Work-related disease in general practice: a systematic review

OBJECTIVES: The objective was to answer the following questions: What is the prevalence of potentially work-related diseases in the general practice population? What is the incidence of consulting a GP for a potentially work-related disease? What is the relationship between diseases seen in general practice and work ability? METHODS: Cochrane standards and QUOROM principals were used. For this systematic review the available literature was identified in a computerized search of the bibliographical databases Medline, Embase and Osh-rom. A total of 22 publications (24 studies) met the inclusion criteria. RESULTS: In the general practice population high prevalence rates of potentially work-related diseases were found for low back pain, neck pain and shoulder pain. Incidence rates of consulting a GP for a potentially work-related disease were high also. Musculoskeletal disorders were the main reasons for work-related consultations in general practice. Work-related diseases can affect work ability. CONCLUSIONS: Work-related diseases are common, given the high incidence and prevalence of potentially work-related diseases found in the general practice population and seen by the GP. This review underlines the important role of GPs in identifying and managing work-related diseases. GPs should consider the work factor and pay special attention to the effects of work on health, because patients often link their work with their illness.     

Qualitative research interviewing by general practitioners. A personal view of the opportunities and pitfalls

OBJECTIVE: This study looked look at the role of the GP as a qualitative research interviewer and aimed to illustrate areas of methodological difficulty using personal observations made during a qualitative study in general practice. METHODS AND RESULTS: The recently published literature on qualitative research in general practice was reviewed by the author to inform her own qualitative study looking at how women decide how to feed their babies. Some women in the study were patients of the author; some knew that she is a GP but were registered at another practice and some did not know that she is a doctor. In-depth and semi-structured interviews were tape recorded and transcribed. Observations about combining general practice and qualitative research were recorded by the author in a research diary. CONCLUSION: Qualitative research is being advocated as a methodology appropriate for general practice, yet there are many unanswered questions about methodological detail. There are no guidelines to help GPs to decide whether it is appropriate for them to do the interviewing, the practicalities of doing it, and whether they should use their own patients. There is clearly a need for more methodological research to look at how these decisions influence the data and to inform GPs who are considering a qualitative study.      

Are vocationally trained general practitioners better GPs? A review of research designs and outcomes

Implicit and explicit in reviews of and changes to vocational education for general practitioners in the 1990s is the challenge to defend the assumption that vocationally trained GPs are better GPs. This paper provides a review of the international literature which has reported on outcomes of general practice vocational training programmes. Through the review we identify both the types of research methodologies used (including a brief discussion of their strengths and limitations) and the outcomes reported of vocational training. Twenty-five studies on the outcomes of vocational training are reviewed. These studies used multiple data sources and one of four methodologies: pre- and post-training comparisons, analysis of learners' or teachers' accounts, audits of general practice or analysis of examination pass rates. When collated, the following range of outcomes from vocational training were identified: improved quality of patient care, increased knowledge, improved general practice skills, increased confidence and desirable GP attitudes and personality traits, increased adherence to practice guidelines and higher examination pass rates. The paper concludes with a summary of research and education issues which arise when we examine the question posed at the outset: are trained GPs better GPs?     

Which literature retrieval method is most effective for GPs?

BACKGROUND: Evidence-based medicine requires new skills of physicians, including literature searching. OBJECTIVE: To determine which literature retrieving method is most effective for GPs: the printed Index Medicus; Medline through Grateful Med; or Medline on CD-ROM. METHODS: The design was a randomized comparative study. In a continuing medical education course, three groups of health care professionals (87 GPs and 16 other health care professionals) used one of the literature retrieval methods to retrieve citations on four search topics related to general practice. For the analysis in pairs, we used the search results of the 75 participants who completed all four assignments. As outcome measures, we used precision, recall and an overall search quality score; we also had a post-course questionnaire on personal characteristics, experience with computers, handling medical literature and satisfaction with course instruction and search results. RESULTS: The recall and overall search quality scores in the Index Medicus groups (n = 32) were higher (P = <0.001) than those in the CD-ROM groups (n = 31). In addition, the search quality scores in the Grateful Med groups (n = 12) were higher (P < 0.003) than those in the CD-ROM groups. There were no differences in precision. CONCLUSION: In the period 1994-1997, the printed Index Medicus was the most effective literature retrieval method for GPs. For inexperienced GPs, there is a need for training in electronic literature retrieval methods.     

