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General practice in New Zealand has evolved into a 'user pays' system and although operating within a national health service, it has many interesting differences from general practice in the United Kingdom. Emphasis is placed on biculturalism in health care. Income is derived through a fee for service, which includes a proportion from patients dependent on their means tested reimbursement from the government for provision of general medical services. Consultations are fewer in number and longer in duration. New Zealand society has considerable awareness in the area of medical ethics and there is a medical insurance scheme which covers ill health as a result of accidents. Great advances have been made in provision for out of hours work. New Zealand has its own royal college of general practitioners, membership examination and scheme for vocational training. This paper, based on the authors' personal experience of 12 months' study leave in New Zealand in 1991-92, examines these important areas of difference and reflects on the health reforms that are currently taking place in New Zealand.
Assessment within general practice training curricula is necessary to both guide learning and to make certification decisions about competence to practise without supervision in the community, but there is a risk that the two roles could become confused. This paper proposes a conceptual framework that explains the relationship between formative assessment, in-training assessment and end-point assessment, as adopted by the Royal Australian College of General Practitioners Training Programme. The literature is reviewed to suggest assessment formats that could provide a means of making decisions about progress through training without harming the important role of providing feed-back to guide learners.
93 general practitioners participating in a WHO field trial testing the ICD-10-primary health care classification system in German-speaking countries completed a questionnaire dealing with their practice of diagnosis and treatment of patients with depressive disorders. There was a great variety of diagnoses that were often vague. Counselling tended to be "good advice" instead of specific intervention. Antidepressant medication mostly consisted of tricyclic antidepressants in rather low dosages. Only few of the general practitioners informed patients thoroughly about side-effects and risks of antidepressant medication.
OBJECTIVES: To obtain from house officers who had rotated through general practice in their pre-registration year their views about their experience; and, separately, to compare the overall hours and type of work performed by hospital based and general practice based house officers. DESIGN: Postal questionnaire; and self recording of working hours and duties during four consecutive weeks. SETTING: Inner London teaching hospital and nearby general practice. PARTICIPANTS: 28 preregistration house officers in general practice, 1981-91; and 12 preregistration house officers, four each in medicine, surgery, and general practice. RESULTS: 26 out of 28 questionnaires were returned (response rate 93%). Twelve respondents were following or thinking of following a career in general practice. Twenty five respondents were satisfied with the clinical and educational aspects of the general practice rotation and would recommend the rotation, and 25 thought four months was about the right length of time in general practice. With regard to hours and type of work performed, hospital based house officers worked on average 55.5 hours a week (excluding on call), with an average of 12.5 hours (22.5%) spent in clinical activities; general practice based house officers worked about 41 hours a week, of which 24 hours (58%) were in clinical activities. House officers in hospital received less than one hour's specific teaching a week; those in general practice received nearly three hours' a week. CONCLUSIONS: A preregistration rotation in general practice is a popular alternative to the hospital based rotation. Although this is a limited study, other medical schools should consider introducing general practice options for preregistration house officers.
OBJECTIVE: The prevalence of antibiotic resistance in a country reflects the local consumption of antibiotics. The majority of antibiotics are prescribed in general practice and most prescriptions are attributable to treatment of respiratory tract infections (RTIs). The aim of this study was to compare general practitioners' (GPs') prescribing of antibiotics for respiratory tract infections in a country with a high prevalence of antibiotic resistance (Spain) with a country with a low prevalence of antibiotic resistance (Denmark). METHODS: A group of GPs in Copenhagen and Barcelona registered all contacts ( n=2833) with patients with RTIs during a 3-week period between 1 November 2001 and 31 January 2002. RESULTS: Overall, Spanish GPs treated a higher proportion of patients than Danish GPs. After adjusting for unequal distribution of age and sex, we found that Spanish GPs prescribed significantly more antibiotics to patients with focus of infection in tonsils and bronchi/lungs. Narrow-spectrum penicillin was the most used antibiotic in Denmark, representing 58% of all prescriptions issued, followed by macrolide and broad-spectrum penicillin. In Spain, prescriptions were distributed among a great number of compounds, with broad-spectrum penicillins and combinations of amoxicillin plus beta-lactamase inhibitors most frequently used. CONCLUSION: The substantial difference in the way GPs manage respiratory tract infections in Denmark and Spain cannot be explained by different patterns of RTIs in general practice. The discrepancies indicate variations in national recommendations, different treatment traditions or different impact of pharmaceutical marketing.
