Biomedical subjects
Publications and source records attributed to M Modell.
A general practitioner-staffed direct access telephone advice line was made available for 30 minutes every morning at an inner-London practice to advise patients with urgent problems. Users valued the service, but the impact on surgery consultations was too small for this to be advocated as an alternative to emergency consultations.
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OBJECTIVES: To obtain students' perceptions of the educational quality of the general internal medicine teaching overall and to determine whether specific learning objectives were better addressed in general practice or in hospital. DESIGN: The survey was carried out after a 10 week block of general internal medicine, consisting of five weeks taught in general practice and five weeks taught in a teaching hospital. Students were randomly allocated to start in either general practice or hospital. The outcome measure was a questionnaire survey of students perceptions' of their learning on the two halves of the block. Each student completed the same questionnaire twice: once after their hospital experience and once after their general practice experience. Statistical Analysis was carried out using the SPSS package for Windows 3.1. Group means were calculated for each response, and the mean differences for each student's responses for the two learning environments were analysed using t-tests for paired samples. SETTING: Royal Free and University College Medical School at University College London. SUBJECTS: The study population was the entire annual intake (n = 225) of students into the first clinical year at one UK medical school. RESULTS: Students perceived they learnt more about history taking and physical examination in the community, whereas they learnt more about writing up their clerkings, keeping progress notes and disease management in hospital. CONCLUSIONS: The community and hospital environments appear to have different strengths for the teaching of medical students. These data support judicious transfer of clinical skills teaching from teaching hospitals into general practice, when the circumstances achieved here can be duplicated. However, some aspects of the clinical attachment, particularly record keeping and disease management, are probably better taught in hospital at present.
The amount of undergraduate medical education delivered in general practice is expanding rapidly, both in the United Kingdom and internationally. There are a number of challenges facing general practice as well as medical schools, health authorities and primary care groups, which must be met for this development to be sustainable. These include: impact on service general practice; resources; difficulties with integrating basic sciences with clinical teaching; recruitment, training and maintenance of GP tutors; quality control; impact on academic departments of primary care; and the importance of rigorous evaluation of educational initiatives. Possible solutions are discussed, such as development of university linked practices and the move toward a culture of 'evidence-based education', where all medical education is scrutinized for effectiveness.
OBJECTIVE: To investigate the feasibility of improving screening for carriers of haemoglobin disorders in general practice by using a nurse facilitator to work with primary care teams and the relevant haematology laboratories; to identify problems in communication between all those involved in delivering the service, and to implement solutions. DESIGN: Two year, practice based randomised controlled trial. SETTING: North London area where 29% of residents and 43% of births are in ethnic groups at risk for haemoglobin disorders. SUBJECTS: 26 of the 93 practices using the services of the area's haematology laboratory agreed to take part and were randomly divided into control and intervention practices. MAIN OUTCOME MEASURE: Change in number of requests for screening tests for haemoglobin disorders made by control and intervention practices in baseline and intervention years. RESULTS: The number of screening tests requested varied from 0-150 in the 93 practices in the baseline year. Study practices tended to have made a moderate number of requests (10-50) during this period. During the intervention year intervention practices made 292 more requests (99% increase) and control practices made 74 fewer requests (23% decrease; P=0.001 for difference in median change). Four practices, three of which were singlehanded, accounted for 75% of the increase. The number of requests from intervention practices, adjusted for baseline requests, was 3.2 times higher than control practices (P<0.0001). CONCLUSION: General practitioners and practice nurses are willing to undertake a new genetic screening service (or expand an existing one) if they are persuaded that it benefits the health of a significant proportion of their practice population. They need appropriate tools (for example, information materials for carriers and groups at risk), and the laboratory must be sensitive to their needs. Preconceptional carrier screening and counselling need to be coupled with antenatal screening.
OBJECTIVE: To determine whether students acquired clinical skills as well in general practice as in hospital and whether there was any difference in the acquisition of specific skills in the two environments. DESIGN: Randomised crossover trial. SUBJECTS AND SETTING: Annual intake of first year clinical students at one medical school. INTERVENTION: A 10 week block of general internal medicine, one half taught in general practice, the other in hospital. Students started at random in one location and crossed over after five weeks. OUTCOME MEASURES: Students' performance in two equivalent nine station objective structured clinical examinations administered at the mid and end points of the block: a direct comparison of the two groups' performance at five weeks; analysis of covariance, using their first examination scores as a covariate, to determine students' relative improvement over the second five weeks of their attachment. RESULTS: 225 students rotated through the block; all took at least one examination and 208 (92%) took both. For the first half of the year there was no significant difference in the students' acquisition of clinical skills in the two environments; later, however, students taught in general practice improved slightly more than those taught in hospital (P = 0.007). CONCLUSIONS: Students can learn clinical skills as well in general practice as in hospital; more work is needed to clarify where specific skills, knowledge, and attitudes are best learnt to allow rational planning of the undergraduate curriculum.
