Continuing education for general practice and the role of the pharmaceutical industry.

A survey of the involvement in and attitudes towards continuing medical education of 101 general practitioners achieved a 95% response rate. Ninety per cent of the 96 doctors worked in practices which held meetings the content of which was organized by representatives of pharmaceutical companies but only 46% worked in practices which organized their own educational meetings. Seventy six per cent attended meetings away from their practice which were organized by drug companies and 75% had attended at some time continuing medical education activities organized by a local postgraduate centre. The promotional aspects of the drug company organized meetings were disliked by a majority of respondents (58%); more of the trainers (62%) and more of those who had entered general practice within the last seven years (71%) disliked this aspect. Nonetheless the educational content of both meetings held in the practice and those held elsewhere was the aspect most liked by over half of the respondents (59% and 53% respectively). Only 16% of all respondents thought that visits by representatives from pharmaceutical companies were educationally valuable and 37% thought that educational events organized by these companies were of value. Surprisingly 60% of those who worked in practices which held meetings organized by drug company representatives thought them to be of little or no educational value. There is clearly a need for practice based continuing medical education but the current level of dependence on drug companies for organizing these meetings must be questioned. Alternative strategies for the provision of independent non-sponsored educational activities should be sought.     

Motivation of general practitioners attending postgraduate education.

BACKGROUND: The 1990 Contract encouraged general practitioners to participate in continuing medical education by providing a financial incentive. AIM: The study was designed: to determine the motivation of general practitioners attending education events; and to compare motivation and reasons for attendance pre- and post-Contract at commercial and non-commercial meetings, and at the different educational categories of Disease Management (DM), Health Promotion (HP) and Service Management (SM). METHOD: Two structured questionnaires were used. The first was sent to all general practitioners in the West of Scotland and asked about motivation pre-1990 Contract and the second, post-Contract, looked at motivation and reasons for attending a course as part of post course assessment. This latter was part of a much larger study evaluating continuing medical education. RESULTS: A total of 1161 practitioners responded to questionnaire I and 552 general practitioners attended 27 randomly selected postgraduate meetings. Finance was a motivator in 3.8% pre-Contract, and this increased to 33.3% post-Contract and was the most commonly stated reason for attendance in 81.3%. Financial incentive had the biggest influence on those attending HP sessions (91.5%), then SM (87.2%) and finally DM (78.6% (chi 2 = 8.68; P < or = 0.013). It was also important to 73% attending drug-company-sponsored meetings compared with 83.7% going to non-commercial ones. Interest was a good motivator both pre- and post-Contract, but more so for DM than other categories and drug company as opposed to non-commercial meetings (chi 2 = 9.4; P < 0.002). Lack of knowledge became a less-important motivator post-Contract, and doctors felt least knowledgeable in SM (62.2%), as opposed to DM (57.9%) and HP (23.6%) (chi 2 = 38.8; P < 0.001, with each differing significantly from both others). Doctors found the topics provided by the pharmaceutical companies more interesting (chi 2 = 9.4; P < 0.002) and the hospitality provided more alluring than scheme meetings (chi 2 = 28.6; P < 0.001). CONCLUSIONS: Finance has a major effect on attendance at postgraduate meetings but may not be a good incentive for learning. Planning for education must take into account the different motivational factors for the different categories. Reasons for attending commercial meetings differ from non-commercial ones and these events should be closely monitored.     

Continuing educational requirements for general practitioners in Grampian.

A postal questionnaire about educational requirements achieved an 81% response from all general practitioners in Grampian. A majority of respondents felt that it was important to keep up-to-date and they were setting aside a number of hours per week to do this. Evening meetings, intensive two to three day courses and week long refresher courses were still popular, as was the idea of small groups resourced by a consultant. Newer forms of continuing education, for example, audio and videotape and distance learning were not popular. Journals still remained an important way of keeping up-to-date. These results help in planning the rational use of postgraduate resources for the future.     

Attitudes towards practice nurses--survey of a sample of general practitioners in England and Wales.

