What do general practitioners do differently when consulting with a medical student?

Objectives The practice of having medical students see patients in a general practice setting, in their own consulting rooms, prior to the GP preceptor joining the consultation does not increase general practitioner (GP) consultation time. How do GPs meet the needs of both patient and student without extending consultation time? This study sought to quantify and compare GP consultation activities with and without students. Methods This was a prospective cohort study of 523 videotaped consultations. Consultations were analysed in 15‐second intervals using a modified Davis observation code to define GP activity. Estimated marginal means were calculated using mixed model analysis accounting for confounding factors. Results In comparison with consulting alone, GPs precepting a student spent 37 seconds less time examining patients (P = 0.001), 41 seconds less on patient management, and 1 minute, 31 seconds less on clerical and other activities (P < 0.001). This created time for GPs to take a history from both the student and patient (39 seconds longer; P = 0.002) and to teach students (1 minute, 10 seconds; P < 0.001). Discussion General practitioner activity in the consultation changes significantly when precepting a student; GPs spend longer exploring the history in order to unpack the student’s clinical reasoning, verify the patient’s story and resynthesise the information. They spend less time on examination, management and clerical activities and presumably delegate or defer these activities. Conclusions This organising of clinical activities in order to meet the needs of both patient and student is likely to require different processing skills to solo consulting.     

Sustained benefits of a community dietetics intervention designed to improve oral nutritional supplement prescribing practices

Background: Healthcare professionals working in the community do not always prescribe oral nutritional supplements (ONS) according to best practice guidelines for the management of malnutrition. The present study aimed to determine the impact of a community dietetics intervention on ONS prescribing practices and expenditure 1 year later. Methods: The intervention involved general practitioners (GPs), practice nurses, nurses in local nursing homes and community nurses. It comprised an education programme together with the provision of a new community dietetics service. Changes in health care professionals’ nutrition care practices were determined by examining community dietetics records. ONS prescribing volume and expenditure on ONS were assessed using data from the Primary Care Reimbursement Service of the Irish Health Service Executive. Results: Seven out of 10 principal GPs participated in the nutrition education programme. One year later, screening for malnutrition risk was better, dietary advice was provided more often, referral to the community dietetics service improved and ONS were prescribed for a greater proportion of patients at ‘high risk’ of malnutrition than before (88% versus 37%; P < 0.001). There was a trend towards fewer patients being prescribed ONS (18% reduction; P = 0.074) and there was no significant change in expenditure on ONS by participating GPs (3% reduction; P = 0.499), despite a 28% increase nationally by GPs on ONS. Conclusions: The community dietetics intervention improved ONS prescribing practices by GPs and nurses, in accordance with best practice guidelines, without increasing expenditure on ONS during the year after intervention.     

Norwegian GPs' participation in multidisciplinary meetings: A register-based study from 2007

Background  

An increasing number of patients with chronic disorders and a more complex health service demand greater interdisciplinary collaboration in Primary Health Care. The aim of this study was therefore to identify factors related to general practitioners (GPs), their list populations and practice municipalities associated with a high rate of GP participation in multidisciplinary meetings (MDMs).     

Factors affecting general practice collaboration with voluntary and community sector organisations

Collaborative working between general practice (GP) and voluntary and community sector (VCS) organisations is increasingly championed as a means of primary care doing more with less and of addressing patients’ “wicked problems”. This paper aims to add to the knowledge base around collaborative practice between GPs and VCS organisations by examining the factors that aid or inhibit such collaboration. A case study design was used to examine the lived‐experience of GPs and VCS organisations working collaboratively. Four cases, each consisting of a GP and a VCS organisation with whom they work collaboratively, were identified. Interviews (n = 18) and a focus group (n = 1) were conducted with staff within each organisation. Transcribed data were analysed thematically. Whilet there are similarities across cases in their use of, for example, Health Trainers and social prescribing, the form and function of GP‐VCS collaborations were unique to their local context. The identified factors affecting GP‐VCS collaboration reflect those found in previous service evaluations and the broader literature on partnership working; shared understanding, time and resources, trust, strong leadership, operational systems and governance and the “negotiation” of professional boundaries. While the current political environment may represent an opportunity for collaborations to develop, there are issues yet to be resolved before collaboration—especially more holistic and integrated approaches—becomes systematically embedded into practice.     