Mixed feelings: satisfaction and disillusionment among Australian GPs

BACKGROUND AND AIMS: Medical practitioners' satisfaction with their work impacts on quality of care for their patients and on their own sense of fulfillment. Reforms introduced in the early 1990s into Australian general practice have led to concerns over the morale of GPs. This study examines satisfaction and dissatisfaction of GPs with regard to the reform strategy. METHOD: GPs throughout Australia were approached via a popular GP magazine to express their views in a questionnaire comprising closed-end and open-ended questions enquiring about satisfaction with their current role and sources of satisfaction (and dissatisfaction) of working in general practice. Factor analysis was used to identify different sources of satisfaction (and dissatisfaction), which were intercorrelated and which together represented underlying factors. Logistic regression modelling was used to determine which sources were most strongly associated with being satisfied (or not satisfied), and to explore GP characteristics associated with satisfaction. RESULTS: A total of 2186 questionnaires were returned, representing the opinions of 14-18% of Australian GPs. Two-thirds (68%) of respondents reported being satisfied, most frequently with the variety of work and establishing relationships with patients and their families. Six satisfaction factors were identified on factor analysis, the most important characterizing social and interpersonal roles. Leading sources of dissatisfaction related to perceived interference by the government. Six dissatisfaction factors were identified on factor analysis, the most important characterizing governmental issues. However, on logistic regression other sources of dissatisfaction (reflecting disillusionment) were most strongly associated with not being satisfied. CONCLUSIONS: The main sources of satisfaction are those which typify the long-term caring role of the community GP. While the reform strategy aimed to address problems with the organization and financing of general practice, the resulting intervention is the focus of dissatisfaction. Among dissatisfied GPs these attitudes may arise primarily from a sense of disillusionment.      

Psychiatric training for family doctors: what do GP registrars want and can a brief course provide this?

CONTEXT: About 40% of British General Practitioners (GPs) train formally in a psychiatric post as part of their general practice training, but such training may not fully meet the needs of future GPs. A specific course in psychiatry for family doctors has run in Manchester for more than a decade. METHOD: Semi-structured interviews conducted with GP registrars before attending the Manchester course in psychiatry with questionnaire follow-up afterwards to ascertain (a) the training 'wants' of GP registrars and (b) whether the course was providing them. RESULTS: GP registrars most frequently wanted training in communication skills, how to access the resources that are available to GPs, the detection of psychiatric illness, drug treatment and the management of aggression. The course was successful in satisfying the first three but failed in the last two. There was trend for those who attended Manchester Medical School, which scored significantly higher on number of topics covered at undergraduate level, to perceive a greater need for training than those who attended other medical schools. However, there was no evidence to link self-perception of greater need with having already worked in general practice during postgraduate training. CONCLUSIONS: More attention needs to be paid to how to address the specific mental health skills training requirements of GP registrars both within the attachment in psychiatry and during the practice year. Preliminary research is required to devise teaching packages before they are entirely satisfactory for GP education.     

Computer technology and the nutrition support professional: make it work for you!

Healthcare professionals caring for patients receiving enteral and parenteral nutrition (PN) are faced with the need to develop and expand their technologic skills. Patients and their caregivers are finding information from the Internet that healthcare professionals are then tasked with evaluating for accuracy and veracity. Healthcare professionals themselves must be able to rapidly find information to answer clinical questions that arise during daily practice. Information-seeking skills must be well developed in order to find information from the Internet, as well as in the professional literature. Such skills include the ability to formulate a search strategy that limits extraneous results as much as possible yet ensures that relevant results are not missed. In addition, electronic health records are being implemented in many facilities now, with a national goal of an electronic health record in place by 2014. Clinicians must be involved with implementation at all stages, including planning, purchasing, implementing, and evaluating an electronic system. Electronic health records can include very sophisticated components that provide for computerized physician order entry (CPOE) and decision support. Nutrition support must be an integral part of these systems. This paper provides some background information on the Internet and the World Wide Web, along with strategies to find information using search engines. Information is also provided on the use of MEDLINE to search medical literature. Finally, a brief overview of the electronic health record is provided, with suggestions for involvement by nutrition support clinicians in implementation of electronic health records in the workplace.     

