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1.
Trevor Lambert Fay Smith Michael Goldacre 《The British journal of general practice》2013,63(616):e726-e733
Background
In the UK many practising GPs did not choose general practice as their first choice of career when they originally graduated as doctors.Aim
To compare job satisfaction of GPs who chose general practice early or later in their career.Design and setting
Questionnaires were sent to all UK-trained doctors who graduated in selected years between 1993 and 2000.Method
Questionnaires were sent to the doctors 1, 3, 7 and 10 years after graduation.Results
Of all 3082 responders working in general practice in years 7 and 10, 38% had first specified general practice as their preferred career when responding 1 year after graduation, 19% by year 3, 21% by year 5, and 22% after year 5. Job satisfaction was high and, generally, there was little difference between the first three groups (although, when different, the most positive responses were from the earliest choosers); but there were slightly lower levels of job satisfaction in the ‘more than 5 years’ group. For example, in response to the statement ‘I find enjoyment in my current post’, the percentages agreeing in the four groups, respectively, were 91.5%, 91.1%, 91.0% and 88.2%. In response to ‘I am doing interesting and challenging work’ the respective percentages were 90.2%, 88.0%, 86.6% and 82.6%.Conclusions
Job satisfaction levels were generally high among the late choosers as well as the early choosers. On this evidence, most doctors who turn to general practice, after preferring another specialty in their early career, are likely to have a satisfying career. 相似文献2.
Watson J Humphrey A Peters-Klimm F Hamilton W 《The British journal of general practice》2011,61(591):e645-e649
Background
Recruitment to general practice has had periods of difficulty, but is currently going through a phase of relative popularity in the UK.Aim
To explore motivators for career choice and career satisfaction among UK GP trainees and newly qualified GPs.Design and setting
Cross-sectional web-based questionnaire of GP trainees and GPs within the first 5 years of qualification in the UK.Method
All 9557 UK GP trainees and 8013 GPs who were within the first 5 years of qualification were invited to participate by email. Further publicity was conducted via general practice publications and the internet.Results
Overall, there were 2178 responses to the questionnaire (12.4% response rate, 61.5% women, 61.8% trainees). Levels of satisfaction were high, with 83% of responders stating that they would choose to be a doctor again; of these, 95% would choose to be a GP again. The most frequently cited reason for choosing general practice was ‘compatibility with family life’, which was chosen by 76.6% of women and 63.2% of men (P<0.001). Other reasons given were: ‘challenging medically diverse discipline’ (women 59.8%, men 61.8%, P = 0.350), ‘the one-to-one care general practice offers’ (women 40.0%, men 41.2%, P = 0.570), ‘holistic approach’ (women 41.4%, men 30.1%, P<0.001), ‘autonomy and independence’ (women 18.0%, men 34.8%, P<0.001), ‘communication’ (women 20.6%, men 12.2%, P<0.001), ‘negative experiences in hospital’ (women 12.8%, men 9.8%, P= 0.036), and ‘good salary’ (women 7.8%, men 14.9%, P<0.001).Conclusion
The most important reason for both women and men choosing general practice as a career in the UK is its compatibility with family life. As such, changes to UK primary care that decrease family compatibility could negatively impact on recruitment. 相似文献3.
Fiona Fox Michael Harris Gordon Taylor Karen Rodham Jane Sutton Brian Robinson Jenny Scott 《The British journal of general practice》2009,59(568):811-818
Background
Current evidence about the experiences of doctors who are unwell is limited to poor quality data.Aim
To investigate GPs'' experiences of significant illness, and how this affects their own subsequent practice.Design of study
Qualitative study using interpretative phenomenological analysis to conduct and analyse semi-structured interviews with GPs who have experienced significant illness.Setting
Two primary care trusts in the West of England.Method
A total of 17 GPs were recruited to take part in semi-structured interviews which were conducted and analysed using interpretative phenomenological analysisResults
Four main categories emerged from the data. The category, ‘Who cares when doctors are ill?’ embodies the tension between perceptions of medicine as a ‘caring profession’ and as a ‘system’. ‘Being a doctor–patient’ covers the role ambiguity experienced by doctors who experience significant illness. The category ‘Treating doctor–patients’ reveals the fragility of negotiating shared medical care. ‘Impact on practice’ highlights ways in which personal illness can inform GPs'' understanding of being a patient and their own consultation style.Conclusion
Challenging the culture of immunity to illness among GPs may require interventions at both individual and organisational levels. Training and development of doctors should include opportunities to consider personal health issues as well as how to cope with role ambiguity when being a patient and when treating doctor–patients. Guidelines about being and treating doctor–patients need to be developed, and GPs need easy access to an occupational health service. 相似文献4.