Practice nursing has expanded rapidly since the 1990 contract for general practitioners. In 1990, a national survey was undertaken of the attitudes of a random sample of general practitioners towards practice nurses. Responses to the postal questionnaire were received from 41.9% of the 4800 general practitioners sampled. Of the responding general practitioners, 90.0% were satisfied with the role of the practice nurse within their practice. To fulfil the requirements of the 1990 contract for general practitioners 50.7% had created a new nursing post, and 83.1% had expanded the role of nurses already employed; 89.7% wished to see further expansion of the practice nurse's role. However, lack of space was the factor most frequently reported as limiting the expansion of the practice nurse's role, mentioned by 76.0% of general practitioners. Only 43.7% of general practitioners recognized lack of opportunities for practice nurse training as a hindrance to role expansion. The key to managing the expansion of the role of the practice nurse lies in the provision of resources and in training. A pressing need exists for a national training scheme based in general practice.     

How do general practitioners qualify for their PGEA?

On average, general practitioners (GPs) achieved their five-day annual target for the postgraduate educational allowance (PGEA) mainly by attending short meetings in the disease management category. The pattern of uptake closely resembled that of provision, with relatively few meetings and attendances in the health promotion category. Sponsored meetings attracted more participants than non-sponsored ones, but mean attendances at all types of meetings were low. Implications and recommendations are discussed.     

Changes in general practice organization: survey of general practitioners'' views on the 1990 contract and fundholding.

BACKGROUND: General practitioners' views on two major changes in the organization of general practice--the 1990 contract for general practitioners and fundholding, introduced in 1991--have not been researched in any great detail. AIM: A study in 1993 sought to investigate the views of general practitioners from group practices and of single-handed general practitioners, in family health services authority areas with different socioeconomic characteristics, on the 1990 contract for general practitioners, fundholding and the effects of these two changes in general practice organization. METHOD: One general practitioner partner from each of 323 group practices in six family health services authority areas of England was invited for interview and 142 single-handed general practitioners in the study areas were sent a postal questionnaire. The interview and questionnaire sought general practitioners' views on the 1990 contract and fundholding, reasons for their opinions, and views on the effects of these reforms on workload and the quality of service. Other information was recorded on fundholding status, workload pressures, outreach clinics, budget surpluses, retirement plans, and opinions on a salaried service. RESULTS: A total of 260 group practice general practitioners (80%) participated in the study and 80 single-handed general practitioners (56%) returned questionnaires, 78 of which could be analysed. Over half of all respondents were opposed or strongly opposed to both the 1990 contract and fundholding. However, despite this opposition, a sizeable minority of group practice practitioners (38%) agreed that the quality of services provided had improved or considerably improved since the 1990 contract. Workload appeared to have increased, with the proportion of respondents who reported being always under pressure increasing from 12% in 1987 to 41% in 1993. All but one respondent considered administration to have increased. Some respondents were considering early retirement. One of the solutions proposed to alleviate problems in inner city general practice, a salaried service, received little support, even from those general practitioners working in areas which might be expected to benefit. CONCLUSION: Dissatisfaction of general practitioners with the National Health Service reforms was expressed in continued opposition, in concerns about workload and levels of administration, and in a desire to retire early. Suitable ways of improving general practitioner morale must be sought.     

Characteristics of general practitioners who are high attenders at educational meetings.

The characteristics of general practitioners in the west of Scotland who are high attenders at meetings accredited for the postgraduate education allowance were studied. One hundred and seventy one principals in general practice (9.5%) had attended more than 35 half-day sessions of accredited education between 1 April 1989 and 31 December 1990 and 34 doctors (1.9%) had attended more than 45 half-day sessions. The highest percentage of the doctors worked in Greater Glasgow and Lanarkshire. The doctors who were high attenders were relatively more likely to be women, to be members of the Royal College of General Practitioners and to work in a training practice. The majority of the doctors had been qualified for between 10 and 30 years and worked in group practices of three or more doctors. The characteristics of high attenders contrast markedly to doctors who are low attenders. That there were such a large number of high attenders at educational meetings is encouraging.     

Postgraduate education allowance: general practitioners'' attendance at courses outwith their region.

