 questionnaires, nor were there any differences in the proportion of completed MISS-21 questionnaires between type of practice or between practices serving different geographic populations, suggesting that the items were acceptable to patients. There were highly significant positive correlations (0.21‐0.63) between scores on the MISS-21 and all aspects of satisfaction with previous consultations, providing supportive evidence for the construct validity of the MISS-21. Conclusion. This study has demonstrated that the use in British general practice of the 29-item MISS developed in the USA should be treated with caution. However, a new 21-item version with the same four subscales as the 29-item MISS was developed which has satisfactory internal reliability. The correlations between subscales suggest that they represent fairly discrete but overlapping aspects of satisfaction. Evidence is produced suggesting that patients have less difficulty completing the MISS-21 and that it is applicable for assessing satisfaction with the consultation in different practice types and populations in the UK. Limited data supporting the construct validity of the MISS-21 are presented. While this study does not provide a full assessment of the MISS-21, we believe it provides evidence for its psychometric properties, which suggests that it is a valid and reliable instrument for the assessment of patient satisfaction with individual consultations in British general practice.

Meeting patient expectations of care: the major determinant of satisfaction with out-of-hours primary medical care?

Abstract: Methods. We surveyed 3457 patients who requested out-of-hours care from five practices, two general practice out-of-hours co-operatives and a deputizing service in an English health authority during late 1997. The independent variables were: the service providing the care (service type), where out-of-hours care was given (location of care) and whether the care met the patient’s expectations. The independent variable was overall patient satisfaction with out-ofhours care. Results. Patients who received the care they hoped for (their idealized expectation was met) were more satisfied than those who did not. Patients who attended centres were more satisfied with the care received than those who had had home visits. Patients were more satisfied if they received care from the co-operative which did not employ assistants than from the deputizing service. Idealized expectation (care which was hoped for) match, location of care and service type explained 34, 2 and 4% of the variance, respectively. Age, sex, ethnicity, access to a car, normative/comparative expectation (care which was expected) and whether patients expected and received telephone advice, a home visit or domiciliary care, and the delay between request for care and care provision were not independently associated with satisfaction. Conclusions. Meeting or failing to meet the care patients hoped for is an important predictor of patient satisfaction with out-of-hours care. Purchasers and providers of out-of-hours care should consider whether and how patient expectation of service can be managed. This may reduce patient dissatisfaction with the service they provide. These findings also have important implications for the design of studies which use patient satisfaction as an outcome variable.

Barriers to developing the nurse practitioner role in primary care: The gp perspective

Abstract: BACKGROUND: Opportunities exist to develop an advanced nursing role in general practice and there is growing evidence that appropriately trained nurses can reduce cost and GP workload without compromising quality of care or patient satisfaction. Despite the shortfall of doctors entering British general practice and the difficulties doctors report in managing an increasing workload in primary care, few British practices have chosen to adopt this potential solution. An exploration of the barriers to the development of a nurse practitioner role is therefore timely. OBJECTIVE: To explore the views of British GPs regarding their attitudes towards developing an advanced nursing role in general practice. METHODS: A focus group study of GPs from four general practices in Yorkshire selected purposefully to represent a spectrum of experience in working with different nursing roles in general practice. Each focus group consisted of between 6 and 8 participants. A structured framework was used to elicit views, the group meetings were recorded and subjected to content analysis by two independent assessors. Inter-rater reliability was high (K = 0.921; 95% confidence limits 0.86-0.98). RESULTS: The study highlighted significant concerns by GPs with regard to the nurse practitioner role in general practice. Four themes were identified that may be impeding the development of advanced nursing roles in general practice. These are concerned with threats to GP status, including job and financial security, nursing capabilities, including training and scope of responsibility, and structural and organizational barriers. CONCLUSIONS: There is a need to acknowledge GP concerns and encourage a more widespread debate about the appropriate mix of skills required in primary care. Joint educational events and the development of GP preceptorship may help to develop a greater understanding of the potential value of advanced nursing roles in general practice.

Do lipid-lowering drugs cause erectile dysfunction? A systematic review.