Mark Ashworth Peter Schofield Stevo Durbaba Sanjiv Ahluwalia 《The British journal of general practice》2014,64(620):e168-e177
Background
Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care.Aim
The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care.Design and setting
Retrospective cross-sectional study in general practices in England.Method
Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. Outcome measures: multilevel regression models adjusted for clustering.Results
GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the ‘doctor care’ (n = 6) and ‘overall satisfaction’ (n = 2) domains but not to any of the ‘nurse care’ or ‘out-of-hours’ domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients.Conclusion
Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as ‘listening’ or ‘care and concern’. 相似文献5.
Background
The percentage of newly qualified doctors in the UK who want a career in general practice declined substantially in the 1990s. The English Department of Health expects that half of all doctors will become GPs.Aim
To report on choices for general practice made by doctors who qualified in 2000, 2002, 2005, 2008, and 2009.Design and setting
A structured, closed questionnaire about future career intentions, sent to all UK medical graduates.Method
Questionnaires sent 1 year after qualification (all cohorts) and 3 years after (all except 2008 and 2009).Results
Percentages of doctors who expressed an unreserved first choice for general practice in the first year after qualification, in the successive five cohorts, were 22.2%, 20.2%, 23.2%, 21.3%, and 20.4%. Percentages who expressed any choice for general practice — whether first, second or third — were 46.5%, 43.4%, 52.6%, 49.5%, and 49.9%. Three years after qualification, an unreserved first choice was expressed, in successive cohorts, by 27.9%, 26.1%, and 35.1%. Doctors from newly established English medical schools showed the highest levels of choice for general practice.Conclusion
The percentage of doctors, in their first post-qualification year, whose first choice of eventual career was general practice has not changed much in recent years. By year 3 after qualification, this preference has increased in recent years. At years 1 and 3, the overall first choice for general practice is considerably lower than the required 50%, but varies substantially by medical school. In depth studies of why this is so are needed. 相似文献6.
7.
Jonathan Hammond Katja Gravenhorst Emma Funnell Susan Beatty Derek Hibbert Jonathan Lamb Heather Burroughs Marija Kovand?i? Mark Gabbay Christopher Dowrick Linda Gask Waquas Waheed Carolyn A Chew-Graham 《The British journal of general practice》2013,63(608):e177-e184
Background
General practice receptionists fulfil an essential role in UK primary care, shaping patient access to health professionals. They are often portrayed as powerful ‘gatekeepers’. Existing literature and management initiatives advocate more training to improve their performance and, consequently, the patient experience.Aim
To explore the complexity of the role of general practice receptionists by considering the wider practice context in which they work.Design and setting
Ethnographic observation in seven urban general practices in the north-west of England.Method
Seven researchers conducted 200 hours of ethnographic observation, predominantly in the reception areas of each practice. Forty-five receptionists were involved in the study and were asked about their work as they carried out their activities. Observational notes were taken. Analysis involved ascribing codes to incidents considered relevant to the role and organising these into related clusters.Results
Receptionists were faced with the difficult task of prioritising patients, despite having little time, information, and training. They felt responsible for protecting those patients who were most vulnerable, however this was sometimes made difficult by protocols set by the GPs and by patients trying to ‘play’ the system.Conclusion
Framing the receptionist–patient encounter as one between the ‘powerful’ and the ‘vulnerable’ gets in the way of fully understanding the complex tasks receptionists perform and the contradictions that are inherent in their role. Calls for more training, without reflective attention to practice dynamics, risk failing to address systemic problems, portraying them instead as individual failings. 相似文献8.
Sharon Spooner 《The British journal of general practice》2016,66(643):e136-e142
Background
There is clear evidence that general practice has become a less popular career choice and among GPs there are high levels of dissatisfaction and demotivation. Little empirical evidence has emerged to indicate which factors contribute intrinsic value to the working lives of GPs and sustain their ongoing commitment.Aim
To understand which aspects of work continue to motivate and engage senior GPs by exploring their narrative accounts.Design and setting
This was part of a qualitative study in which senior GPs and hospital specialists contributed narratives in which they reflected on their working lives.Method
Individual, open interviews were conducted with eight GPs who had graduated in the early 1980s. Thematic analysis and situational analysis mapping were used to identify and connect related themes.Results
During interviews in which doctors drew on a wide range of encounters and experiences, they revealed which aspects of work were associated with greater intrinsic rewards and contributed to their continuing motivation. Having chosen careers that suited their preferred settings and working practices, they recounted adjustments made in response to new challenges and confirmed experiencing greater enjoyment when performing roles affirming their sense of providing valued health care.Conclusion
This study’s findings offer an alternative angle from which to consider the current unpopularity of general practice careers. The article proposes that long-term engagement of practitioners may be achieved through provision of adequate supportive resources to allow them to enact a sense of medical identity that matches with their acquired expectations of their role in the NHS. 相似文献9.
