The journey of incontinent women from community to university clinic; implications for selection bias, gatekeeper function, and primary care

BACKGROUND.: The selection process of patients from community to hospitalsmay introduce bias into research and hamper the generalizationof hospital-based research back to general practice. OBJECTIVE.: The objective of this study was to use female urinary incontinenceas a model in an attempt to provide empirical support for selectionbias. METHOD.: The analyses are based on three populations of incontinent women:community level (epidemiological survey, 535 women), primarycare level (general practice, prospective clinical study, 105women), and secondary care level (university hospital, prospectiveclinical study, 228 women). RESULTS.: The general practice patients were older and the hospital patientsyounger than those in the community. From community via generalpractice to hospital, there was an increase in duration, frequencyof leakage, amount of leakage, severity and perceived impactof incontinence. Help-seeking at the primary care level wasassociated with increasing age and severity, and with urge symptomsand substantial impact. Referral from general practice to hospitallevel was only associated with age and urge symptoms. CONCLUSIONS.: The study provides empiriéal evidence to support theexistence of selection bias. This phenomenon must not be overlookedwhen recommendations developed at the consultant level are presentedat a level with a significantly different clinical picture ofa condition. Keywords. Urinary incontinence, women, general practice, referral, consultation.     

Clinical exposure during clinical method attachments in general practice

BACKGROUND: There has been a significant decline in medical students' clinical experience in hospitals. Hospital-based teaching is struggling to provide medical students with sufficient experience of the common health problems of our industrialized ageing society. Hence, general practice has become an important locus for medical education. Published evidence, however, that students can access appropriate clinical experience in general practice is sparse. OBJECTIVE: To determine students' clinical exposure during clinical and method attachments based in general practice at two medical schools. EDUCATIONAL INITIATIVE: Students were attached to general practice tutors to learn clinical method in internal medicine. METHOD: General practice tutors from two medical schools collected data on age, gender, diagnoses, symptoms and signs of the patients they invited to teaching sessions. RESULTS: The frequency of diagnoses, symptoms and signs seen by medical students are recorded. Students mostly saw patients with chronic illnesses; the commonest diagnoses were ischaemic heart disease and angina. DISCUSSION: Our study has recorded the largest published database of clinical diagnoses, symptoms and signs encountered by students learning clinical method in general practice. It shows that students obtained a wealth of experience with patients with common chronic diseases. Students must also learn in the hospital setting, to experience the presentation of acute illness. The combination of teaching in these two settings is likely to provide the most effective technique to ensure that students encounter the common, acute and chronic conditions that affect patients in the 21st century.     

Research in general medicine,role of the medical thesis

General practice doctors are naturally presented as being actors on the front lines of public health. The ability of general practitioners to be aware of and deal with public health questions largely depends upon their training. Perhaps one could consider the general practitioner's thesis as a preparatory analytical work within the area of their future field of practice. Do these theses serve to provide food for thought on general practice and its contribution to public health, and if not, could they? An analysis conducted within four medical schools in western France demonstrates that the work produced for general medicine identified as such only constitutes a fraction of the overall number of medical (non-university) theses (approximately 5%). Two possible explanations may be put forward. First, on the one hand, the theses highly depend on the context of the training and the work produced is a direct result of this. Second, on the other hand, the current methods of indexing notes in the university databases does not enable general medicine to be clearly seen and visibly recognised as an academic discipline. Two questions then remain: Can medical theses be considered as research? Should research in general medicine be carried out solely by general practitioners? It is vital that resources from outside the medical field be raised and mobilised for general practice research, whose themes are multi-disciplinary and not only clinical.     

Qualitative outcome assessment and research on chronic disease management in general practice. Highlights from a keynote lecture,EGPRN May 2011, Nice

At its 2011 conference in Nice, France, the European General Practice Research Network (EGPRN), considered the issue of Relevant Outcome Measures in General Practice Research into Chronic Diseases. This paper, which is adapted from a keynote lecture given during that conference, considers the role of qualitative outcome assessments in research. Such assessments have a great deal in common with the patient-centred approach of general practice as they can capture the overall state of a patient rather than capturing only certain aspects. Research suggests that patients can be categorized, based on qualitative outcome assessment, and over time might change category. This approach to assessment brings to our attention alternative ways of considering the future: future as currently being made or future as predictable, at least to some extent. Although general practice needs the evidence from research that predicts the future, it also needs to engage in research that seeks to understand patients as they make their future, and to understand the impact of clinical interventions on this process.     

