PubMed · 8415086
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S Norwood. Practice nurses. Training questions.. https://pubmed.ncbi.nlm.nih.gov/8415086/
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Patient referrals from general practice for suspected heart failure are increasing the demand for echocardiograms, many of which are normal. We investigated whether general practitioners could be more selective by referring only patients with abnormal electrocardiograms for echocardiography. The electrocardiograms of 200 patients attending a heart failure clinic were analysed by a consultant cardiologist and two general practitioners. All three assessors examined the electrocardiograms independently and unaware of the echocardiography results. The correlation between abnormal electrocardiograms and left ventricular systolic dysfunction on echocardiography was assessed, together with the concordance between the assessors in their electrocardiogram interpretations. One hundred and sixty-five patients had echocardiographic evidence of left ventricular systolic dysfunction. When interpreted by a cardiologist, the electrocardiogram had a sensitivity of 89.1% and a specificity of 45.7% in predicting left ventricular systolic dysfunction. The general practitioners' results were comparable to the cardiologist's. We estimate that using the electrocardiogram to select patients could reduce the number of open access echocardiograms performed for suspected heart failure by up to 43% but would miss 10% of those with significant left ventricular systolic dysfunction. We therefore do not recommend selecting patients for open access echocardiography on the basis of electrocardiographic abnormalities.
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.
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