Jette M?ller Ahrensberg Rikke Pilegaard Hansen Frede Olesen Henrik Schr?der Peter Vedsted 《The British journal of general practice》2012,62(600):e458-e465
Background
Knowledge of how children with cancer present in general practice is sparse. Timely referral from general practice is important to ensure early diagnosis.Aim
To investigate the presenting symptoms and GPs’ interpretations of symptoms of children with cancer.Design and setting
A Danish nationwide population-based study including children (<15 years) with an incident cancer diagnosis (January 2007 to December 2010).Method
A questionnaire on symptoms and their interpretation was mailed to GPs (n?=?363). Symptoms were classified according to the International Classification of Primary Care (ICPC)-2 classification.Results
GPs’ response rate was 87% (315/363) and GPs were involved in the diagnostic process of 253 (80.3%) children. Symptoms were few (2.4 per child) and most fell into the category ‘general and unspecified’ (71.9%), apart from patients with tumours of the central nervous system (CNS), whose symptoms fell mostly in the category ‘neurological’ (for example, headache). Symptoms like pain, swelling/lump, or fatigue were reported in 25% of the patients and they were the most commonly reported symptoms. GPs interpreted children’s symptoms as alarm symptoms in 20.2%, as serious (that is, not alarm) symptoms in 52.9%, and as vague symptoms in 26.9%. GPs’ interpretation varied significantly by diagnosis (P<0.001).Conclusion
Children with cancer presented with few symptoms in general practice, of which most were ‘general and unspecified’ symptoms. Only 20% presented alarm symptoms, while 27% presented vague and non-specific symptoms. This low level of alarm symptoms may influence the time from symptom presentation in general practice to final diagnosis. 相似文献10.
Stefan B?sner Simone Hartel Judith Diederich Erika Baum 《The British journal of general practice》2014,64(626):e532-e537
Background
Headache is one of the most common symptoms in primary care. Most headaches are due to primary headaches and many headache sufferers do not receive a specific diagnosis. There is still a gap in research on how GPs diagnose and treat patients with headache.Aim
To identify GPs’ diagnostic approaches in patients presenting with headache.Design and setting
Qualitative study with 15 GPs in urban and rural practices.Method
Interviews (20–40 minutes) were conducted using a semi-structured interview guideline. GPs described their individual diagnostic strategies by means of patients presenting with headache that they had prospectively identified during the previous 4 weeks. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters.Results
Regarding GPs’ general diagnostic approach to patients with headache, four broad themes emerged during the interviews: ‘knowing the patient and their background’, ‘first impression during consultation’, ‘intuition and personal experience’ and ‘application of the test of time’. Four further themes were identified regarding the management of diagnostic uncertainty: ‘identification of red flags’, ‘use of the familiarity heuristic’, ‘therapeutic trial’, and ‘triggers for patient referral’.Conclusion
GPs apply different strategies in the early diagnostic phase when managing patients with headache. Identification of potential adverse outcomes accompanied by other strategies for handling uncertainty seem to be more important than an exact diagnosis. Established guidelines do not play a role in the diagnostic workup. 相似文献11.
Jenny C Ingram Michael W Calnan Rosemary J Greenwood Terry Kemple Sarah Payne Michael Rossdale 《The British journal of general practice》2009,59(558):e16-e24
Background
Emergency admissions to hospital at night and weekends are distressing for patients and disruptive for hospitals. Many of these admissions result from referrals from GP out-of-hours (OOH) providers.Aim
To compare rates of referral to hospital for doctors working OOH before and after the new general medical services contract was introduced in Bristol in 2005; to explore the attitudes of GPs to referral to hospital OOH; and to develop an understanding of the factors that influence GPs when they refer patients to hospital.Design of study
Cross-sectional comparison of admission rates; postal survey.Setting
Three OOH providers in south-west England.Method
Referral rates were compared for 234 GPs working OOH, and questionnaires explored their attitudes to risk.Results
There was no change in referral rates after the change in contract or in the greater than fourfold variation between those with the lowest and highest referral rates found previously. Female GPs made fewer home visits and had a higher referral rate for patients seen at home. One-hundred and fifty GPs responded to the survey. Logistic regression of three combined survey risk items, sex, and place of visit showed that GPs with low ‘tolerance of risk’ scores were more likely to be high referrers to hospital (P<0.001).Conclusion
GPs'' threshold of risk is important for explaining variations in referral to hospital. 相似文献12.