In a general practice population of 57 000, 32 patients suffering from Parkinson's disease were identified from repeat prescription indexes and direct questioning of all members of the primary health care team. Of these patients 26 were receiving an L-dopa preparation and 10 an anticholinergic drug. The only newer drug found to be in use was bromocriptine and three patients were receiving this treatment.Of the 26 patients receiving an L-dopa preparation one received L-dopa alone, six L-dopa with benserazide (Madopar, Roche) and 19 L-dopa with carbidopa (Sinemet, Merck, Sharp and Dohme). The patients treated with Sinemet were receiving inadequate doses of carbidopa - three quarters received less than 75 mg per day which was in part a reflection of the low doses of L-dopa the patients received, the average dose being 468 mg per day. The L-dopa preparations were given in adequately spaced doses.The general practitioner made the diagnosis in 20 of the 32 cases and was in control of the drug therapy in 15 cases, however 25 cases were referred for specialist advice.
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OBJECTIVE: To assess the acceptability and safety of a minor illness service led by practice nurses in general practice. DESIGN: Multicentre, randomised controlled trial. SETTING: 5 general practices in south east London and Kent representing semi-rural, suburban, and urban settings. PARTICIPANTS: 1815 patients requesting and offered same day appointments by receptionists. INTERVENTION: Patients were assigned to treatment by either a specially trained nurse or a general practitioner. Patients seen by a nurse were referred to a general practitioner when appropriate. MAIN OUTCOME MEASURES: The general satisfaction of the patients as measured by the consultation satisfaction questionnaire. Other outcome measures included the length of the consultation, number of prescriptions written, rates of referral to general practitioners, patient's reported health status, patient's anticipated behaviour in seeking health care in future, and number of patients who returned to the surgery, visits to accident and emergency, and out of hours calls to doctors. RESULTS: Patients were very satisfied with both nurses and doctors, but they were significantly more satisfied with their consultations with nurses (mean (SD) score of satisfaction 78.6 (16. 0) of 100 points for nurses v 76.4 (17.8) for doctors; 95% confidence interval for difference between means -4.07 to -0.38). Consultations with nurses took about 10 minutes compared with about 8 minutes for consultations with doctors. Nurses and doctors wrote prescriptions for a similar proportion of patients (nurses 481/736 (65.4%) v doctors 518/816 (63.5%)). 577/790 (73%) patients seen by nurses were managed without any input from doctors. CONCLUSION: Practice nurses seem to offer an effective service for patients with minor illnesses who request same day appointments.
AIMS: To examine whether variations in pathology test requesting between different general practices can be accounted for by sociodemographic or other descriptive indicators of the practice. METHOD: This was a comparative analysis of requesting patterns across a range of pathology tests representing 95% of those requested in general practice, in 22 general practices in a single district, serving a population of 165 000. Spearman correlation coefficients were calculated and both the top and bottom fifths of activity were displayed graphically to detect trends at the extremes of the ranges. RESULTS: The proportion of women of childbearing age, median practice Townsend scores, or the existence of specialist miniclinics within the practice did not have a demonstrable impact on requesting patterns. A weak correlation was found between the proportion of elderly patients and creatinine/electrolyte testing but not for the other two tests examined for this patient group. CONCLUSIONS: The large differences observed in general practice pathology requesting probably result mostly from individual variation in clinical practice and are therefore potentially amenable to change.
