Saying 'goodbye' to single-handed practices; what do patients and staff lose or gain?

BACKGROUND: The practice setting is, next to the GP and staff, an important determinant of the quality of care. Differences between single-handed practices and group practices in practice management and organization could therefore provide clues for improvement. An explorative, cross sectional survey was conducted in 766 general practices in The Netherlands comparing single-handed practices with group practices. OBJECTIVE: The study is looking for answers on aspects of the organization and management that are lost or gained when single-handed GPs and practices are replaced by group practices. METHODS: Between 1999 and 2003 GPs and their practices were assessed using a validated practice visit method (VIP) consisting of 303 indicators describing 56 dimensions of practice management. Instruments used consisted of questionnaires for patients, GPs, practice assistant and a direct observer in the practice. Single-handed practices (1 GP) were compared to group practices or health centres (>2.0 GPs) comparing raw scores on dimensions of practice management. In addition, data were analysed in a regression model with specific aspects of practice management as dependent variables using a general linear model procedure. Independent variables included 'single-handed/group practice', 'rural/ urban' 'part-time/full-time' and 'male/female'. RESULTS: Group practices scored better on nearly all aspects of infrastructure except those rated by patients. Patients gave single-handed practices higher marks for service, accessibility and even for the facilities. In single-handed practices GPs reported that they worked more and experienced higher levels of job stress. They delegated less of the medical technical tasks but there is no difference in delegation of preventive tasks/treatment of chronic diseases. Group practices had more computerized medical information and more quality assurance activities, but gave less patient information. Single-handed practices spent more hours on continuous medical education. DISCUSSION AND CONCLUSION: The quality of the practice infrastructure and the team scored better in group practices, but patients appreciated the single-handed practice better. The advantages of single-handed practices could be a challenge for group practices to give better personal, continuous care and to put the patient perspective before organizational considerations. This is underlined by the better score on patient information of single-handed practices. Single-handed practices can reduce their vulnerability and openness to high demand by opening up to the requirements of organised primary care.     

What's said and what's done: the reality of sexually transmitted disease consultations

OBJECTIVE: Indirect data collection methods, or approaches which disturb usual practice, are generally used in health care evaluation. We have compared what doctors report at interview what is observed by an identified researcher with an unobtrusive measure of their usual practice. DESIGN: Private practitioners who provide a service to sexually transmitted disease (STD) patients were interviewed regarding their usual case management. An identified researcher carried out structured observations of consultations between physicians and patients. Simulated clients then sought consultations, presenting a standardised history and symptom profile. Structured reporting of the history taking, examination, treatment and counselling aspects of these consultations was undertaken. SUBJECTS: Eighteen private practitioners in Madras (now Chennai), India. MAIN OUTCOME MEASURES: Comparisons between interviews, observations by identified researchers and the experiences of simulated clients were carried out. RESULTS: Interviews with physicians and observations by identified researchers indicated more favourable practice than was seen during simulated client visits. These differences were substantial and would lead to a severe misrepresentation of the actual situation-and thus of intervention needs, if data from interviews or observations were relied upon. CONCLUSIONS: The usual methods used in the evaluation of medical services and in carrying out medical audit may produce highly unreliable findings. STD services in the study area are failing to realise their potential of improving the sexual health of populations. The methodological and substantive findings of this study could be combined through the introduction of simulated client visits in the monitoring, improvement and licensing of STD (and perhaps other medical) services.     

Dissociable correlates of recollection and familiarity within the medial temporal lobes

Regions in the medial temporal lobes (MTL) have long been implicated in the formation of new memories for events, however, it is unclear whether different MTL subregions support different memory processes. Here, we used event-related functional magnetic resonance imaging (fMRI) to examine the degree to which two recognition memory processes-recollection and familiarity-were supported by different MTL subregions. Results showed that encoding activity in the rhinal cortex selectively predicted familiarity-based recognition, whereas, activity in the hippocampus and posterior parahippocampal cortex selectively predicted recollection. Collectively, these results support the view that different subregions within the MTL memory system implement unique encoding processes that differentially support familiarity and recollection.     

精神病患者的院外接诊与护理

院外接诊是医院深化改革后提出的一项方便患者,并为患者家属、单位解除就诊不便的改革措施。从而保证精神病患者安全、及时就诊,防止患者发生危险。作者就院外接诊精神病患者中易出现的问题提出了相应的护理措施。     

大庆市社区产后访视现状调查与分析

目的了解大庆市社区产后访视服务现状。方法随机抽取大庆市各社区产后2年内的妇女800人和从事产后社区访视人员42人作为调查对象进行问卷调查,并进行对比分析。结果社区入户产后访视率为73.04%;接受社区入户访视组产后42天体检率明显高于未接受社区入户访视产妇组(P<0.01);从事访视人员中工作经历低于1年者占26.19%,有42.86%的访视人员未按规定对本社区的产妇进行产后访视。结论社区产后访视仍存在着较多问题。     

Tsunami

Tsunami is a fictionalized, based on the true story of a mother and baby patients who attended my rural clinic for 12 months and disappeared. (All personal identifiers have been removed.)     

146例产后家庭访视指导效果分析

目的了解医生产后家庭访视指导对产妇和新生儿的影响，提高产妇和新生儿的健康水平。方法对我辖区（崇文门地区）20052007年分娩的产妇及其新生儿的资料进行了回顾性统计分析。结果第一次和第二次产后家庭访视喂养方式比较，两次的喂养方式构成不同（P〈0．01），第二次访视母乳喂养的比例显著高于第一次（P〈0．01）；第一次和第二次访视新生儿湿疹、臀红发生情况比较，第二次访视新生儿湿疹、臀红发生的比例均低于第一次，差异有统计学意义（P均〈0．05）；第一次和第二次访视脐部护理正确情况比较，第二次访视脐部护理正确率较第一次高，差异有统计学意义（P〈0．01）。结论产后家庭访视医生的指导对产妇和新生儿的健康有促进作用。     

家庭随访对居家腹膜透析患者依从性的影响

目的研究家庭随访对居家腹膜透析患者遵医行为的影响。方法将80例持续性非卧床式腹膜透析患者分为干预组和对照组。干预组出院后每月通过家庭随访进行健康教育,内容包括:强调无菌操作的观念、坚持正确的导管出口处护理、操作前洗手戴口罩、保持清洁的透析环境、遵医嘱按时透析、严格控制水钠的摄入、腹膜透析管的护理、适当活动、加强营养、按时复诊的重要性。对照组每1～2个月来医院复诊。两年后观察两组患者的自我管理能力。结果干预组患者的遵医行为高于对照组(P<0.05),腹膜透析并发症低于对照组。结论家庭随访可提高患者的遵医行为,增强患者的自我管理能力。