Amy Waller Mariko Carey Danielle Mazza Serene Yoong Alice Grady Rob Sanson-Fisher 《The British journal of general practice》2015,65(634):e312-e318
Background
GPs are often a patient’s first point of contact with the health system. The increasing demands imposed on GPs may have an impact on the quality of care delivered. Patients are well placed to make judgements about aspects of care that need to be improved.Aim
To determine whether general practice patients perceive that the care they receive is ‘patient-centred’ across eight domains of care, and to determine the association between sociodemographic, GP and practice characteristics, detection of preventive health risks, and receipt of patient-centred care.Design and setting
Cross-sectional survey of patients attending Australian general practice clinics.Method
Patients completed a touchscreen survey in the waiting room to rate the care received from their GP across eight domains of patient-centred care. Patients also completed the Patient Health Questionnaire (PHQ-9) and self-reported health risk factors. GPs completed a checklist for each patient asking about the presence of health risk factors.Results
In total 1486 patients and 51 GPs participated. Overall, 83% of patients perceived that the care they received was patient-centred across all eight domains. Patients most frequently perceived the ‘access to health care when needed’ domain as requiring improvement (8.3%). Not having private health insurance and attending a practice located in a disadvantaged area were significantly associated with perceived need for improvements in care (P<0.05).Conclusion
Patients in general practice report that accessibility is an aspect of care that could be improved. Further investigation of how indicators of lower socioeconomic status interact with the provision of patient-centred care and health outcomes is required. 相似文献13.
G?ran Waller Katarina Hamberg Annika Forssén 《The British journal of general practice》2015,65(638):e624-e629
Background
In epidemiological research, self-rated health is an independent predictor of mortality, cardiovascular diseases, and other critical outcomes. It is recommended for clinical use, but research is lacking.Aim
To investigate what happens in consultations when the question ‘How would you assess your general health compared with others your own age?’ is posed.Design and setting
Authentic consultations with GPs at health centres in Sweden.Method
Thirty-three planned visits concerning diabetes, pain, or undiagnosed symptoms were voice-recorded. Dialogue regarding self-rated health was transcribed verbatim and analysed using a systematic text condensation method. Speaking time of patients and doctors was measured and the doctors’ assessment of the value of the question was documented in a short questionnaire.Results
Two overarching themes are used to describe patients’ responses to the question. First, there was an immediate reaction, often expressing strong emotions, setting the tone of the dialogue and influencing the continued conversation. This was followed by reflection regarding their functional ability, management of illnesses and risks, and/or situation in life. The GPs maintained an attitude of active listening. They sometimes reported a slight increase in consultation time or feeling disturbed by the question, but mostly judged it as valuable, shedding additional light on the patients’ situation and making it easier to discuss difficulties and resources. The patients’ speaking time increased noticeably during this part of the consultation.Conclusion
Asking patients to comparatively self-rate their health is an effective tool in general practice. 相似文献14.
Neil Perkins Anna Coleman Michael Wright Erica Gadsby Imelda McDermott Christina Petsoulas Kath Checkland 《The British journal of general practice》2014,64(628):e728-e734
Background
The 2012 Health and Social Care Act in England replaced primary care trusts with clinical commissioning groups (CCGs) as the main purchasing organisations. These new organisations are GP-led, and it was claimed that this increased clinical input would significantly improve commissioning practice.Aim
To explore some of the key assumptions underpinning CCGs, and to examine the claim that GPs bring ‘added value’ to commissioning.Design and setting
In-depth interviews with clinicians and managers across seven CCGs in England between April and September 2013.Method
A total of 40 clinicians and managers were interviewed. Interviews focused on the perceived ‘added value’ that GPs bring to commissioning.Results
Claims to GP ‘added value’ centred on their intimate knowledge of their patients. It was argued that this detailed and concrete knowledge improves service design and that a close working relationship between GPs and managers strengthens the ability of managers to negotiate. However, responders also expressed concerns about the large workload that they face and about the difficulty in engaging with the wider body of GPs.Conclusion
GPs have been involved in commissioning in many ways since fundholding in the 1990s, and claims such as these are not new. The key question is whether these new organisations better support and enable the effective use of this knowledge. Furthermore, emphasis on experiential knowledge brings with it concerns about representativeness and the extent to which other voices are heard. Finally, the implicit privileging of GPs’ personal knowledge ahead of systematic public health intelligence also requires exploration. 相似文献15.