Evaluating a primary care psychology service in Ireland: a survey of stakeholders and psychologists

Primary care psychology services (PCPS) represent an important resource in meeting the various health needs of our communities. This study evaluated the PCPS in a two‐county area within the Republic of Ireland. The objectives were to (i) examine the viewpoints of the service for both psychologists and stakeholders (healthcare professionals only) and (ii) examine the enactment of the stepped care model of service provision. Separate surveys were sent to primary care psychologists (n = 8), general practitioners (GPs; n = 69) and other stakeholders in the two counties. GPs and stakeholders were required to rate the current PCPS. The GP survey specifically examined referrals to the PCPS and service configuration, while the stakeholder survey also requested suggestions for future service provision. Psychologists were required to provide information regarding their workload, time spent on certain tasks and productivity ideas. Referral numbers, waiting lists and waiting times were also obtained. All 8 psychologists, 23 GPs (33% response rate) and 37 stakeholders (unknown response rate) responded. GPs and stakeholders reported access to the PCPS as a primary concern, with waiting times of up to 80 weeks in some areas. Service provision to children and adults was uneven between counties. A stepped care model of service provision was not observed. Access can be improved by further implementation of a stepped care service, developing a high‐throughput service for adults (based on a stepped care model), and employing a single waiting list for each county to ensure equal access.     

Current approaches to obesity management in UK Primary Care: the Counterweight Programme

Background/Aims Primary care is expected to develop strategies to manage obese patients as part of coronary heart disease and diabetes national service frameworks. Little is known about current management practices for obesity in this setting. The aim of this study is to examine current approaches to obesity management in UK primary care and to identify potential gaps in care. Method A total of 141 general practitioners (GPs) and 66 practice nurses (PNs) from 40 primary care practices participated in structured interviews to examine clinician self‐reported approaches to obesity management. Medical records were also reviewed for 100 randomly selected obese patients from each practice [body mass index (BMI) ≥30 kg m^?2, n = 4000] to review rates of diet counselling, dietetic or obesity centre referrals, and use of anti‐obesity medication. Computerized medical records for the total practice population (n = 206 341, 18–75 years) were searched to examine the proportion of patients with a weight/BMI ever recorded. Results Eighty‐three per cent of GPs and 97% of PNs reported that they would raise weight as an issue with obese patients (P < 0.01). Few GPs (15%) reported spending up to 10 min in a consultation discussing weight‐related issues, compared with PNs (76%; P < 0.001). Over 18 months, practice‐based diet counselling (20%), dietetic (4%) and obesity centre (1%) referrals, and any anti‐obesity medication (2%) were recorded. BMI was recorded for 64.2% of patients and apparent prevalence of obesity was less than expected. Conclusion Obesity is under‐recognized in primary care even in these 40 practices with an interest in weight management. Weight management appears to be based on brief opportunistic intervention undertaken mainly by PNs. While clinicians report the use of external sources of support, few patients are referred, with practice‐based counselling being the most common intervention.     

Management of bibliographic information by Dutch researchers in general practice

BACKGROUND: As a result of changes in information technology and the rapid growth of publications methods of searching the literature have changed. Systematic searching of the growing literature has become very important. It is not known whether researchers in general practice search systematically, and whether they have incorporated computerized sources in their research practice. OBJECTIVES AND METHODS: We aimed to assess the methods of literature research used by GPs. We interviewed eight GP researchers, two information specialists and a psychologist working in primary health care organizations. RESULTS: The GP researchers began their search in their private book collections, or asked colleagues for information. Later in the search process, they used computerized information sources. Medline on CD-ROM and the computer-based indexes of two Dutch journals were most widely used. The GPs found it difficult to locate the appropriate terms to describe their research questions. Knowledge of the methodology of literature research, and skills required to use the information sources efficiently were lacking. There was a need for instruction and training in the use of information sources. GPs need a telephone help desk where their questions can be answered adequately. CONCLUSIONS: GP researchers search the literature unsystematically. Although computerized databases were being used, knowledge and skills related to the use of these information sources must be improved.      