Abstract: Background Erectile dysfunction (ED) is common although under-reported by patients. Along with the better known causes of ED, drug-induced impotence needs to be considered as a cause of this symptom. Lipid-lowering drugs have been prescribed increasingly. Their relationship to ED is controversial. Objectives Our aim was to clarify the relationship between lipid-lowering therapy and ED. A secondary aim was to assess the value of the systematic review procedure in the area of adverse drug reactions. Methods A systematic review was carried out using computerized biomedical databases and Internet sources. Terms denoting ED were linked with terms referring to lipid-lowering drugs. Information was also sought from regulatory agencies. Results A significant literature was identified, much from obscure sources, which included case reports, review articles, and information from clinical trials and from regulatory agencies. Information from all of these sources identified fibrates as a source of ED. A substantial number of cases of ED associated with statin usage have been reported to regulatory agencies. Case reports and clinical trial evidence supported the suggestion that statins can also cause ED. Some information on possible mechanisms was obtained, but the mechanism remains uncertain. Conclusions The systematic review procedure was applied successfully to collect evidence suggesting that both statins and fibrates may cause ED. More numerous reports to regulatory agencies complemented more detailed information from case reports to provide a new perspective on a common area of prescribing.

Effects of guided written disclosure of stressful experiences on clinic visits and symptoms in frequent clinic attenders

Abstract: BACKGROUND Psychosocial variables such as major stressful life events/daily stressful events have been associated with health care utilization. OBJECTIVE Our aim was to examine the effects of a guided disclosure protocol (GDP) of past traumas on symptoms and clinic visits among frequent clinic attenders. METHODS Forty-one frequent clinic attenders (> or =2 visits/3 months) took part. Patients were randomly assigned individually to either a casual content writing control group (n = 19) or a trauma content writing experimental GDP group (n = 22). GDP patients wrote about an upsetting event chronologically (day 1), verbally described their thoughts and feelings and described the event's impact on life (day 2), and finally wrote about their current perspective on and future coping with the event (day 3). Three months later, patients were reassessed blindly for symptoms and clinic visits, and an average of 15 months later they were assessed blindly for clinic visits again. RESULTS Compared with controls, GDP patients reported lower symptom levels at 3 months (2.3 versus 5.2), and made fewer clinic visits during the 3 (1.3 versus 3.0) and 15 month (5.1 versus 9.7) follow-ups. The percentage of GDP patients making > or =10 visits during the 15 month follow-up was smaller (10%) than among controls (33%). CONCLUSIONS The findings extend previous findings to frequent clinic users, using a new form of written disclosure aimed at shifting trauma from implicit to explicit memory. The GDP may be an inexpensive additional intervention in primary care for reducing symptoms and clinic visits among frequent clinic users.

Educational strategies to promote evidence-based community pharmacy practice: a cluster randomized controlled trial (RCT)

Abstract: Background Community pharmacists have increasing involvement in the self-management of minor illness as a result of the availability of a wider range of over-the-counter (OTC) medicines. We undertook a randomized controlled trial (RCT) to assess the effectiveness and efficiency of educational strategies to implement evidence-based guidelines for the sale of OTC anti-fungals in the community pharmacy setting. Objective The aim of the study was to compare the effectiveness and efficiency of two guideline dissemination strategies in community pharmacy settings. Methods A 2 x 2 factorial, cluster RCT was conducted with 60 community pharmacies in the Grampian region of Scotland. The interventions included dissemination of an evidence-based guideline for OTC management of vulvovaginal candidiasis (thrush) by postal dissemination (control), educational outreach visit or attendance at a continuing professional education session. Pre- and post-intervention simulated patient visits were made to participating pharmacies. The simulated patients completed assessment forms following each visit. The primary outcome was the appropriateness (based upon the guidelines) of sale or no sale of OTC anti-fungals. Results There were no significant differences in the proportion of appropriate outcomes following educational outreach [odds ratio (OR) = 1.1; 95% confidence interval (CI) 0.52 to 2.45] or continuing professional education (OR = 0.88; 95% CI 0.41 to 1.91). Conclusions Neither strategy was effective in improving the appropriateness of OTC management of vulvovaginal candidiasis by community pharmacy staff. Further research is needed to identify barriers to guideline implementation and evidence-based practice in this setting.