Qualitative outcome assessment and research on chronic disease management in general practice. Highlights from a keynote lecture, EGPRN May 2011, Nice

At its 2011 conference in Nice, France, the European General Practice Research Network (EGPRN), considered the issue of Relevant Outcome Measures in General Practice Research into Chronic Diseases. This paper, which is adapted from a keynote lecture given during that conference, considers the role of qualitative outcome assessments in research. Such assessments have a great deal in common with the patient-centred approach of general practice as they can capture the overall state of a patient rather than capturing only certain aspects. Research suggests that patients can be categorized, based on qualitative outcome assessment, and over time might change category. This approach to assessment brings to our attention alternative ways of considering the future: future as currently being made or future as predictable, at least to some extent. Although general practice needs the evidence from research that predicts the future, it also needs to engage in research that seeks to understand patients as they make their future, and to understand the impact of clinical interventions on this process.     

Expert nurses and the division of labour in hospitals

This article analyses nursing expertise with a particular focus at the level of clinical and organizational practice. Through an examination of a specialist team of hospital nurses, and drawing on the concept of a community of practice, the article provides a critique of discussions of nursing expertise which can be overly normative, individualistic or divorced from practice. The theoretical background to our analysis is the division of labour in health care; the case study on which this analysis is based is a particular health policy: the introduction of critical care outreach services. The empirical portions of the article are based on a qualitative study of eight such services in England. In the first part of the analysis we elaborate on three ways in which 'expertise' can be deployed in practice: teaching and training; consultancy and advice; and practical clinical action. Each of these is shown to be related to the development of a community of practice. In the second part of the analysis we examine in more detail the impact of outreach nurses on the division of labour in health care and on traditional occupational hierarchies. A general implication of our findings is that expertise has fundamentally social characteristics which need to be acknowledged in academic and policy discourse.     

Quality indicators for general practice: A practical guide for health professionals and managers. Edited by Martin Marshall, Stephen Campbell, Jenny Hacker and Martin Roland

Edited by Martin Marshall, Stephen Campbell, Jenny Hacker andMartin Roland Published in 2002 by Royal Society of Medicine Press Ltd, London,UK. ISBN 1-85315-488-1; Price £19.50. Quality indicators for general practice: A practical guide forhealth professionals and managers is a practical book. It brieflyoverviews a process for developing quality indicators relevantto British general practice, and then presents indicators for19 common clinical conditions. A final chapter discusses thepossible uses (and avoidance of misuses) of the indicators.This edited text will be of great use to clinicians workingin British general practice, as well as managers, clinical governanceleaders, and others working to improve the quality of primarycare. Because it is the result of a binational collaboration,the process     

Critical appraisal of articles about clinical audit

OBJECTIVE: To summarize the most important criteria used in critical appraisal of publications about clinical audit by the review of the relevant English language literature. METHODS: Electronic databases, including Medline, Science Direct, and Ingenta Select, and Internet search were used to find relevant English language publication between 1985 and 2005. Hand search and the reference lists search for publications were also applied. In addition, researchers were also contacted for publications. RESULTS: The literature is surprisingly scarce about the critical appraisal of clinical audit publications. As a result hand search was as important as electronic search. The following three screening criteria can be used in order to critically appraise the scientific literature: (a) whether or not valid and relevant criteria and standards were used to evaluate clinical practice, (b) the criteria were used systematically on a representative sample of patients, and (c) the results are important and applicable (generalizable) in our practice. The publication is useful if it helps to improve the quality of our own clinical practice. CONCLUSION: Critical appraisal criteria can be used to improve the quality of clinical audit, and disseminate the results of audit, as well as find high quality evidence for designing and implementing quality improvement initiatives.     

General practitioners, skin lesions and the new contract.

We reviewed all skin lesions received in our laboratory from general practitioners (GPs) during a three-month period before the introduction of the new contract for GPs and during the same period a year later. For comparison we also reviewed skin lesions received from the general and plastic surgeons. Particular attention was paid to the completeness of excision. There was a significant increase in the number of skin lesions removed in general practice after the introduction of the new contract. Both benign and malignant lesions were more likely to be incompletely excised by GPs compared with surgeons. The GPs first noted to carry out minor surgery after the new contract came into force were less likely to have completely excised lesions than their more experienced colleagues. We suggest the future monitoring of lesions removed in general practice, possibly by the formation of a joint audit group.     