GPs working in solo practice: obstacles and motivations for working in a group? A qualitative study

OBJECTIVE: Our aim was to analyse the obstacles and eventual motivations of solo GPs for working in group practice. METHODS: A qualitative study using 12 focus groups was carried out in primary care in French-speaking Belgium. The subjects comprised four samples of GPs: 20 GP trainers, 18 GP trainees, 25 women GPs and 25 other GPs. The focus groups were taped and transcribed. Two independent researchers carried out the analysis using the QSR NUD.IST software. RESULTS: The participants (88 GPs) did not share a common definition of group practice-in particular multidisciplinary working-the need for a common pool of patients and shared premises. Their main sources of motivation for eventually setting up a group practice were better quality of life, continuity of care and sharing professional knowledge. The main obstacles were a required agreement between colleagues, the loss of a personal patient-GP relationship, budgetary constraints, and divergent views on group practice and GPs' profession (especially true for the association of GPs from different age groups). CONCLUSION: The current study shows that GPs working solo have divergent views of group practice. However, they clearly perceive advantages to this type of association (e.g. better quality of life and continuity of care). This study also confirms the high level of stress and tiredness felt by GPs and especially senior practitioners.     

Continuing professional development for general practitioners: supporting the development of professionalism

Medical Education 2010: 44 : 412–420 Objectives The profession of medicine has long been characterised by virtues such as authorisation, specialisation, autonomy, self‐regulation and adherence to an ethical code of practice, and its complexity has granted it the privilege of self‐regulation. Studies have shown continuing professional development (CPD) for general practitioners (GPs) to be most effective when it is set up within a multi‐method design. This paper reports a research‐based evaluation of a 2‐year educational CPD project for 21 GPs. Methods The project focused on the issue of ‘children in need’ and was delivered through group supervision, teaching days, an e‐portfolio, literature, newsletters and a desk checklist. A mixed‐methods evaluation design was used. Results The GPs demonstrated an overall preference for supervision as an authentic method for self‐directed professional development because it facilitated the creation of a common platform for relevant and useful knowledge in the context of general practice. Other methods were perceived as less valuable for GPs’ CPD. Conclusions The results suggest that general practitioners need to establish a common platform of shared experiences before engaging in multi‐professional CPD. Participation in the supervision allowed the three groups of GPs to develop their professional skills, but left them with a desire for more training in establishing cooperative practices with their partners in care. The professional challenges discussed during the supervision sessions were important elements of the national GP Curriculum, but not all elements of professionalism were covered.     

Promoting clinically effective practice: general practitioners' awareness of sources of research evidence

BACKGROUND: Practitioners are being encouraged to base their clinical practice on research evidence. In order to do this, they must be aware of and use the sources of evidence. METHODS: A questionnaire survey was undertaken to establish GPs' awareness of research evidence in their clinical practice and, in fundholding practices, its influence on purchasing plans. Questionnaires were sent to 360 lead fundholders in North Thames Region and 440 of a random sample of the remaining general practitioners in the region for comparison. RESULTS: Questionnaires were returned by 62% of lead fundholders and 63% of GPs in the random sample. There was limited use of the electronic sources of clinical effectiveness. There was greater reported awareness of published sources of research evidence and fundholding GPs were significantly more likely to have referred to publications summarizing research evidence. CONCLUSIONS: GPs seem to make more use of published clinical effectiveness sources than the electronic databases. Consequently, they need educational and technical support if they are to make full use of the available sources of research evidence available in other media.      

GP home visiting in 18 European countries Adding the role of health system features

Objectives: To describe and compare GP home visiting in 18 European countries and to test a set of hypotheses concerning the independent role of GP personal characteristics, type and organisation of the practice, and particularly, features of the healthcare system.

Methods: Data were used from the European Study of GP Task Profiles, collected by means of a uniform postal questionnaire in the national languages. Dependent variable is the self-reported number of home visits made by the GP. Independent variables at GP level are: GP's age and gender; involvement in out-of-hours care; urbanisation of the practice; mode and size of the practice; estimated over-representation of elderly, young children and socially deprived in the practice. At national level: gatekeeping position, employment status and density of GPs. In the multivariate analysis a hierarchical linear model was used in order to take into account the variables at two levels.