The place of evidence-based medicine among primary health care physicians in Riyadh region, Saudi Arabia

Abstract: Background Evidence-based medicine (EBM) is a style of practice in which doctors manage problems by reference to valid and relevant information. Unfortunately, research consistently has shown that clinical decisions rarely are based on the best available evidence. Since primary care is the essential foundation in effective health care systems, it follows that providing evidence-based primary care would reflect positively on the community's health. Objectives Our aim was to explore the awareness and the attitude of primary health care physicians (PHCPs) towards evidence-based medicine (EBM) and determine their related educational needs. Methods A questionnaire study was carried out of all 650 PHCPs practising at the Ministry of Health Primary Health Care Centres in Riyadh region, Saudi Arabia. Main outcome measures were respondents' attitude towards EBM, ability to access and interpret evidence, perceived barriers to practising EBM and the best method of moving from opinion-based medicine to EBM. Results Respondents (n = 559) mainly welcomed EBM and agreed that its practice improves patient care. They had a low level of awareness of extracting journals, review publications and databases, and even if aware, many did not use them. The most commonly read journals by the PHCPs were The Practitioner and Medicine Digest. Only 16% had access to bibliographic databases and 10% to the worldwide web. The respondents showed a partial understanding of the technical terms used in EBM. The major perceived barriers to practising EBM were patient overload and lack of personal time. Respondents thought that the most appropriate way to move towards EBM was by learning the skills of EBM (43%), followed by using evidence-based guidelines developed by colleagues (37%). Conclusions Efforts towards improving access to evidence-based guidelines and summaries are urgently needed. Teaching all the PHCPs literature searching and critical appraisal skills by feasible and friendly methods should be considered.

Managing depression in primary care: another example of the inverse care law?

Abstract: Background: depression is a common problem, often being recurrent or becoming chronic. The National Service Framework for Mental Health (published by the Department of Health, 1999) states that people with depression should continue to be predominantly managed in primary care. There is much evidence that the detection and management of depression by GPs could be improved, but little work has focused on GPs’ views of their work with depressed patients. Objectives: this was a qualitative study exploring GP attitudes to the management of patients with depression. Views of GPs in socio-economically deprived areas are compared with those serving more affluent populations. Methods: semi-structured interviews were conducted with two groups of GPs in north-west England. One group of GPs (22) were practising in inner-city areas, and a second group (13) in suburban and semi-rural practices. All were Principals in practices that participated in undergraduate teaching. The interviews were audio-taped and subsequently transcribed verbatim. Analysis was by constant comparison until category saturation of each theme was achieved. Results: subjects conceptualized depression as an everyday problem of practice, rather than as an objective diagnostic category. Thematic coding of their accounts suggests a tension between three kinds of views of depressed people: (i) That depression is a common and normal response to life events or change and that it reflects the medicalization of these conditions; (ii) That the label or diagnosis of depression offers a degree of secondary gain to both patients and doctors, particularly to those GPs practising in inner-city areas and (iii) That inner-city GPs experienced on-going management of depressed people as an interactional problem, in contrast to those GPs serving a less deprived population who saw depression as a treatable illness and as rewarding work for the GP. Conclusion: depression is commonly presented to GPs who feel that the diagnosis often involves the separation of a normal reaction to environment and true illness. For those patients living in socio-economically deprived environments, the problems, and therefore the depression, are seen to be insoluble. This has an important implication for the construction of educational interventions around improving the recognition and treatment of depression in primary care: some doctors may be reluctant to recognize and respond to such patients in depth because of the much wider structural and social factors that we have suggested in this paper. That it is the doctors working with deprived populations who express these views, means that the ‘Inverse care law’ [Tudor Hart J. The inverse care Law. Lancet 1971; 1(7696): 405–412] operates in the management of depression

Striking the right balance in colorectal cancer care--a qualitative study of rural and urban patients.