There is national and international interest in increasing the community-based component of undergraduate medical education, but more research is needed on its potential, practicability and effectiveness. The objective of the study was to examine the feasibility and efficacy of general practitioners teaching basic clinical skills to first year clinical medical students in the community. The structure and methods of evaluation of the programme are described. Evaluation tools included semistructured interviews of general practitioner tutors; student questionnaires; assessment of student performance; and costs of the programme. The great majority of the students found the programme enjoyable (81 out of 81, 100%) and educational (79 out of 81, 97%). Students' performance in the end of rotation Objective Structured Clinical Examination suggested that clinical skills are acquired at least as well in the community as in the hospital. Tutors identified the personal benefits of this teaching as development of their own clinical skills and the stimulation of teaching. The programme has been successfully expanded from 24 students to 230 students annually and has demonstrated that community-based teaching can usefully contribute to undergraduate medical education in the area of clinical skills teaching. Key practical issues for schools contemplating similar initiatives are presented.
Asthma is a chronic disease estimated to affect 6-7% of the total UK population. In addition, a number of studies have shown that asthma has become commoner since the 1970s, especially in children. The diagnosis of asthma can be difficult and its management requires the involvement of patients in a long-term treatment plan, something which general practitioners may be unable to achieve easily in the average 10-min consultation. As a consequence, asthma is underdiagnosed and undertreated. Deaths from the disease are often avoidable with timely and sufficient use of the available medication. In order to support this, the British Thoracic Society (BTS) has published guidelines for asthma management based upon a stepwise approach, in which a patient is categorized as being on one of five steps according to the severity of his or her asthma. The guidelines give "rules of thumb" for deciding when the patient should move up or down the steps. The most recent version of the guidelines also included special rules for children. Within a recent European Community project on Advanced Informatics in Medicine (AIM), we developed a prototype decision support system for asthma management targeted at the primary care setting and based on the British Thoracic Society guidelines. This paper reports this development, and describes the further work needed on the prototype. Plans for evaluation of the knowledge bases and for future full application production are also described.
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The General Medical Council has issued a call for an increase in community-based medical education, and many medical schools are enhancing the community component of their curricula. This paper uses the experience of a community-based junior medical firm to explore the potential costs, and highlight some of the unresolved problems, which a major transfer of education to the community might engender. Community-based medical education is not a cheap option. The cost of this programme for the academic year 1992-93 was 266,494 pounds, or 60 pounds per student session. This compares with the Service Increment for Teaching and Research (SIFTR) provision of 41,140 pounds per student per annum, or (excluding the 25% of SIFTR which is supposed to cover research costs), 64 pounds per student session. There are a number of possible ways of funding community-based education, including a diversion of SIFTR toward departments of primary health care. As this would have serious implications for the financial viability of some medical schools, an urgent discussion about the future funding of medical education is required.
Asthma is a common chronic disease of the lungs caused by inflammation of the airways affecting 6-7% of the population. Asthma is becoming commoner and there is evidence of under-diagnosis and poor management. Guidelines have been developed aimed at improving quality of care and in reducing social costs of asthma. The paper discusses an approach to implementing guidelines through decision-support system in primary care, based on methods developed in the AIM GAMES-II project. We also describe a prototype system that has been developed and a programme of clinical evaluation.