Results: Frequencies of home visits differed considerably, both between individual GPs and between countries. Correlates at practice level, known from the literature, were confirmed, such as age and gender of the GP and composition of the practice population. Important additional explanation was found at health system level. Numbers and variation in home visits among GPs were much lower in countries where GPs have a stronger position as gatekeepers. For independently working GPs the number of home visits was generally higher than in other countries.

Conclusions: Home visits are no lost ground for general practice. GPs in a strong position can more easily decide on home visits on the basis of need. In the future, more pressure on home visits must be expected. This will ask for solutions which go beyond the individual level.     

Evaluation of the rural South Australian Tri-division Adolescent Health Project

ABSTRACT: The Adolescent Health Project (AHP) was a rural pilot project aimed at strengthening the relationship between general practitioners (GPs) and adolescents within three Divisions of general practice. The evaluation assessed the implementation of the AHP model and strategies and their impact. The AHP used a centralised management/support and local delivery model. The AHP improved GP relationships and comfort with dealing with young people, and improved GP relationships with school counsellors. Divisional relationships with local schools improved. Students reported increased knowledge about GPs, increased confidence and comfort with accessing GPs. The AHP delivered a popular project to GPs, GP clinics, schools, school counsellors and students, which built the capacity of divisions, GPs, and schools to improve adolescent health care provision. Further research questions have emerged: What are the patterns of relationships between GPs and adolescents, and between GPs and school counsellors, and what strategies work best to sustain such relationships?     

The attitudes of Australian GPs to evidence-based medicine: a focus group study

BACKGROUND: Over the last 6 years there has been an exponential increase in the publication of medical literature on evidence-based medicine. In Australia, as in many other parts of the world, there have been calls for an increase in the practice of evidence-based medicine. In general practice, two major themes of criticism have been the lack of relevant research evidence in primary care and the failure of evidence-based medicine to take into account the complexity of the consultation. OBJECTIVE: We aimed to explore the attitudes of Australian GPs to evidence-based medicine. METHODS: We conducted a qualitative study using evidence-based guidelines as a model to explore attitudes within focus group interviews. Focus group data were analysed using grounded theory methodology. The study was set in the Australian cities Melbourne, Adelaide and Darwin. The subjects were 27 GPs in five focus groups. RESULTS: Data were used to generate a model illustrating factors affecting the consideration and use of evidence within consultations. Prior beliefs and experience had a strong influence on decision-making. Overall, the GPs had a positive attitude to evidence-based medicine and stated that this could be a helpful strategy for meeting their information needs. These needs arose during the consultation and were frequently generated by patients. The evidence-based approach was regarded as particularly useful when patients required validation of their management or had specific queries. However, the GPs also expressed some concerns, such as the application of evidence from clinical trials to individuals, and the appropriateness of using research evidence with certain patients. They also feared a move away from the 'art of medicine'. None of the GPs expressed a need for critical appraisal skills. CONCLUSIONS: The Australian GPs in this study had mixed views about the increasing profile of evidence-based medicine, and the use of this paradigm in practice. Acceptability was more likely to be influenced by relevance to general practice and local contextual and patient factors than by the strength, or critical quality of the evidence.     

Factors associated with the use of primary care services: the role of practice nurses

Rising demand for and costs of health care have led to an increasing role of practice nurses in primary care in many countries, including the United Kingdom. Previous research has explored how practice nurse care differs from that provided by general practitioners (GPs) in terms of costs and health outcomes, and has highlighted the importance of matching skills and experience with roles and responsibilities. However, there has been little research to compare the characteristics of patients seen by GPs and practice nurses in primary care. We aim to investigate the factors associated with the use of practice nurse visits, and to compare these with the factors associated with GP use. We jointly model the use of practice nurse and GP visits using a bivariate probit regression model with a large set of covariates taken from two rounds of the Health Survey for England (2001, 2002). We find that practice nurse use is associated with age and gender, health, socioeconomic and supply variables. There are differences in the factors associated with practice nurse and GP use. Chronically ill patients are more likely to see a practice nurse, while acute ill health has a stronger association with the probability of seeing the GP. Practice nurse use is also correlated with a narrower range of health conditions compared with GP use. We also found differences between practice nurse and GP visits with respect to the association with economic activity, ethnic group, number of children, degree of urbanisation, and distance to practice.     