Abstract: Results. Patients wanted rapid diagnosis, specialist treatment and good communication, but their experiences of and perspectives on these areas were often divergent. Delays in diagnosis could stem from late presentation by patients, but also from early presentation when the cancer could go undetected. GP continuity was desirable, but sometimes implicated in delays. Patients preferred their GPs to be advocates, not gatekeepers. The context, however, was one where some patients pursued their care tenaciously while others did not. For some, speed of progress through the system was everything, but others found this could be impersonal. Outlying patients had to balance transport difficulties with the benefits of distant specialist treatment. Some patients wanted full information to be provided directly, but others could not cope with this. Conclusions. From patients’ perspectives, ideal cancer care cannot be achieved in a uniform way. For some of the key goals of cancer treatment to be met, including rapid access to specialist treatment for all and good communication of bad news and test results, a balance must be struck which tailors care to individuals.

Patients' views and feelings on the community-based teaching of undergraduate medical students: a qualitative study.

Abstract: BACKGROUND The 1993 directive Tomorrow's Doctors recommended an increase in community-based teaching. In response, many new programmes have been established focusing on the teaching of clinical skills to pairs or groups of students in general practice, when patients are asked to see the students in the practice or in their homes, specifically to assist with teaching. This differs from the traditional model of teaching primary care, when one student sits with the doctor while s/he consults. Although current research suggests that patients are happy for one student to be present during a consultation with their GP, little or nothing is known about their views of this new method of teaching basic clinical skills in the community. If the new community-based teaching programmes are to be sustainable, continuing support from the patients is necessary. Students have been taught clinical skills in the community at University College London Medical School for several years. Research has demonstrated its effectiveness and its popularity with students. However, to date, patients' views have not been explored. OBJECTIVE Our aim was to determine the patients' views and feelings on community-based teaching, in order to discover both the positive and negative aspects for participating patients. METHOD A qualitative semi-structured interview study was carried out in undergraduate teaching general practices in North London. RESULTS Respondents felt very positive about participating in the community-based teaching programme. There were two underlying components to this: altruism and personal gain. Within altruism, reasons included: provision of a service to the community and repaying the system. Aspects of personal gain included: improved knowledge, improved self-esteem and companionship. Patient concerns included: embarrassment, reinforcement of the sick role and concerns about student access to notes. CONCLUSIONS Patients enjoy their involvement in community-based teaching and perceive themselves as making a valuable contribution. The findings of the research will be reassuring for doctors who presently are involved and those who plan to be involved in the future. Doctors need to be aware of the possible shifts in the doctor-patient relationship when actively seeking patients' help in the teaching.

US military veterans' perceptions of the conventional medical care system and their use of complementary and alternative medicine.

Abstract: Background Use of complementary and alternative medicine (CAM) is growing quickly in the USA, prompting hypotheses about why people turn to CAM. One reason for increasing use of CAM modalities may be dissatisfaction with the conventional care system. However, recent studies suggest that dissatisfaction is not a major factor. Objectives This paper provides another perspective on the possible relationship between dissatisfaction with conventional care and the use of CAM. Methods Qualitative data collection, in the form of 12 focus groups with 100 CAM users, was used to inquire about issues surrounding the use of CAM. Focus group participants were military veterans enrolled in the Southern Arizona VA Health Care System, and their significant others. Qualitative analysis identified key themes emerging from the focus groups. Results Although participants were satisfied in general terms with their conventional care, there were particular aspects of the conventional care system that they criticized. Dissatisfaction with aspects of conventional care, particularly its reliance on prescription medications, was an important component in their motivation to use CAM. Results also suggest that the conventional medical system's lack of holism (inadequate information regarding diet, nutrition and exercise, and ignorance of social and spiritual dimensions) is also an important motivation for turning to CAM in this particular population. Conclusions Independent research and a sense of responsibility on the part of focus group participants for their own health seemed to be taking them outside the domain of the conventional health care system.