Acceptability of a shared cancer follow-up model of care between general practitioners and radiation oncologists: A qualitative evaluation

Introduction

Facilitators to implement shared cancer follow-up care into clinical practice include mechanisms to allow the oncologist to continue overseeing the care of their patient, two-way information sharing and clear follow-up protocols for general practitioners (GPs). This paper aimed to evaluate patients, GPs and radiation oncologists (ROs) acceptance of a shared care intervention.

Methods

Semi-structured interviews were conducted pre- and post intervention with patients that were 3 years post radiotherapy treatment for breast, colorectal or prostate cancer, their RO, and their GP. Inductive and deductive thematical analysis was employed.

Results

Thirty-two participants were interviewed (19 patients, 9 GPs, and 4 ROs). Pre intervention, there was support for GPs to play a greater role in cancer follow-up care, however, patients were concerned about the GPs cancer-specific skills. Patients, GPs and ROs were concerned about increasing the GPs workload. Post intervention, participants were satisfied that the GPs had specific skills and that the impact on GP workload was comparable to writing a referral. However, GPs expressed concern about remuneration. GPs and ROs felt the model provided patient choice and were suitable for low-risk, stable patients around 2–3 years post treatment. Patients emphasised that they trusted their RO to advise them on the most appropriate follow-up model suited to their individual situation. The overall acceptance of shared care depended on successful health technology to connect the GP and RO. There were no differences in patient acceptance between rural, regional, and cancer types. ROs presented differences in acceptance for the different cancer types, with breast cancer strongly supported.

Conclusion

Patients, GPs and ROs felt this shared cancer follow-up model of care was acceptable, but only if the RO remained directly involved and the health technology worked. There is a need to review funding and advocate for health technology advances to support integration.

Patient or Public Contribution

Patients treated with curative radiotherapy for breast, colorectal and prostate cancer, their RO and their GPs were actively involved in this study by giving their consent to be interviewed.     

PREDICTORS FOR HIDDEN PROBLEM DRINKERS IN GENERAL PRACTICE

In The Netherlands general practice attenders are not usuallyquestioned about their drinking habits. The objective of thisstudy was to determine to what extent easily available data(e.g. age, gender) can be used to identify categories of patientswho are at risk of problem drinking as a preliminary to moreintensive screening. Sixteen practices with a total populationof 32,000 patients were involved in the study. All problem drinkersknown by their GPs and a random sample of one in ten patientsnot thought to be problem drinkers were admitted to the studyat their first surgery visit during a 1-year period. A screeningquestionnaire was used to find hidden problem drinkers amongstthe individuals thought to be non-problem drinkers. The overallresponse rate was 91% (n=1405). Problem drinking was detectedin 6% (n=82) of the group regarded by the GPs as non-problemdrinkers (n=1283). Male gender, smoking, life events and chronicsocial problems were the strongest non-alcohol-related predictorsof hidden problem drinking. We conclude that a pre-selectionof patients with a greater risk of problem drinking can be madewithout information related directly to alcohol. Case-findingin this category is much more effective and probably much moreacceptable both to the GP and the patients, than the screeningof all patients.     

Primary prevention of cardio-metabolic diseases in general practice: A Dutch survey of attitudes and working methods of general practitioners

Abstract

Background: To study the attitudes and working methods of general practitioners (GPs) in primary prevention of cardiovascular diseases, diabetes mellitus and chronic kidney diseases. Methods: A questionnaire with questions about attitude and working methods in the primary prevention of cardiovascular diseases, diabetes mellitus and chronic kidney diseases in general practice was sent to a representative sample of 1,100 Dutch GPs. The questionnaire was developed in collaboration with experts in general practice, cardiovascular disease, diabetes and kidney disease. Results: A total of 330 GPs completed and returned the questionnaire (30% response). Only a quarter of the GP's actively invite patients for preventive measurements. Preventive measures are mainly performed by the GP when a patient asks for it or when patients visit a GP for other complaints. The main reasons for performing preventive tests were a positive family history, obesity and smoking. Most GPs consider detection of these diseases as worthwhile, but detection should particularly focus on the group of patients with the highest risk on these diseases.