Clare McDermott Richard Coppin Paul Little Geraldine Leydon 《The British journal of general practice》2012,62(601):e538-e545
Background
Decisions regarding the hospitalisation of nursing home residents may present a difficult dilemma for GPs. There are pressures to admit very frail patients with exacerbations of illness even though such frailty may limit the possible health gains. As ‘gatekeepers’ to NHS, GPs are expected to make best use of resources and may be criticised for ‘inappropriate’ admissions. Little is understood about the influences on GPs as they make such decisionsAim
To explore GPs views on factors influencing decisions on admitting frail nursing home residents to hospital.Design and setting
A purposive sample of 21 GPs from two counties in the South of England.Method
Data from semi-structured, one-to-one interviews with GPs were analysed using thematic analysis following principles of the constant comparative method.Results
This study suggests that while clinical assessment, perceived benefits and risks of admission, and patients’ and relatives’ preferences are key factors in determining admissions, other important factors influencing decision making include medico-legal concerns, communications, capability of nursing homes and GP workload. These factors were also perceived by GPs as influencing the feasibility of keeping patients in the nursing home when this was clinically appropriate. Key areas suggested by GPs to improve practice were improving communication (particularly informational continuity), training and support for nursing staff, and peer support for GPs. Local initiatives to address these issues were very variable.Conclusion
Developing a systematic palliative care approach to address poor documentation and communication, the capability of nursing homes, and medico-legal concerns has the potential to improve decision-making regarding hospital admissions. 相似文献16.
Jane Roberts Ann Crosland John Fulton 《The British journal of general practice》2014,64(622):e254-e261
Background
Psychological difficulties are common in adolescents yet are not often addressed by GPs. Anxiety and uncertainty about professional practice, with a reluctance to medicalise distress, have been found among GPs. GP involvement in this clinical area has been shown to be influenced by how GPs respond to the challenges of the clinical consultation, how they view young people and their perception of their health needs, and a GP’s knowledge framework.Aim
To explore the relationship between the above three influences to develop an overarching conceptual model.Design and setting
Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities.Method
Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis.Results
In total 19 GPs were recruited: 10 were female, the age range was 29–59 years, with a modal range of 40–49 years. Three levels of analysis were undertaken. This study presents the final stage of analysis. GP ‘enactment of role’ was found to be the key to explaining the relationship between the three influencing factors. Three role archetypes were supported by the data: ‘fixers’, ‘future planners’, and ‘collaborators’.Conclusion
The role of GPs in managing adolescent psychological difficulties is unclear. Policy advocates a direct role but this is unsupported by education and service delivery. GPs adopt their own position along a continuum, resulting in different educational needs. Better preparation for GPs is required with exploration of new, more collaborative models of care for troubled adolescents. 相似文献17.
Chris Shiels Mark Gabbay Jim Hillage 《The British journal of general practice》2014,64(620):e137-e143
Background
The ‘fit note’, with the opportunity for the GP to advise that a patient ‘may be fit’ to do some work, was introduced in April 2010.Aim
To estimate numbers of fit notes with ‘may be fit’ advice, the types of advice, and factors associated with any inclusion of such advice in the fit note.Design and setting
Cross-sectional analysis of fit note data from 68 general practices in eight regions of England, Wales and Scotland.Method
Collection of practice fit note data via GP use of carbonised pads of fit notes for a period of 12 months.Results
The ‘may be fit’ box was ticked on 5080 fit notes (6.4% of all fit notes in study). But there was a wide variation in completion rates across the 68 practices (from 1% to 15%). The most prevalent individual item of advice was to ‘amend duties’ of patient as a prerequisite for return to work (included in 42% of all notes containing any ‘may be fit’ advice). Advice was often incomplete or irrelevant, with some GPs failing to comply with official guidance. Inclusion of any ‘may be fit’ advice was independently associated with the patient being female, less socially deprived and having a physical health reason for receiving a fit note.Conclusion
Unlike other studies that have relied upon eliciting opinion, this study investigates how the fit note is being used in practice. Findings provide some evidence that the fit note is not yet being used to the optimum benefit of patients (and their employers). 相似文献18.
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Jill Phillips Constance Dimity Pond Nerida Elizabeth Paterson Cate Howell Allan Shell Nigel P Stocks Susan M Goode John E Marley 《The British journal of general practice》2012,62(601):e546-e553