The birth of the International Classification of Primary Care (ICPC). Serendipity at the border of Lac Léman

Abstract: Twenty years ago, in early spring, we were sitting in the Japanese garden of the WHO Headquarters in Geneva. It was the last day of a week of hard work, together with Sue Meads from the US National Centre for Health Statistics (NCHS), on the Reason for Encounter Classification. Since 1978, WHO had—with fiscal support from the NCHS—invited us several times to come over and prepare a classification representing patients' ('subject-ive') demand for care. This seemed important for health care planning, as an addition to data collected with ICD reflecting 'objective' patients' need from a medical perspective. Internationally, the focus of ICD was shifting from mortality towards morbidity, and thus the reasons to visit a doctor became of more interest. The three of us seemed to be rather well equipped for this exercise: two family physicians (FPs) with experience in family practice morbidity statistics, and a taxonomer who, as a country doctor's daughter, felt equally sceptical about many diagnoses and the utility of the resulting interventions. Sitting there, we discussed our present situation. We had just finished the field trial version of the Reason for Encounter Classification, together with a manual for its use. 1 Support from WHO, NCHS and WONCA would soon facilitate field trials in Australia (Charles Bridges (Cees de Geus and Henk Lamberts), Norway (Bent Bentsen) and the USA (Maurice Wood and Sue Meads). The atmosphere in WHO headquarters was optimistic. The Report Health for all in the year 2000 was on its way, as was ICD-10 as the centre of a 'family of classifications'. It was quietly accepted that FPs would not use ICD-10 (~10 000 classes) as a diagnostic classification, but that the ICD-9-related primary care classification ICHPPC-2 (370 classes) would be succeeded by an ICD-10-related version. 2 The trial version of the Reason for Encounter Classification contained ~700 classes. 1 Included were 200 symptoms , complaints, concerns, fears and psychosocial problems not available in ICD-9 and ICHPPC-2, because of the observation that patients often formulate health problems as symptoms and complaints. In addition, they sometimes formulate their problem as a diagnosis (I'm here for my hypertension), so most diagnostic classes of ICHPPC-2 were also included in the new classification. An essential and really new element was the inclusion of reason for encounter rubrics for patients' requests such as: I would like a prescription, a referral, a blood test; would you please measure my blood …

Asking for ‘rules of thumb’: a way to discover tacit knowledge in general practice

Abstract: Background. Research in decision-making has identified heuristics (rules of thumb) as shortcuts to simplify search and choice. Objective. To find out if GPs recognize the use of rules of thumb and ...

'I saw the panic rise in her eyes, and evidence-based medicine went out of the door.' An exploratory qualitative study of the barriers to secondary prevention in the management of coronary heart disease.

Abstract: Background. Coronary heart disease (CHD) is the leading cause of death in the UK, yet only 50% of CHD patients receive appropriate secondary prevention. Objectives. To explore GP attitudes to evidence about CHD, and to identify factors influencing the implementation of secondary prevention in GP consultations. Methods. Semi-structured interviews and focus groups exploring consultations with patients previously diagnosed as having CHD. Results. Use of evidence is influenced by credibility. Lack of time was the greatest barrier to accessing evidence and to implementing secondary prevention. Patients were more likely to receive secondary prevention in a dedicated clinic. Patient characteristics including physical and mental co-morbidity mitigate against secondary prevention. GPs experienced difficulty balancing implementation of evidence with the demands of the doctor–patient relationship. Conclusions. The doctor–patient relationship may act as a barrier to the delivery of secondary prevention in primary care. It may be time to re-evaluate models of these relationships and reconsider the strategies for implementing evidence.

Obstacles to effective treatment of depression: a general practice perspective

Abstract: Methods. A structured postal questionnaire was sent to all GPs (3530) in the 11 geographical areas visited during the CSAG study. Results. A total of 1703 (48%) GPs returned the questionnaire. The main obstacles to providing a good service for people with depression included not having enough time, a lack of services to refer to and difficulty in accessing services. More than half of the respondents (58%) were aware of guidelines for the management of depression, and 62% had attended a teaching session on depression within the last 3 years. Factors that influenced GPs to refer people with depression to other services were risk to the patient, a clear need for specialist treatment and the need for assessment. Overall, GPs appeared to be satisfied with the quality of specialist services. Conclusions. GPs appeared to view obstacles to providing effective treatment of depression as being more allied to external issues, in particular service provision, rather than internal factors such as their own knowledge and skills. The study revealed continuing concerns over excessive workload, and longstanding difficulties with the interface between primary and secondary mental health services.