A study was undertaken to investigate the number of doctors attending postgraduate education courses outwith their own region. During the one year study period general practitioners from the west of Scotland obtained 2262.0 half-day sessions accredited for the postgraduate education allowance from 335 different courses outwith their region and 10 different distance learning programmes. Four hundred and thirteen doctors from the west of Scotland region (22.6%) attended courses in other areas and 85 doctors (4.6%) participated in 258.6 half-days of distance learning. More than half of the education sessions (56.0%) were in the category of disease management. Sixty four doctors (3.5%) attended 10 or more half-day sessions outwith their region. Almost half the courses were in England and 32.5% of courses were in south east Scotland. Over the same period 122 doctors outwith the area attended 263 different courses in the west of Scotland region. Despite concern regarding the removal of travel and subsistence contributions for postgraduate education activities, general practitioners are attending education courses outwith their region.     

Survey of young principal groups in the United Kingdom

Of 164 young principal groups identified, 107 replied to a questionnaire asking for details of the groups and their activities. Eighty one per cent of the groups had been in existence for less than five years and 57% gave continuing medical education as one of the reasons for forming the group. The majority of groups were run informally and 55% had social meetings to which spouses were invited. The groups varied in size from six to 50 members and members' surgeries were the most popular meeting place. Clinical topics proved the most successful and group discussion was the preferred form of meeting. Groups formed for less than three years were less likely to have meetings with specialists than groups formed for three years or more and were more likely to have discussions about personal/partnership problems. Although 67% of the groups had sought outside help at some time 78% did not need any help at present.

These self-help groups appear to be self-sufficient and to be meeting the continuing education and personal/social needs of young principals.

     

Postgraduate education allowance: educational attainment of subscribers and non-subscribers to a centrally organized educational scheme.

The educational attainment of general practitioners in the west of Scotland region who subscribed to a centrally organized educational scheme for the postgraduate education allowance was compared with that of their colleagues who did not subscribe to the scheme. During the year studied (1990-91) 1712 of the 1830 principals in general practice in the region had sufficient sessions to claim their postgraduate education allowance. Of these 1712 doctors the 1353 who subscribed to the educational scheme attended a mean of 15.7 educational half day sessions during the study year in comparison with a mean of 12.5 half days attended by the 359 doctors who did not subscribe to the scheme. This difference was observed in all three categories of education--disease management, service management and health promotion--and was greatest in health promotion where subscribers attended a mean of 4.7 half days and non-subscribers 3.1. The doctors who were members of the scheme had achieved a better balance of education. A higher number had attended an educational day in each of the three categories, with the increase being 10.5% for subscribers versus non-subscribers for disease management, 20.0% for service management and 39.1% for health promotion. The differences between the two groups were greater for combinations of categories and 66.6% of subscribers had attended an educational day in each of the three categories compared with 40.9% of non-subscribers. A centrally organized educational scheme for a region can give a balanced spread of education and is likely to meet the educational requirements of the new contract for general practitioners.     

General practitioners' attendance at courses accredited for the postgraduate education allowance.

An analysis was undertaken in the northern half of the South Western Regional Health Authority of general practitioners' attendance at courses accredited for the postgraduate educational allowance over one year. A total of 358 courses provided 2341 hours of accredited education and produced a total general practitioner attendance of 50,389 hours. The mean attendance per principal in the area was 49.2 hours although the region may be a net importer of attenders from outside the area. Of the 50,389 total hours of attendance, 28.3% were in health promotion, 48.2% in disease management and 23.5% in service management. Course provision and attendance varied considerably over the year. September, October and November accounted for 42.7% of the total hours of attendance, compared with 6.8% in June, July and August. Courses of two to four days or of one week duration accounted for 48.3% of total attendance hours; 10.1% of total attendance hours were at commercially organized courses and 5.6% at courses organized by practices. A total of 66.1% of attendance hours were in postgraduate centres and 6.8% in the practice. Courses with more than 30 participants accounted for 15.9% of courses attended. A total of 174 general practitioners and others organized courses, 21 of them influencing 33,521 hours of general practitioner education. The study shows that in this area, there was an encouraging provision, range and uptake of continuing education courses for general practitioners. The concentration of educational activities in postgraduate centres underlines the need for increased provision for developing educational skills for clinical tutors.     

