Why do general practitioners prescribe antibiotics for acute infective conjunctivitis in children? Qualitative interviews with GPs and a questionnaire survey of parents and teachers

BACKGROUND: Acute infective conjunctivitis in children is a common presentation in primary care. Treatment is usually with antibiotics and prescribing may be affected by non-clinical factors. AIMS: To investigate the non-clinical determinants of the management of acute infective conjunctivitis in children. DESIGN: Qualitative interviews with GPs and a questionnaire survey of parents of children with acute infective conjunctivitis and teachers. SETTING: GPs in Sheffield and Berkshire and parents of children with acute infective conjunctivitis and schools in Oxfordshire. METHODS: Semi-structured telephone interviews of 39 GPs. Questionnaire survey of 326 parents of children enrolled into a trial of acute infective conjunctivitis treatment. Questionnaire survey of 223 nurseries and primary schools in Oxfordshire. RESULTS: All three groups agreed that acute infective conjunctivitis was a mild condition. Parents were certain about the benefits of antibiotic treatment and sought early consultations with their GP in a desire to get their child back to school. GPs sometimes collude with a parent's request to prescribe to enable school attendance. Despite this 54.2% (95%CI 48.5-59.8%) children missed a mean of 1.85 days from school and 28.6% of parents (95%CI 23.5-33.7%) missed a mean of 1.5 days off work. CONCLUSION: Social factors, including the need for children to attend day care or school and parents to go to work, contribute to the decision to prescribe antibiotics for children with acute infective conjunctivitis. Understanding these issues and changing school policies in line with national guidance may reduce pressure on GPs to prescribe for this condition.     

Developing a new line of patter: can doctors change their consultations for sore throat?

BACKGROUND AND OBJECTIVES: Doctors report pressure from peers to reduce prescribing of antibiotics for minor respiratory illnesses, and from patients to do the opposite. It has been suggested that doctors adopt a more patient-centred consulting style in order to encourage patient satisfaction and shared decision-making. No evidence exists that such changes are achievable. We developed a new, on-site method for training postgraduates and used this for teaching patient-centred intervention. Here, we examine whether this training method is associated with changes in consulting patterns in consultations for sore throat with children, among doctors from a single group practice. METHODS: Audiotaped consultations (simulated and real) conducted before and after training were analysed and interviews were carried out with participants about the impact of training. SETTING: A general practice in South Wales. PARTICIPANTS: Four general practitioners who consulted with 25 real and simulated patients participated in the study. MAIN OUTCOME MEASURES: Four patient-centred skills used by doctors and 2 patient behaviours measured before and after training were identified. RESULTS: Three out of 4 practitioners produced clear evidence of changes in patient-centred consulting skills. These changes were evident in simulated and real consultations 2 and 4 weeks later, respectively. Prior to training the doctors produced only five examples of patient-centred skills in 10 consultations. After training they produced 39 examples in 15 consultations. CONCLUSIONS: Evidence from both consultations and interviews indicated that the intervention and training were well received and had been put into practice.     

Socially responsible antibiotic choices in primary care: a qualitative study of GPs' decisions to prescribe broad-spectrum and fluroquinolone antibiotics

BACKGROUND: There is considerable variation within and between countries in general medical practitioners' (GPs') prescribing of broad-spectrum antibiotics such as fluroquinolones, and resistance to these agents is increasing worldwide. Urgently promoting cautious fluroquinolone prescribing in primary care may limit increase in resistance. OBJECTIVE: We therefore interviewed 40 GPs in order to explore the reasons for their choice of prescribed antibiotic, in particular their decision to prescribe fluroquinolones. METHODS: We used a grounded theory approach to data collection and analysis, incorporating purposive and theoretical sampling, based on high and average fluroquinolone prescribing. Interviews were conducted with 26 GPs from practices known to be high prescribers of fluroquinolone antibiotics and 14 from average fluroquinolone prescribing practices. RESULTS: Chosing to prescribe a broad-spectrum antibiotic such as a fluroquinolone, rather than a narrow-spectrum antibiotic, related to a number of clinical considerations, perceptions of patient expectations and organizational influences. GPs from high fluroquinolone prescribing practices were more likely to prioritize patients' immediate needs, whereas GPs from average prescribing practices were more likely to consider longer term issues. GPs from both high and average fluroquinolone prescribing practices justified their antibiotic choices on the basis of a desire to do their best for their patients and society. CONCLUSION: Choosing to prescribe powerful, broad-spectrum antibiotics such as fluroquinolones, as well as choosing to keep these agents in reserve, was justified on the basis of social responsibility. Strategies to change fluroquinolone and broad-spectrum antibiotic prescribing will need to take into account clinicians' perceptions of social responsibility.     