How do GPs diagnose and manage acute infective conjunctivitis? A GP survey

Abstract: Objective: to determine GPs’ diagnosis and management of acute infective conjunctivitis (AIC)—one of the commonest but least researched acute infections seen in primary care. Methods: a postal questionnaire survey of 300 GPs from two Health Authorities in Southern England. Results: 236 (78%) GPs returned the questionnaire. 92% of those responding felt confident or very confident in the diagnosis of AIC. 95% usually prescribe topical antibiotics for AIC despite 58% stating that they thought at least half of the cases they see are viral in origin and only 36% believing that they could discriminate between bacterial and viral infection. There was considerable variability in GPs’ use of individual signs to make the diagnosis of AIC (from 99% using eye discharge to 31% using conjunctival oedema) and in the features used to discriminate viral from bacterial infection (from 87% using type of discharge to 47% using amount of discharge). GPs rarely perform eye swabs or give patient information leaflets to patients with AIC. Conclusion: most GPs still prescribe topical antibiotics for most cases of AIC—a condition where only half of the cases are likely to be due to a bacterial infection, and even bacterial infections are self-limiting. Further research is needed to explore the potential benefits and disadvantages of topical antibiotics, and to develop clinical or microbiological methods to help GPs to target antibiotic prescription.

The effectiveness of local adaptation of nationally produced clinical practice guidelines

Abstract: BACKGROUND Local adaptation is often reported in the literature to be an important strategy in achieving local ownership and relevance of guidelines in order to increase the likelihood of their uptake and implementation. However, the process is also potentially time-consuming and costly. OBJECTIVE The aim of this study was to determine the impact of local adaptation of nationally produced clinical practice guidelines (CPGs) on the knowledge, attitude and reported practices of GPs. METHODS Two Divisions of General Practice in Adelaide, Australia were selected and randomized to adapt a nationally produced CPG (on Stroke Prevention) by the National Health and Medical Research Council or use the original version. The order of the interventions was reversed for a second guideline (on management of Lower Urinary Tract Symptoms in Men). An identical multifaceted dissemination strategy was adopted for both sets of guidelines in the two divisions. Prior to the intervention, a random sample of 200 GPs from each Division was sent a postal survey about their knowledge, attitudes and reported practices. This was repeated 3 months after the dissemination phase. RESULTS Sixty-one per cent (243/400) of the GPs responded to the initial survey and, of these, 76% (184/243) responded to the follow-up survey. Overall, awareness of both sets of guidelines was significantly increased. For stroke, 38% of respondents across both Divisions reported that their practice had changed as a result of the guidelines. For management of lower urinary tract symptoms in men, the corresponding proportion was 52%. Agreement with specific recommendations from both guidelines was also increased following their dissemination. However, these changes were independent of whether or not the guidelines had been locally adapted. The local adaptation process involved no substantive change in content and was estimated to cost AUD$5600 (per Division) independent of the costs of the dissemination process. CONCLUSIONS Whilst this study found significant changes in knowledge, attitude and reported practice as a result of disseminating guidelines, it did not find any additional effect from the local adaptation process itself. This suggests that the emphasis and investment in promoting guideline implementation should be placed on multifaceted dissemination strategies rather than local adaptation per se.

Danish GPs' perception of disease risk and benefit of prevention

Abstract: BACKGROUND Uncertainty and risk are central issues in relation to health and health care services. Healthy individuals do not necessarily fall ill, despite the presence of risk factors. It has been documented that doctors, health service administrators and patients are more inclined to choose interventions against risk factors when information about the effects is presented in terms of relative risk reductions rather than absolute risk reductions. OBJECTIVES The objective of the study was to gain better insight into how GPs perceive risk of disease, and how this perception is influenced by the way the risk is presented, e.g. whether changes in risk are presented in absolute or relative terms. METHODS Questionnaires with clinical episodes were sent to 1500 Danish GPs. The GPs were randomized into four groups of 375, who all received the same case story with information about risk reduction achieved through medical treatment phrased in terms of either relative risk reduction, absolute risk reduction, number needed to treat or all of the aforementioned terms of risk reduction. The GPs were asked whether they would recommend medical treatment as primary prevention, knowing the case story and expected risk reduction. RESULTS The GPs' attitude towards recommending medical treatment was dependent on the phrasing of risk reductions. Seventy-two per cent of doctors who received all information on risk reductions would definitely or probably recommend medication, while 91% would recommend medication if information only about relative risk reduction was given, and 63% would recommend medication if information was given in terms of absolute risk reduction or number needed to treat. CONCLUSION In order to advise patients in a rational way, in addition to knowledge of the patients' preferences, doctors need to take into account all available measures of risk reductions.