BACKGROUND: Currently the National Health and Medical Research Council (NH&MRC) recommend the use of a 23 gauge, 25 mm long needle inserted 45-60 degrees into the anterolateral thigh for paediatric vaccination. AIM: To assess the compliance of general practitioners (GPs) in a rural practice division with vaccination practice (site and needle size and gauge) prescribed for infants and toddlers by the NH&MRC. METHOD: In 1999, a questionnaire survey was sent by the divisional office to all 150 GPs in the Hunter Rural Division of General Practice. The questionnaire collected demographic data (age, gender, university of graduation, number of paediatric vaccines administered per week) and elicited responses about the site of vaccination and the size and gauge of needle to be used for children 2-18 months and 18 months and older. RESULTS: Completed questionnaires were available from 112 GPs (74.6% completion rate). There was a high level of compliance with the NH&MRC proscription of buttock vaccination with only 4.3% and 4.1% of responses to the question of vaccination site at 2-18 months and 18 months and older respectively nominating this site. The anterolateral thigh was the favoured site for vaccination in children 2-18 months old (77.5% of responses) with the deltoid being the favoured site in children 18 months and older (59.2% of responses). There was a very low level of compliance with the NH&MRC recommended standard needle (23 gauge, 25 mm long, blue hub needle) (3.5% of responses). The orange hub needle (25 gauge, 16 mm long needle) was most favoured (48.7% of responses) with additional strong support for the 25 gauge, 25 mm long needle (40.2% of responses). CONCLUSION: In the Hunter Rural Division of General Practice there was good compliance with the NH&MRC's recommendations for site of vaccination, but not needle size and gauge to be used in infants and small children. Imprecise wording of these recommendations has created apparent uncertainty about the site of vaccination of children at 18 months of age.
BACKGROUND: General practitioners are aware of the need to provide easily accessible health promotion information for their patients. Although many practices use health promotion posters in their surgeries, there appears to have been no formal evaluation of their effectiveness. AIM: A study was undertaken to investigate whether patients read and remembered waiting room posters, and if so, what factors influenced this. METHOD: A short questionnaire was distributed to patients in one practice following their consultation. It asked what they remembered of the poster display in the waiting room. RESULTS: Of 319 patients attending a doctor during the study period 82% said they had noticed the posters, 95% of whom reported they had also read them. Patients over 50 years of age were significantly more likely to say they had read the posters than younger patients, but significantly fewer showed interest in further information. The sex of patients did not influence their reading of posters or their interest in further health promotion literature. The longer patients had to wait for the doctor, the more likely they were to remember the subject of the posters correctly. Some subjects appeared to attract more patients' attention than others, in particular the displays about smoking cessation and about the human immunodeficiency virus (HIV) and the acquired immune deficiency syndrome (AIDS). Overall 53% said they would be interested in more information. CONCLUSION: Patients say they read and remember the subject of waiting room posters. Posters in the waiting room can increase awareness of health promotion issues.
Many questions have been raised about both programs, but one cannot say objectively that one is good or one is bad. Our energies must be concentrated on the development of the best comprehensive postdoctoral program so that the public may be better served. GPR and AEGD programs together produce over a thousand graduates each year. Is there really a difference between the two graduates? Is one a mini-oral surgeon? Is one a "superdentist"? Will they command higher fees, thereby raising the cost of dental care? How great a difference should there be? The students have succeeded in completing programs that are rigorous and demanding. The graduates can be no better than the institutions and the programs they represent. Regional differences still exist; for example, some metropolitan hospitals will not admit the dental general practitioner to staff or visiting staff positions. Why? Ideally, for the 60 percent of the training that is devoted to general practice principles, we should strike a balance and make sure that each program has definable standards. At the same time, we should permit enough flexibility to allow for the inevitable regional differences. Students should be able to select the program and location they prefer, confident that broad-based standards will be met, and assured of the practical as well as theoretical excellence of every program that is offered. How can we afford not to go with certification?