Patient and GP agreement on aspects of general practice care

OBJECTIVE: The aim of the present study was to compare patient and GP priorities for general practice care. METHODS: A questionnaire survey was carried out in general practice in Denmark which included 900 consecutive patients aged over 18 years from 15 practices collected in 1995, and 919 randomly sampled GPs in 1999. The postal questionnaire, developed by the EUROPEP group, contained 40 questions about eight aspects of primary care. Participants were asked to state their priorities for each question ranging from "not at all important" to "most important". A reminder questionnaire was sent to non-responders after 2 weeks. Top priority percentages ("very/most important") were calculated for each question as were differences between participant groups. RESULTS: Questionnaires were answered by 771 (85.7%) patients and 584 (64.2%) GPs. Their priorities were highly correlated (r = 0.754, P < 0.001). Patients gave higher priority than GPs to availability and accessibility of the practice and seeing the same GP. The GP should be capable of providing information on illness, investigations and treatments and patient associations, and should know the patient's history and be regularly updated through courses. CONCLUSIONS: Patient and GP priorities for primary care were highly correlated. The higher priority awarded by patients than by GPs to specific aspects of primary care should be acknowledged when organizing and developing general practice.     

Is patient involvement possible when decisions involve scarce resources? A qualitative study of decision-making in primary care

Greater patient involvement has become a key goal of health care provision. This study explored the way in which general practitioners (GPs) in the UK manage the dual responsibilities of treating individual patients and making the most equitable use of National Health Service (NHS) resources in the context of the policy of greater patient involvement in decision-making. We undertook a qualitative study incorporating a series of interviews and focus groups with a sample of 24 GPs. We analysed GP accounts of decision-making by relating these to substantive ethical principles and the key procedural principle of explicitness in decision-making. GPs saw patient involvement in positive terms but for some GPs involvement served an instrumental purpose, for instance improving patient 'compliance'. GPs identified strongly with the role of patient advocate but experienced role tensions particularly with respect to wider responsibilities for budgets, populations, and society in general. GPs had an implicit understanding of the key ethical principle of explicitness and of other substantive ethical principles but there was incongruence between these and their interpretation in practice. Limited availability of GP time played an important role in this theory/practice gap. GPs engaged in implicit categorisation of patients, legitimating this process by reference to the diversity and complexity of general practice. If patient involvement in health care decision-making is to be increased, then questions of scarcity of resources, including time, will need to be taken into account. If strategies for greater patient involvement are to be pursued then this will have significant implications for funding primary care, particularly in terms of addressing the demands made on consultation time. Good ethics and good professional practice cost money and must be budgeted for. More explicit decision-making in primary care will need to be accompanied by greater explicitness at the national level about roles and responsibilities. Increased patient involvement has consequences for GP training and ways of addressing rationing dilemmas will need to be an important part of this training. Further research is needed to understand micro-decision-making, in particular the spaces in which processes of implicit categorisation lead to distorted communication between doctor and patient.     

Medical literature search practice in paediatric junior medical staff: a questionnaire survey

With increasing medical knowledge and emphasis upon evidence-based medicine, it is essential for practitioners to have optimal literature searching skills. There are limited data regarding the use of online information retrieval (IR) systems by paediatric junior medical officers (JMO). The aims of this questionnaire-based study of a group of JMO were to assess the accessibility, frequency of use and preferences for electronic information resources, and to ascertain their perceived adequacy of training and expertise in online searching. Questionnaires were distributed to 319 JMO at two Australian children's hospitals. A total of 106 questionnaires were returned (33.2% response rate). Twenty-four-hour access to electronic medical databases was available to almost 90% of respondents at work or home. Five or less online searches per month were performed by 53.7% of respondents. Previous formal training in database searching was reported by 72.4% of respondents, but over half felt it had been inadequate. Most JMO (91.5%) acknowledged a need for further training in search skills. In spite of widespread availability of online resources, use of these resources was sub-optimal in this group of trainee doctors. Most respondents reported a need for further training in electronic searching. Continuing targeted education in electronic database searching is required to ensure that future doctors develop skills to ensure optimal use of medical literature.