Do consultations in rural general practice take more time when practitioners are precepting medical students?

CONTEXT: At Flinders University, Adelaide, a subset of students on the 4-year, graduate-entry medical course chooses to spend Year 3 based in rural general practice as part of the Parallel Rural Community Curriculum (PRCC). This programme is equivalent to the tertiary teaching hospital option in terms of student educational outcomes. However, there is concern that this success comes at the cost of lost consulting time for the general practitioners (GPs) who supervise these students. OBJECTIVE: This study aimed to quantify the impact of medical students on the consulting time of rural GP supervisors. METHODS: We carried out a prospective cohort study using analysis of videotape recordings. Study subjects were GPs supervising PRCC medical students and working from their own consulting rooms in the clinic setting. Main outcome measures were mean consultation times in sessions with and without medical students. RESULTS: Using mixed model analysis accounting for clustering of consultations within doctors, and controlling for confounding factors, the estimated marginal mean of regular consultation time was 13 minutes, 27 seconds, which was not significantly shorter than that of precepting consultations (12 minutes, 48 seconds) or parallel consultations (12 minutes, 24 seconds). CONCLUSIONS: Consultation length does not increase when rural GPs supervise medical students using a parallel consulting model.     

GPs' perspectives on managing time in consultations with patients suffering from depression: a qualitative study

BACKGROUND: Although there is widespread concern that general practice consultations are too short for doctors to provide a high quality of care for patients, the relationship between the length and outcome of these consultations remains unclear. Research to date has neglected the subjective experience of consultation time of both patients and GPs. OBJECTIVES: Our aim was to investigate GP perspectives on consultation time and the management of depression in general practice. METHOD: A qualitative interview-based study was carried out of 19 GPs from eight West Midlands general practices. RESULTS: The GPs in this study acknowledged the pressure of work and resource constraints in general practice. However, they did not feel these prevented them from providing good support and treatment for depression. They were confident in the effectiveness of antidepressants and their own skills in providing counselling support, and were able to utilize time flexibly in responding to patients' variable needs. Depression was viewed as a relatively straightforward problem that usually could be managed within the resources available to general practice. CONCLUSION: The doctors generally did not experience time to be a limiting factor in providing care for patients with depression. This is in contrast to the more acute sense of time pressure commonly reported by patients which they felt undermined their capacity to benefit from the consultation. GPs need to be more aware of patient anxieties about time, and to devise effective means of raising patients' sense of time entitlement in general practice consultations.     

Antibiotic use in upper respiratory tract infections in New Zealand

Upper respiratory tract infections (URTIs) are a common reasonfor presentation to general practitioners. The current studyused computerised consultation records of 100 222 patients from17 general practices in New Zealand for the 12-month period1 July 1991–30 June 1992. URTIs were noted in 8.9% ofall consultations: 44.1% of cases were children aged less than10 years. Females presented more frequently than males for allages above five years. Fifteen different antibiotics were prescribedfor URTIs, but in 22.5% of cases no antibiotic was prescribed.There was no statistically significant difference in the likelihoodof a successful outcome with or without antibiotic therapy (²= 0.76, P > 0.05). The treatment failure profile of someantibiotics highlights the need for more prescriber education,especially as the range of medications available for generalpractitioner prescribing increases.     

Primary care reform: a pilot study to test the evaluative potential of the Patient Enablement Instrument in Poland