The purpose of the study was to evaluate the short-term effects of population based screening for carriers of cystic fibrosis. The outcome measures included perceptions of health, anxiety, and understanding of test results. Those adults aged between 18 and 45, registered with a general practice in Inner London, who accepted the offer of carrier testing, completed questionnaires before testing, upon receipt of results, and three months later. Full data were obtained from 427 with negative test results and 14 carriers. Receipt of results had no effect upon perceptions of health or perceived risk of having an abnormal baby. Those receiving a positive test result were significantly more anxious upon receipt of this result. By three months, this anxiety had dissipated. While knowledge of the test improved from before to after testing, by three months there was some decay. Although the residual risk among those with a negative result of being a carrier was given as 1:135, at least 17% of those receiving a negative result incorrectly believed that they were at no risk of having a child with cystic fibrosis. Five of the 14 receiving a positive result erroneously believed that their results meant that they probably, but not definitely, carried the gene for cystic fibrosis. In the longer term the greatest problem of population screening would appear to be one of false reassurance rather than anxiety. Longer term studies are needed to determine how well carrier status information is retained, and how carriers and carrier couples plan and respond to pregnancy and how much understanding they retain of their test results.
The identification of the gene for cystic fibrosis has led to the possibility of population based screening for carriers of cystic fibrosis to identify couples at risk of having an affected child. Pilot studies have shown that screening is feasible and does not cause untoward anxiety, though the uptake of testing varies considerably with the setting and method of invitation. Screening offered at times when individuals (and health professionals) perceive it as directly relevant will probably gradually become established in the United Kingdom. This review examines the role of general practice in genetic carrier screening as exemplified by cystic fibrosis. General practice has a pivotal role from the beginning in providing individuals and couples with information, facilitating testing of patients' relatives and of carriers identified by screening elsewhere (such as antenatal clinics), and offering testing in the context of reproduction. Screening for the cystic fibrosis gene will probably be followed by other genetic screening programmes.
OBJECTIVE: To determine the acceptability and feasibility of screening for carriers of cystic fibrosis in a primary care setting. DESIGN: Follow up study over 15 months of patients offered carrier testing by mouthwash. SETTING: A general practice in inner London. SUBJECTS: 5529 patients aged 18-45 invited by various methods and combinations of methods (letter, booklet, personal approach) for testing. MAIN OUTCOME MEASURES: Uptake of screening, anxiety, and knowledge of test. RESULTS: 957 (17%) invitees were screened over the 15 months. 28 carriers and no carrier couples were detected. Uptake rates were 12% (59/502 patients) among patients invited by letter and tested by appointment; 9% (47/496) among patients invited by letter, with leaflet, and tested by appointment; 4% (128/2953) among patients invited by letter six weeks before the end of the study and tested by appointment; 17% (81/471) among patients offered passive opportunistic testing; 70% (453/649) among patients offered active opportunistic testing; and 25% (22/88) among patients offered active opportunistic testing by appointment. A short term rise in anxiety among those given a positive test result had dissipated by three months. At three months about one fifth and one third of those given positive and negative results respectively did not understand their results correctly. CONCLUSION: These results suggest that the strongest variable in determining uptake of screening is the active approach by a health professional offering immediate testing. It remains to be resolved whether the high uptake rates achieved by active recruitment indicate a supply push for this new test rather than a demand from the population.
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Using conventional means of process development, it would take decades and hundreds of millions of dollars to develop technology for recycling of water and solid waste for lunar missions within the next thirty years. Since we anticipate neither that amount of time nor level of funding, new methodologies for developing life support systems (LSS) technologies are essential. Computerized modeling and simulation (CMAS) is a tool that can greatly reduce both the time and cost of technology development. By CMAS, we refer to computer methods for correlating, storing and retrieving property data for chemical species and for solving the phenomenological equations of physical/chemical processes (i.e., process conditions based on properties of materials and mass and energy balances, equipment sizing based on rate processes and the governing equations for unit operations). In particular, CMAS systems can be used to evaluate a LSS process design with minimal requirements for laboratory experimentation. A CMAS model using ASPEN PLUS is presented for a vapor compression distillation (VCD) system designed for reclaiming water from urine.
In a study of patients' perceptions of the transition from hospital to the community, 115 elderly people registered with a central London group practice were interviewed shortly after they arrived home. Many patients received little notice of discharge, a third being told on the day they left the hospital. A third felt they had been discharged too soon and those living alone were significantly less likely to return to a heated home containing basic items of food. Seventy-seven patients, including 80% of those living alone were visited by family, friends or professionals within three days of coming home. Eighty-six per cent of non-professional visitors were women. Several of the elderly couples appeared to be under considerable stress and not all individuals were receiving the help they considered most appropriate to their needs. Many of the problems identified were due to poor communication between practice, hospital and patients. We suggest several measures aimed at improving the quality of that communication, so as to ensure that available resources can be mobilized to support this vulnerable group of people.