Demographic characteristics of general practitioners attending educational meetings.

There are many factors which influence general practitioners' behaviour with regard to attendance at education meetings. The demographic characteristics of general practitioners in the west of Scotland attending educational meetings were studied over a two year period. A total of 1672 doctors had attended sufficient sessions to claim their postgraduate education allowance and of these 1551 (93%) responded to the questionnaire. Overall attendance at meetings did not vary between age groups, but older doctors (those born before 1935) attended the highest mean number of education sessions on disease management and the lowest mean number on service management and health promotion. Doctors in rural areas attended fewer meetings than those in urban areas with the largest difference in the disease management category. Doctors from smaller practices attended significantly fewer sessions on service management than those from larger practices. There was no difference between sexes regarding the mean total number of education sessions attended but men attended significantly more sessions on service management and women attended more on health promotion. Full-time doctors attended more service management sessions than part-time doctors. Those who were widowed or divorced attended fewer sessions in total, the differences being greatest in service management and health promotion. Multiple regression analysis showed that location of practice, whether working full time or part time and marital status had a small but statistically significant bearing on overall attendance at meetings. Although the differences are small, these factors should be noted by education providers, negotiators and government.     

Annual assessments of patients aged 75 years and over: views and experiences of elderly people.

BACKGROUND. The 1990 contract requires general practitioners to offer all their patients aged 75 years and over an annual health check. Increasing importance is being placed on consumers' views of service provision. AIM. A study was undertaken in June 1992 to investigate elderly patients' views and experiences of the annual health check, and to compare these with the previously reported views of general practitioners and practice nurses who had also been surveyed as part of the study. METHOD. Twenty family health services authorities wrote to a sample of 1500 elderly patients asking if the patient's name could be passed to researchers. Patients who agreed were then interviewed. RESULTS. A total of 664 elderly patients (44%) were interviewed. Only 64% of respondents were aware of their entitlement to a health check. Vulnerable patients, such as those in poor health or who lived alone, were less likely to know about the health checks than other patients. Only 31% of respondents thought they had had a health check. Of these, fewer than half recalled the doctor or nurse discussing the findings with them, although 80% of doctors reported that they always or mostly discussed results with patients. Elderly patients were more likely to recall the physical aspects of the health check rather than discussion about particular health aspects. However, doctors and nurses felt that routine checks were useful for giving advice rather than detecting medical problems. Of those who had had a health check, 82% reported no improvement in their health as a result, but 93% thought that they were a good idea. Only 7% of doctors thought they were of value, compared with the majority of nurses. CONCLUSION. It appeared that the inverse care law was operating, with those more in need of the service being less likely to have known about it. Discrepancies were found between general practitioners' and practice nurses' reports of service provision and those of elderly patients. Evidence about the cost-effectiveness of regular health checks may help the conflict between professional scepticism and consumer enthusiasm for these assessments.     

General practitioners and their learning styles.

Continuing medical education sessions are often poorly attended by general practitioners. One reason may be that these traditionally consist of lectures by hospital consultants with a strong theoretical bias which may have little relevance to the learning needs of general practitioners. To compare the learning styles of teachers and learners in general practice, learning style questionnaires were administered to 50 hospital clinical tutors, 78 general practitioner trainers, 63 trainees and 47 non-trainer principals. The questionnaire covered four different learning preferences: activist, reflector, theorist and pragmatist. The findings showed that the learning styles of hospital tutors and general practitioner trainers were statistically significantly different to those of non-trainer principals and trainees. The tutors and trainers scored much higher on theorist styles and to a lesser extent on reflector and pragmatist styles. There were no significant differences on activist scores. Since teachers tend to teach in their preferred learning style, which may not match the style of the recipients, these findings have implications for continuing medical education in general practice. These implications are discussed.     

Who should give lifestyle advice in general practice and what factors influence attendance at health promotion clinics? Survey of patients' views.