Conclusion: GPs have a positive attitude towards primary prevention of cardiovascular diseases, diabetes mellitus and chronic kidney diseases, but primary prevention should be focused on patients at risk.     

Patient enablement after a consultation with a general practitioner—Explaining variation between countries,practices and patients

BackgroundPatient enablement is a concept developed to measure quality in primary health care. The comparative analysis of patient enablement in an international context is lacking.ObjectiveTo explain variation in patient enablement between patients, general practitioners (GPs) and countries. To find independent variables associated with enablement.DesignWe constructed multi‐level logistic regression models encompassing variables from patient, GP and country levels. The proportions of explained variances at each level and odds ratios for independent variables were calculated.Setting and ParticipantsA total of 7210 GPs and 58 930 patients in 31 countries were recruited through the Quality and Costs of Primary Care in Europe (QUALICOPC) study framework. In addition, data from the Primary Health Care Activity Monitor for Europe (PHAMEU) study and Hofstede''s national cultural dimensions were combined with QUALICOPC data.ResultsIn the final model, 50.6% of the country variance and 18.4% of the practice variance could be explained. Cultural dimensions explained a major part of the variation between countries. Several patient‐level and only a few practice‐level variables showed statistically significant associations with patient enablement. Structural elements of the relevant health‐care system showed no associations. From the 20 study hypotheses, eight were supported and four were partly supported.Discussion and ConclusionsThere are large differences in patient enablement between GPs and countries. Patient characteristics and patients’ perceptions of consultation seem to have the strongest associations with patient enablement. When comparing patient‐reported measures as an indicator of health‐care system performance, researchers should be aware of the influence of cultural elements.     

Introducing an electronic Palliative Care Summary (ePCS) in Scotland: patient, carer and professional perspectives

Background An electronic Palliative Care Summary (ePCS) is currently being implemented throughout Scotland to provide out-of-hours (OOH) staff with up-to-date summaries of medical history, patient understanding and wishes, medications and decisions regarding treatment of patients requiring palliative care: automatic twice daily updates of information from GP records to a central electronic repository are available to OOH services. Aims To identify key issues related to the introduction of ePCS from primary care and OOH staff, to identify facilitators and barriers to their use, to explore the experiences of patients and carers and to make recommendations for improvements. Methods Twenty-two semi-structured interviews were carried out with a purposive sample of health professionals [practice nurses (3 interviews), GPs (12 interviews), a practice manager (1 interview) from practices using different computing software systems] and patients and/or carers (6 interviews for whom an ePCS had been completed). Interviews were digitally recorded, transcribed and analysed thematically. Results Patients and carers were reassured that OOH staff were informed about their current circumstances. OOH staff considered the ePCS allowed them to be better informed in decision making and in carrying out home visits. GPs viewed the introduction of ePCSs to have benefits for in-hours structures of care including advance care planning. No interviewee expressed concern about confidentiality. Barriers raised related to the introduction of new technology including unfamiliarity with the process, limited time and information technology skills. Conclusions The ePCS has clear potential to improve patient care although several implementation issues and technical problems require to be addressed first to enable this. GPs and community nurses should identify more patients with malignant and non-malignant illnesses for completion of the ePCS.     

A cost study of a general practitioner hospital in the Netherlands

Objective: To perform a cost study of the first general practitioner (GP) hospital in the Netherlands.

Methods: We conducted a cost study in a GP hospital in the Netherlands. Data on healthcare utilisation from 218 patients were collected for a period of one year. The costs of admission to the GP hospital were compared with the expected costs of the alternative mode of care. In the GP hospital three types of bed categories were distinguished: GP beds (admission and discharge by GPs, n=131), rehabilitation beds (recovery from hospital surgery, n=62) and nursing home beds (hospital patients awaiting a vacancy in a nursing home, n=25). GPs were interviewed to indicate the best alternative form of healthcare for the GP bed patients in the absence of a GP hospital (dichotomised for this study into ‘hospital’ or ‘home care’). For the ‘rehabilitation’ and ‘nursing home’ patients the alternative care mode was admission to a hospital.