BACKGROUND: The General Medical Council has recommended that medical students should gain more experience in general practice. AIM: The study set out to determine patients' reactions to the presence of medical students in general practice consultations. METHOD: Patients attending a random sample of general practice surgeries completed a questionnaire following consultation with and without a medical student present in six general practices in the Oxford area. RESULTS: The questionnaires were completed by 278 patients. Only eight (3%) of all respondents had negative responses to the presence of a medical student. Of those completing questionnaires following a teaching consultation, 107 (56%) felt positively about the presence of students, compared with 36 (41%) who had attended a nonteaching surgery. Only three patients (1%) felt the quality of the consultation to be impaired by the presence of a student, while 48 patients (17%) felt there to be some improvement. The majority felt that the sex of the student was unimportant, but significantly more female than male patients (17% versus 5%) felt that it made a difference. CONCLUSION: Only a small proportion of patients object to the presence of a medical student in general practice consultations. A significant minority said that the presence of a student improves the consultation.
Based on general practitioners' referral letters and hospital records, we made a retrospective analysis of a cohort of 177 consecutive cases of meningococcal disease that occurred during a period of 10 years in the County of North Jutland, Denmark. The analysis concerned diagnostic problems in general practice, prognosis, pre-hospital antibiotic treatment and its effect on subsequent cultures, and degree of obligatory notification. The referring doctor suspected meningococcal disease/central nervous infection in 123 patients (69.5%). Neck stiffness and petechiae were related to a correct referral diagnosis, in contrast to the occurrence of a non-petechial rash. The presence of disseminated intravascular coagulation was associated with the mortality rate, which was 0.062. The therapeutic recommendations of the Danish Health Authorities were followed in only 25 of the 98 patients who fulfilled the criteria for pre-hospital parenteral antibiotic treatment. Pre-hospital antibiotic treatment was related to negative culture of spinal fluid or blood. Seven of the 177 patients were not notified according to the rules. Difficulties in pre-hospital diagnosis seem not to influence the lethal course of the disease.
Attitudes among general practitioners to confidentiality were studied in Denmark in 1980 and in 1984 and in France in 1980 using mailed questionnaires. A number of typical situations in general practice were described. The doctors were asked whether they would disclose information about the patient in the situations described. In a parallel study the same situations were described and lay people were asked whether in their opinion the doctor should disclose information or preserve confidentiality. The results showed some similarities but some marked differences between Danish and French practitioners; the Danish doctors attached more importance to the opinion of their patients. During the period from 1980 to 1984 a pronounced change in attitudes occurred among the Danish practitioners towards restraining information about the patients. In many questions the doctors' answers were in accordance with the expectations of lay people, especially regarding the preservation of confidentiality. But, contrary to the doctor's opinion, lay people expect that the doctor would provide information if the patient had given consent.
At present general practitioners lack a tool for defining the level of disability of individual patients and groups of patients with arthritis. An assessment technique (health assessment questionnaire) developed in the United States is described, and its use in general practice evaluated. Sixty two patients agreed to be visited at home to compare their observed abilities when performing the tasks of the health assessment questionnaire. The health assessment questionnaire (HAQ) is easily understood and takes patients only 10-15 minutes to complete. The numerical scores (range 0-3) for disability obtained on the postal questionnaire are close to the observed scores when patients are visited at home.
Partners in general practice have to buy any equipment they want themselves. As a result partners in high investing practices have lower net incomes. Of the 297 practices in Devon and Cornwall, 265 responded to a questionnaire listing 115 possible items of practice equipment. Overall, practices seemed to be fairly well equipped. Key findings were that 193 of those who responded had an electrocardiograph, 206 had a kit for minor operations, 119 owned a computer, and less than one third owned a microscope. Most of these practices were high investors. There seems to be a shift away from some traditional instruments towards expensive information technology. Government policies are encouraging the use of computers and such equipment, though funds are not necessarily being made available for this purpose.