BACKGROUND: Health promotion activity in general practice has increased greatly since 1990. A large proportion of this work is undertaken by practice nurses. Little is known about patients' views about the providers of health promotion or their views about general practice health promotion clinics. AIM: A study was carried out in 1992 to determine patients' views about the provision of health promotion advice by general practitioners and practice nurses and their views about attending health promotion clinics. METHOD: A postal questionnaire was sent to a random sample of 1750 patients aged 16 years and over from five general practices in south Tyneside. The questionnaire explored patients' preferences regarding health promotion advice from the general practitioner or practice nurse in relation to four areas of lifestyle advice and factors that might encourage patients to attend a health promotion clinic. RESULTS: A response rate of 75% was obtained from 1639 eligible patients. Receiving health promotion advice from either the general practitioner or the practice nurse was the most commonly preferred option expressed by patients overall. The ability of health promotion clinic staff to deal with patients' concerns about their illness and short waiting times were more likely to influence patients' attendance at health promotion clinics than the presence of a general practitioner or practice nurse. CONCLUSION: In the present study, many patients found health advice received from practice nurses and general practitioners equally acceptable. However, it was the ability of health professionals to respond to patients' health concerns in the health promotion clinic rather than the type of health professional running the clinic that was important for patients.     

Impact of the 1990 contract for general practitioners on night visiting.

BACKGROUND. The 1990 contract for general practitioners extended the hours of eligibility for night visiting claims by 25% and introduced financial incentives to discourage the use of deputizing services. AIM. This study set out to examine the impact of these contract changes on the rate and pattern of night visiting. METHOD. Family health services authority data were used to compare trends in night visiting before and after the introduction of the new contract. Rates were calculated separately for those authorities which might be expected to have a high rate of visiting because of their demographic structure and those that might be expected to have a high rate because of their socioeconomic composition, thus separating out these two sets of factors combined in the Jarman index. RESULTS. Rates of night visiting increased by 33% between 1989 and 1990 while the proportion of visits made by deputies fell by 19%. These changes could not simply be explained either by the extension of eligible hours or the success of financial incentives in changing behaviour in the appropriate direction. It was found that the effect of the new contract was to increase visiting most in family health services authorities with a high proportion of elderly people living alone, that is, where demand would be expected to be higher. In previous years there had been little variation in visiting rates between authorities with a high proportion of those aged 65 years and over living alone and those with a low proportion. The effect of the contract was also to increase rates of visiting most in affluent authorities, that is, where demand would be predicted to be lower. This again marked a sharp break with trends in previous years in that the gap between the high rates in the deprived family health services authorities and lower rates in the most affluent authorities narrowed. CONCLUSION. The 1990 contract achieved the government's policy aims of promoting night visiting by principals and discouraging the use of deputies in its first year. However, the finding that doctors responded more to demand from elderly people and affluent people than from deprived people presents a challenge both for analysis and for policy. It underlines the importance of disaggregating the Jarman index when examining the impact of policy change on local populations and suggests that general practitioners in the most deprived family health services authorities may lack the capacity or the incentive to respond to the changes introduced in the 1990 contract.     

Anti-smoking advice in general practice consultations: general practitioners'' attitudes, reported practice and perceived problems.

BACKGROUND: Anti-smoking advice from general practitioners has proven efficacy. However, general practitioners do not exploit a large proportion of opportunities to discuss smoking with patients. AIM: A study aimed to explore general practitioners attitudes towards discussing smoking with patients and to assess how these influence the quantity of anti-smoking advice that general practitioners report giving during routine consultations. It also aimed to determine the extent to which general practitioners report using evidence-based interventions against smoking and to discover the problems they experience when discussing smoking with patients. METHOD: A postal survey of all 468 general practitioners on the Leicestershire Family Health Services Authority list was conducted. General practitioners' attitudes were assessed by scoring 13 attitude statements using a six-point Likert-type scale. They were also asked to rank (from a list of 12 items) the five approaches that they found most productive and (from a list of 11 items) the five problems that they most commonly encountered when giving anti-smoking advice to patients. RESULTS: A total of 327 questionnaires (70%) were returned. Most respondents (97%) thought that their advice was more effective when linked to patients' presenting problems and 65% reported that linking their anti-smoking advice to patients' presenting complaints was one of their three most preferred approaches to discussing smoking. Advising all presenting smokers to quit was considered by 40% of respondents to be an appropriate use of time but 76% reported that patients' lack of motivation was one of the three most commonly encountered problems. An analysis of the ratings of the 13 statements suggested that general practitioners who reported the greatest smoking cessation activity during routine consultations held more positive attitudes towards discussing smoking with patients. CONCLUSION: This study suggests that general practitioners believe that their anti-smoking advice is more effective when linked to patients' presenting complaints, and this belief appears to be reflected in the way in which general practitioners approach smoking cessation with patients. The findings may indicate that general practitioners are unlikely to accept a role in a population-based anti-smoking strategy which demands that they discuss smoking with all presenting smokers.     