BACKGROUND: Primary health care reform is underpinned by a move towards patient-centred holistic care. This pilot study uses the Patient Enablement Instrument (PEI) to assess outcome at a fundamental level: that of the patient and their doctor at consultation. OBJECTIVES: Our aim was to assess the evaluative potential of the PEI in relation to a reform programme in Poland by (i) comparing the outcomes of consultations (using the PEI) carried out by nine doctors (three diploma GPs who had participated in the training programme, three GPs who had not participated in the training programme and three polyclinic internists); and (ii) relating PEI scores to a proxy quality process measure (consultation length). METHODS: A cross-sectional quantitative questionnaire survey was carried out using the PEI. The subjects were patients consulting with nine doctors distributed within a single region around Gdansk. RESULTS: The overall results with the PEI and consultation length reflected UK experience. In addition, there were significant differences between groups in this pilot study. Patients seen by diploma GPs achieved higher patient enablement scores (mean 4.33, 95% confidence interval 4.09-4.58) relative to GPs (mean 3.44, 3.21-3.67) and polyclinic doctors (mean 3.23, 2.99-3.47). However, there is evidence of appreciable between-doctor variation in PEI scores within groups. The difference in patient enablement between groups was not affected by patient case mix, in contrast to the duration of consultation, which was. Holistically trained diploma GPs spent longer with patients with psychological problems. Patients seen by diploma GPs received longer consultations (mean 12.65 min, 95% confidence interval 12.18-13.13) relative to their colleagues (the GPs' mean was 10.11, 9.82-10.41 min; that of the polyclinic internists was 10.16, 9.81-10.50 min). The duration of consultation was positively correlated with patient enablement. CONCLUSION: The results of such training courses should be examined from the perspective of both the patient and their doctor. Significant differences were found in both patient enablement and consultation length between patients attending groups of doctors delivering primary care, but working from different paradigms. This pilot shows promising results which, if repeated in a larger study, would provide an objective means of evaluating such reform programmes.     

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.     

Using simulated patients to develop doctors' skills in facilitating behaviour change: addressing childhood obesity

Medical Education 2010: 44 : 706–715 Objectives This study aimed to describe the application, feasibility and outcomes of using simulated patients (SPs) to increase the skills of general practitioners (GPs) delivering a behavioural intervention to reduce childhood overweight and mild obesity. Methods Five female actors were trained as SPs. A total of 67 GPs from 46 general practices in Melbourne, Victoria, Australia, conducted two simulated consultation visits regarding healthy lifestyle family behaviour change, during which they practised their skills and received formative feedback. The GPs and SPs rated GP performance immediately after each consultation. Subsequently, 139 parents of overweight or obese 5–9‐year‐old children rated GP performance during real‐life consultations. Other measures included child body mass index (BMI) Z‐scores (at baseline and at a 9‐month follow‐up) and GP‐reported levels of comfort and competence and the perceived value of SP visits. Results Simulated patient ratings, but not GP self‐ratings, of GP performance predicted both parent ratings of real‐life consultations (Spearman’s rho 0.39 for correlation with SP rating at Visit 1) and subsequent reductions in BMI Z‐scores between baseline and follow‐up (Visit 1, rho ? 0.45; Visit 2, rho ? 0.46). GP levels of comfort and competence were maintained during and after the SP visits. A total of 95% of GPs rated simulated consultations as useful, although only 18% said they would pay for them. Conclusions Simulated patient assessment may predict real patient feedback and clinical outcomes, helping to identify doctors who require further training in behaviour change techniques. Randomised controlled trials may establish whether SPs actually raise skills or improve outcomes.     

Meeting and treating cultural difference in primary care: a qualitative interview study

BACKGROUND: Primary care doctors see patients from diverse cultural backgrounds and communication plays an important role in diagnosis and treatment. Communication problems can arise when patient and doctor do not share the same cultural background. OBJECTIVE: The aim of this study was to examine how consultations with immigrant patients are understood by GPs and how GPs manage these consultations. METHODS: Semi-structured interviews with GPs about their experiences with immigrant patients were recorded on audio-tape, transcribed and analysed using a qualitative thematic analysis methodology. A constructivist approach was taken to analysis and interpretation. RESULTS: Culture is not in focus when GPs meet immigrant patients. The consultation is seen as a meeting between individuals, where cultural difference is just one of many individual factors that influence how well doctor and patient understand each other. However, when mutual understanding is poor and the consultation not successful, cultural differences are central. The GPs try to conduct their consultations with immigrant patients in the same way that they conduct all their consultations. There is no specific focus on culture, instead, GPs tend to avoid addressing even pronounced cultural differences. CONCLUSION: This study indicates that cultural difference is not treated in GPs consultation with immigrant patients. Learning about cultural difference's effect on mutual understanding between doctor and patient could improve GPs cross-cultural communication. Increased awareness of the culture the doctor brings to the consultation could facilitate management of cross-cultural consultations.