Group interviews in primary care research: advancing the state of the art or ritualized research?

Abstract: BACKGROUND Focus groups have become an important data gathering technique in primary care research. OBJECTIVES This study provides an integrated review of recent articles that used focus groups as a data collection method to gather information from family physicians. METHODS Medline was searched for articles that used focus groups with family physicians in a North American setting during the 1990s. Articles that met this criteria were critically evaluated to determine who participated, the number of groups conducted, setting, length, inclusion and exclusion criteria, sampling technique and whether the groups were used as part of a larger study. RESULTS The twenty articles discussed herein revealed tremendous variation in how focus group research is conducted and reported. CONCLUSIONS Focus group research is a popular form of qualitative research in primary care research. Journals reporting qualitative research should require that certain basic information be present, thereby advancing the state of the art and permitting readers to better evaluate these articles.

Australian GPs are satisfied with their job: even more so in rural areas

Abstract: Background Australia has seen a constriction of the scope of practice and of professional prerogatives for GPs in the 1990s, which is said to have led to lower job satisfaction, particularly for rural GPs. Objective The aim of this study was to determine levels of job satisfaction and mental health in a rural and an urban sample of GPs, and to correlate population and practice characteristics with lower job satisfaction and morale. Methods A postal survey of GP members of two urban and four rural Divisions of General Practice in New South Wales was carried out using the Wall-Cook-Warr scale and the 12-item General Health Questionnaire (GHQ-12). The overall response rate was 74%. Results Both urban and rural Australian GPs were generally satisfied with their jobs; however, rural GPs had significantly higher job satisfaction scores. The highest levels of satisfaction were recorded for factors denoting autonomy. The lowest ranked factors were hours of work, income and government policy in general practice. GPs without psychological disturbance were significantly more satisfied with their work than those who were disturbed. Lower job satisfaction was significantly associated with urban GPs, GPs who worked full-time and those who used a language other than English during consultations. Poor mental health and working in an urban area were predictive of lower job satisfaction in men, and bulk-billing all patients (i.e. not charging patients a co-payment, but making a consolidated claim to the government funder Medicare) and working full-time were predictive of lower job satisfaction in women. Conclusions Both urban and rural GPs derive a large measure of satisfaction from their job. In particular, rural GPs are satisfied, especially so with their autonomy. Poor mental health was the strongest predictor of lower job satisfaction. The high percentage of GPs with psychological disturbances raises the problem of their access to appropriate mental health services, in particular in rural areas.

Doing qualitative research in general practice: methodological utility and engagement

Abstract: General practice uses an eclectic range of research methodology. This includes increasing reliance upon qualitative research methods. There seem to be two distinct treatments of qualitative research within primary care and, in particular, within general practice research. The first is characterized by a purely utilitarian and technical focus, using a qualitative method because it is the most appropriate means of realizing the aims of the research, while the second is charac- terized by in-depth engagement with the philosophical and paradigmatic aspects of qualitative methodology. In-depth engagement with methodology and theory, and theory building, is an important aspect of masterate and doctoral research within social sciences such as education and anthropology, and in the discipline of nursing, but has not been a feature of qualitative research in medicine. A practical difficulty encountered within postgraduate programmes such as the one in which the author teaches is that when innovative qualitative techniques are used by GPs in their postgraduate research dissertations and theses, it is often beyond GP examiners' own knowledge and experience, yet it fails to measure up to standards established in social sciences, particularly in sociology and anthropology where in-depth reflexive engagement with the theory and philosophy of qualitative methodology is expected. This paper suggests that the value of in-depth engagement with methodology when conducting qualitative research results in creative and innovative ways of conducting research that are consonant with the nature of general practice itself, and strengthens research findings. Therefore, as teachers of research methods and supervisors of research theses, it is important to encourage students conducting qualitative research to engage fully with theoretical and methodological issues.