Physicians' preferences for asthma guidelines implementation

Purpose

Patient care based on asthma guidelines is cost-effective and leads to improved treatment outcomes. However, ineffective implementation strategies interfere with the use of these recommendations in clinical practice. This study investigated physicians'' preferences for asthma guidelines, including content, supporting evidence, learning strategies, format, and placement in the clinical workplace.

Methods

We obtained information through a questionnaire survey. The questionnaire was distributed to physicians attending continuing medical education courses and sent to other physicians by airmail, e-mail, and facsimile.

Results

A total of 183 physicians responded (male to female ratio, 2.3:1; mean age, 40.4±9.9 years); 89.9% of respondents were internists or pediatricians, and 51.7% were primary care physicians. Physicians preferred information that described asthma medications, classified the disease according to severity and level of control, and provided methods of evaluation/treatment/monitoring and management of acute exacerbation. The most effective strategies for encouraging the use of the guidelines were through continuing medical education and discussions with colleagues. Physicians required supporting evidence in the form of randomized controlled trials and expert consensus. They preferred that the guidelines be presented as algorithms or flow charts/flow diagrams on plastic sheets, pocket cards, or in electronic medical records.

Conclusions

This study identified the items of the asthma guidelines preferred by physicians in Korea. Asthma guidelines with physicians'' preferences would encourage their implementation in clinical practice.     

Age differences in physical activity intentions and implementation intention preferences

This study aimed to examine older adults’ physical activity intentions and preferred implementation intentions, and how intentions and preferred implementation intentions differ between older, middle aged and younger adults. A cross-sectional Australian wide telephone survey of 1217 respondents was conducted in 2016. Multiple and ordinal regression analyses were conducted to compare intentions and preferred implementation intentions between older (65 +), middle aged (45–64) and younger adults (< 45). A higher percentage of older adults had no intentions to engage in regular physical activity within the next 6 months (60%) compared to younger adults (25%). Older adults’ most popular preferences included being active at least once a day and for 30 min or less and were more likely to prefer more frequent and shorter sessions compared to younger adults. Both older and middle aged adults were more likely to prefer slower paced physical activity compared to younger adults who preferred fast paced physical activity. Physical activity interventions for older adults should address the high percentage of older adults with no intentions and public health campaigns for older adults should promote 30 min daily sessions of slow paced activity.     

Work patterns of general practitioners before and after the introduction of the 1990 contract.

A questionnaire survey was undertaken to examine the work patterns of general practitioners before and after the introduction of the 1990 contract. A total of 408 and 697 general practitioners responded to the questionnaire in 1989 and 1991, respectively (response rates of 47% and 82%). In 1991 general practitioners reported spending significantly more evenings on paperwork than in 1989 and significantly more reported being exhausted or stressed at the end of five or more working days. General practitioners were significantly less likely to work four or more sessions per week outside the practice in 1991 than in 1989. There was no difference between 1989 and 1991 in the number of surgeries carried out per week or the number of nights spent on call in a month. In 1991 there was no correlation between the Jarman index allocated to a practice principal and the numbers of surgeries per week, sessions worked outside the practice per week, nights on call per month, weekdays exhausted or stressed, or evenings each week spent on paperwork. Older doctors in 1991 were significantly more likely to work 12 or more nights on call per month, to spend more time doing paperwork in the evenings and more likely to report exhaustion than younger doctors. Women doctors in 1991 were significantly more likely to report doing 10 or more surgeries per week than their men colleagues. It has become more common for general practitioners to complete paperwork at home and report exhaustion or stress since the introduction of the 1990 contract.