Results: The mean length of stay was 15 days for the GP beds, 31 days for the rehabilitation beds and 90 days for the nursing home beds. For the GP bed patients the costs were ?2533 per admission compared with ?3792 for hospital stay. For the group of GP bed patients for whom ‘home care’ was the best alternative, the costs were ?2494 for GP hospital days compared with ?2814, the average cost for home care of patients of 65 years and older. For rehabilitation patients the costs per patient were ?4744 compared with ?8041 in a hospital. For patients waiting for admission to a nursing home, these costs were ?13,143 and ?22,670, respectively.

Conclusion: The GP hospital might be a cost-saving alternative for elderly patients in need of intermediate medical and nursing care between hospital and home care. Further research on the cost-effectiveness of the GP hospital compared with home care and nursing home care is needed.     

The influence of perceived accessibility and expertise of healthcare professionals,and service austerity,on mothers' decision-making

Mothers often make key decisions regarding their children's health. They hold core beliefs and attitudes towards healthcare providers, relying on healthcare services to provide support, advice and reassurance. It is crucial that health providers form authentic relationships with families with young children, in order to effectively provide healthcare, support and information as needed. In this paper, we explore mothers' views on the accessibility and expertise of healthcare professionals caring for their child's health. A case study, using a geographic post code as the case boundary was used. Focus groups and semi-structured interviews with mothers of children aged under five years old were conducted. Participants (n = 33) were recruited from local playgroups and six focus groups (19 participants) and 14 individual interviews were conducted. Qualitative data were analysed using thematic analysis. General Practice (including general practitioners [GPs] and practice nurses) was considered to be the preferred option when seeking timely healthcare advice and information. Participant mothers were open to accessing professional advice concerning their child's health, from a range of health professionals and understood the role and potential contribution of various health professionals. However, some factors, influenced mothers' decision-making. These were captured in three themes: maternal perceptions of GPs as accessible experts; practice nurses as approachable and reassuring sources of advice; and difficulty in accessing health visiting services primarily due to service funding cuts. Further investment in primary care services, including expansion of the practice nurse role and an increase in health visiting service provision, may help to provide sufficient support for mothers seeking healthcare advice. In addition, healthcare service strategies, which engage with mothers and ensure nurses are recognised as knowledgeable, accessible, supportive and a suitable alternative to GPs, would be beneficial.     

'Justifiable depression': how primary care professionals and patients view late-life depression? A qualitative study

BACKGROUND: Depression is the commonest mental health problem in elderly people and continues to be underdiagnosed and undertreated. AIM: To explore the ways that primary care professionals and patients view the causes and management of late-life depression. DESIGN: A qualitative study using semistructured interviews. SETTING: One Primary Care Trust in North West England. PARTICIPANTS: Fifteen primary care practitioners comprising nine GPs, three practice nurses, two district nurses and one community nurse; twenty patients who were over the age of 60 and who were participating in a feasibility study of a new model of care for late-life depression [PRIDE Trial: PRimary care Intervention for Depression in the Elderly (a feasibility study in Central Manchester funded by the Department of Health)]. RESULTS: Primary care practitioners conceptualized late-life depression as a problem of their everyday work, rather than as an objective diagnostic category. They described depression as part of a spectrum including loneliness, lack of social network, reduction in function and viewed depression as 'understandable' and 'justifiable'. This view was shared by patients. Therapeutic nihilism, the feeling that nothing could be done for this group of patients, was a feature of all primary care professionals' interviews. Patients' views were characterized by passivity and limited expectations of treatment. Depression was not viewed as a legitimate illness to be taken to the GP. Primary care professionals recognized that managing late-life depression did fall within their remit, but identified limitations in their own skills and capabilities in this area, as well as a lack of other resources to which they could refer patients. CONCLUSION: This study highlights the complicated nature of the diagnosis and management of late-life depression. Protocols for the diagnosis and treatment of depression emphasis the biomedical model which does not fit with the everyday experience of GPs or elderly patients who share the views of primary care professionals that depression is a consequence of social and contextual issues. There is a need for the development of evidence-based provision for older people with depression within primary care, but also a need for elderly patients to be made aware of the legitimacy of presenting low mood and misery to their primary care professional.     

