How do general practitioners use ‘safety netting’ in acutely ill children?

Background: ‘Safety netting’ advice allows general practitioners (GPs) to cope with diagnostic uncertainty in primary care. It informs patients on ‘red flag’ features and when and how to seek further help. There is, however, insufficient evidence to support useful choices regarding ‘safety netting’ procedures.

Objectives: To explore how GPs apply ‘safety netting’ in acutely ill children in Flanders.

Methods: We designed a qualitative study consisting of semi-structured interviews with 37 GPs across Flanders. Two researchers performed qualitative analysis based on grounded theory components.

Results: Although unfamiliar with the term, GPs perform ‘safety netting’ in every acutely ill child, guided by their intuition without the use of specific guidelines. They communicate ‘red flag’ features, expected time course of illness and how and when to re-consult and try to tailor their advice to the context, patient and specific illness. Overall, GPs perceive ‘safety netting’ as an important element of the consultation, acknowledging personal and parental limitations, such as parents’ interpretation of their advice. GPs do not feel a need for any form of support in the near future.

Conclusion: GPs apply ‘safety netting’ intuitively and tailor the content. Further research should focus on the impact of ‘safety netting’ on morbidity and how the advice is conveyed to parents.     

How do general practitioners respond to reports of abnormal chest X-rays?

General practitioners (GPs) in the UK have long had direct access to hospital radiological services, which in theory shortens investigation time and improves the quality of service. Chest X-rays (CXRs) account for a substantial proportion of requests, and we investigated what happened when an abnormality was detected. In one year, 204 GPs in the Nottingham area requested CXRs in 605 patients. 362 were reported normal, 165 abnormal but hospital follow-up not indicated and 71 abnormal with radiological follow-up or hospital referral indicated (mass lesion suspicious of tumours 27, infective shadowing 35, other 9). 64 of the 71 were seen in hospital within three months, and in those with suspected cancer the median time to follow-up was 20 days. These results show that GPs do act on the results of abnormal CXRs, but only 37% of those with a mass suspicious of cancer were seen in hospital within two weeks as recommended by the British Thoracic Society. Time might be saved if GPs agreed to direct referral from the radiology department to respiratory physicians.     

How do general practitioners assess the criteria for due care for euthanasia in concrete cases?

OBJECTIVE: In the Netherlands the law states that physicians are allowed to grant a request for euthanasia or physician-assisted suicide (EAS) if specific criteria for due care are met. This study investigated which sources physicians use to determine whether three of these criteria (unbearable and hopeless suffering, and no realistic alternatives for treatment) are met. METHODS: The data were collected for the project Support and Consultation on Euthanasia in the Netherlands. General practitioners (GPs) received a written questionnaire concerning the most recent request for EAS that they had received. Of the 3614 (60%) GPs who returned the questionnaire, 1681 described the most recent request for EAS. RESULTS: The study shows that physicians used different types of sources, and more than one source, to determine whether the criteria were met. More sources were used when the criteria were met or when a request resulted in EAS. The determination of every criterion required a different approach, but for all criteria discussions with colleagues were important. CONCLUSIONS: Using less sources when a criterion is not met could possibly lead to less extensive consideration of the criteria, and therefore to assessing too easily that the request does not meet the criteria for due care.     

How do general practitioners recognize the definition of multimorbidity? A European qualitative study

Background: Multimorbidity is a challenging concept for general practice. An EGPRN working group has published a comprehensive definition of the concept of multimorbidity. As multimorbidity could be a way to explore complexity in general practice, it was of importance to explore whether European general practitioners (GPs) recognize this concept and whether they would change it.

Objectives: To investigate whether European GPs recognize the EGPRN concept of multimorbidity and whether they would change it.

Methods: Focus group meetings and semi-structured interviews as data collection techniques with a purposive sample of practicing GPs from every country. Data collection continued until saturation was reached in every country. The analysis was undertaken using a grounded theory based method. In each national team, four independent researchers, working blind and pooling data, carried out the analysis. To ensure the internationalization of the data, an international team of 10 researchers pooled the axial and selective coding of all national teams to check the concept and highlight emerging themes.

Results: The maximal variation and saturation of the sample were reached in all countries with 211 selected GPs. The EGPRN definition was recognized in all countries. Two additional ideas emerged, the use of Wonca’s core competencies of general practice, and the dynamics of the doctor–patient relationship for detecting and managing multimorbidity and patient’s complexity.

Conclusion: European GPs recognized and enhanced the EGPRN concept of multimorbidity. These results open new perspectives regarding the management of complexity using the concept of multimorbidity in general practice.

Key Messages

• European general practitioners recognize the EGPRN enhanced, comprehensive concept of multimorbidity.

• They add the use of Wonca’s core competencies and the patient–doctor relationship dynamics for detecting and managing multimorbidity.

• The EGPRN concept of multimorbidity leads to new perspectives for the management of complexity.

     

Elder abuse: do general practitioners know or care?

A pilot survey in Tower Hamlets, London, indicated that many general practitioners (GPs) might not be recognizing abuse of elderly patients through lack of training. The survey was replicated on a large scale in Birmingham, to allow further analysis. 561 Birmingham GPs were mailed questionnaires and responses from 291 were analysed, providing data from 95% of the practices. The findings were similar to those in Tower Hamlets: just under half had diagnosed elder abuse in the previous year. Regression analysis of the combined data-sets (n = 363) indicated that the strongest factor predicting GP diagnosis of abuse was knowledge of 5 or more risk situations (odds ratio 6.77, 95% confidence interval 4.19, 10.93). The findings of these surveys suggest that research-based education and training would help GPs to become better at identifying and managing elder abuse.     

How willing are general practitioners to manage narcotic misuse?

In 1989 a self-administered questionnaire concerning current management of, attitudes to, and knowledge of, narcotic misuse was completed by 206 Inner London general practitioners. Results showed that whilst over three quarters were prepared to offer patients supportive interviews, few were willing to prescribe for them, most preferring to refer to specialist facilities. Only 33 respondents had received adequate training in the management of narcotic misuse, but over a quarter expressed an interest in small group training to improve their skills. These findings are discussed in relation to Department of Health guidelines concerning the management of narcotic misuse.     

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.     

How should general practitioners investigate suspected urinary tract infection? Variations in laboratory-confirmed bacteriuria in South West England

We analysed by age and sex the inter-laboratory variation in submission rates and positivity rates of urine samples from primary care that were submitted to seven microbiology laboratories within the South West of England. There was an almost twofold difference between the lowest and highest submission and positivity rates across all sex and age groups. This could not be accounted for by differences in population, age mix or numbers of nursing home beds. Increased submission in children will increase diagnosis of urinary tract infection (UTI). In contrast, over-investigation in other age groups increases laboratory and primary care costs and, in the asymptomatic elderly, may lead to unnecessary antibiotic treatment. Continued education is needed in primary care to improve the management of urinary symptoms. Laboratory-based studies of UTI are likely to underestimate the true incidence of this infection substantially. Standardised protocols for urine specimen submission are essential for practices and laboratories participating in surveillance of UTI and antibiotic resistance. In our discussion we offer seven recommendations for improving UTI investigation in general practice.