Dissemination of information to General Practitioners: a questionnaire survey

Background  

Early identification of permanent hearing impairment in children enables appropriate intervention which reduces adverse developmental outcomes. The UK Government has introduced a universal hearing screening programme for neonates. All involved health professionals, including those in Primary Care, need to be aware of the service to enable them to offer appropriate support to their patients. A programme of information dissemination within Primary Care was therefore undertaken. The aim of the current study was to determine the extent to which the information had reached General Practitioners (GPs), the GPs' preferred mode of dissemination and the sources from which GPs accessed information     

Development of the EMAP tool facilitating existential communication between general practitioners and cancer patients

Background: General practice recognizes the existential dimension as an integral part of multidimensional patient care alongside the physical, psychological and social dimensions. However, general practitioners (GPs) report substantial barriers related to communication with patients about existential concerns.

Objectives: To describe the development of the EMAP tool facilitating communication about existential problems and resources between GPs and patients with cancer.

Methods: A mixed-methods design was chosen comprising a literature search, focus group interviews with GPs and patients (n?=?55) and a two-round Delphi procedure initiated by an expert meeting with 14 experts from Denmark and Norway.

Results: The development procedure resulted in a semi-structured tool containing suggestions for 10 main questions and 13 sub-questions grouped into four themes covering the existential dimension. The tool utilized the acronym and mnemonic EMAP (existential communication in general practice) indicating the intention of the tool: to provide a map of possible existential problems and resources that the GP and the patient can discuss to find points of reorientation in the patient’s situation.

Conclusion: This study resulted in a question tool that can serve as inspiration and help GPs when communicating with cancer patients about existential problems and resources. This tool may qualify GPs’ assessment of existential distress, increase the patient’s existential well-being and help deepen the GP–patient relationship.     

Experiences of hospital-based multidisciplinary team meetings in oncology: An interview study among participating general practitioners

Background: Cancer care has become complex, requiring healthcare professionals to collaborate to provide high-quality care. Multidisciplinary oncological team (MDT) meetings in the hospital have been implemented to coordinate individual cancer patients’ care. General practitioners (GPs) are invited to join, but their participation is minimal.

Objectives: Aim of this study is to explore participating GPs’ perceptions of their current role and to understand their preferences towards effective role execution during MDT meetings.

Methods: In May to June 2014, semi-structured interviews (n?=?16) were conducted involving GPs with MDT experience in Belgium. The analysis was done according to qualitative content analysis principles.

Results: Attendance of an MDT meeting is perceived as part of the GP’s work, especially for complex patient care situations. Interprofessional collaborative relationships and the GP’s perceived benefit to the MDT meeting discussions are important motivators to participate. Enhanced continuity of information flow and optimized organizational time management were practical aspects triggering the GP’s intention to participate. GPs valued the communication with the patient before and after the meeting as an integral part of the MDT dynamics.

Conclusion: GPs perceive attendance of the MDT meeting as an integral part of their job. Suggestions are made to enhance the efficiency of the meetings.     

The value of case studies

Background: Studies describing GP consultation have identified duration of consultation as an important marker of patient satisfaction. Duration of consultation differs between countries. Objective: The aim of this study was to measure the duration of consultations and the different segments of the consultation in a representative sample of GPs in the Nantes district (France).

Material and methods: 150 GPs in the Nantes district were randomly selected from the telephone directory. A letter of explanation was sent, followed up by a telephone call asking the GPs to receive an observer into their surgery. The observer timed consultations and the different segments of the consultation. Results: 30 out of 150 GPs contacted agreed to participate. 329 consultations were observed. Average duration of consultation was 14 min and 24 s; it was 15 min in non-computerised practices and 12 min and 50 s in computerised practices. Consultations for psychological problems or with many reasons for consulting took longer. Doctors usually talked more than patients, except during long consultations. Patients were not examined in only 2% of consultations. Trainers in general practice had longer consultations. Discussion: Many GPs refused to receive the observer; the ratio of trainers within the group of respondents (40%) was higher than in the general GP population (7–10%). As in other studies, female GPs were overre-presented as active participants. In our sample, the average duration of consultation was longer than in other studies. The finding regarding the duration of consultation in computerised practices may need validation in other studies. EurJ Gen Pract 2000;6:88–92.