Soft governance,restratification and the 2004 general medical services contract: the case of UK primary care organisations and general practice teams

In the UK National Health Service, primary care organisation (PCO) managers have traditionally relied on the soft leadership of general practitioners based on professional self‐regulation rather than direct managerial control. The 2004 general medical services contract (nGMS) represented a significant break from this arrangement by introducing new performance management mechanisms for PCO managers to measure and improve general practice work. This article examines the impact of nGMS on the governance of UK general practice by PCO managers through a qualitative analysis of data from an empirical study in four UK PCOs and eight general practices, drawing on Hood's four‐part governance framework. Two hybrids emerged: (i) PCO managers emphasised a hybrid of oversight, competition (comptrol) and peer‐based mutuality by granting increased support, guidance and autonomy to compliant practices; and (ii) practices emphasised a broad acceptance of increased PCO oversight of clinical work that incorporated a restratified elite of general practice clinical peers at both PCO and practice levels. Given the increased international focus on the quality, safety and efficiency in primary care, a key issue for PCOs and practices will be to achieve an effective, contextually appropriate balance between the counterposing governance mechanisms of peer‐led mutuality and externally led comptrol.     

James Mackenzie, General Practitioner: a modest contribution to the archaeology of clinical reason

This paper focuses on the work of the influential general practitioner and heart specialist, James Mackenzie (1853–1925), and seeks to reconstruct - using some of the perspectives broadly associated with actor-network theory as well as Michel Foucault's work on clinical medicine - the epistemological rationality of his medical programme as a particular kind of network of knowledge. The paper concludes with a brief discussion of some of the implications of this analysis both for the sociological study of medical knowledge, and for our contemporary ideals of medical practice.     

国内外全科医学教育的发展

现代健康观念己经从单纯生物学角度扩展到人的生理、心理、社会和生态环境等综合层面，全科医疗服务模式使世界的社区医疗和基层卫生保健发生很大的改观。本文概述了全科医学的概念，国内外全科医学教育模式以及我国全科医学存在的问题，并提出了加快我国全科医学发展的相应对策。     

安徽省全科医学培训现状、问题及建议

发展社区卫生服务,加快培养全科医师和社区护士是现阶段全科医学教育工作的重点,针时全科医学岗位培训,我省采取了一系列有力措施,正在逐步建立一支专业化、高素质的社区卫生服务人才队伍,极大推动了我省社区卫生服务工作的发展.本文从全科医学组织、网络、基地和师资建设以及培训开展情况等方面进行了介绍,并提出存在的问题和几点建议.     

Community-based learning in obstetrics for undergraduate medical students

Summary: Medical students on their obstetrics and gynaecology attachment were randomly assigned to attend hospital ( n = 24) or general practice ( n = 18) obstetric clinics once weekly for 4 weeks. The students completed self-assessment questionnaires at the beginning and end of the attachment. There was a significant improvement in the level of knowledge and skills required for antenatal care, care in labour and postnatal care by the end of the attachment, with no difference between hospital or general practice groups. There was a significant increase in the level of interest in the future practice of obstetrics only in the general practice group. However, this difference could be explained by the greater number of students in the general practice group who were by chance in the 'no or don't know' category at the start of their attachment. We conclude that general practice based clinical teaching of obstetrics can be a suitable alternative to hospital-based clinical teaching for undergraduate medical students.     

Educational objectives and requirements of an undergraduate clerkship in general practice. The outcome of a consensus procedure

OBJECTIVES: The main aim of this study was to reach consensus between students, faculty and general practice teachers on the educational objectives and requirements of the clerkship in general practice. METHOD: The consensus procedure consisted of four steps and all active general practice teachers (n = 116) were asked to participate in the study. RESULTS: We identified 189 educational objectives: 127 complaints (problems, symptoms, syndromes), 29 clinical skills and 37 objectives concerning the theoretical dimensions of general practice. Educational requirements crystallized to 16 essential preconditions of a teaching practice and 35 didactic activities to be performed by the general practice teachers. CONCLUSIONS: These consensus results will be used to structure the medical curriculum and as guidelines for the educational process during the clerkship.      

'Ending up a GP': a qualitative study of junior doctors' perceptions of general practice as a career

OBJECTIVE: This study aimed to investigate junior doctors' perception of general practice as a career. METHOD: In-depth interviews with a purposive sample of 54 junior doctors were carried out. RESULTS: Three main criteria were identified: clinical content of practice, lifestyle, and organizational context of practice. Clinical content was most highly valued, but was recognized to conflict with lifestyle. Compared with hospital medicine, general practice was associated with inferior clinical content but superior lifestyle. Views on organizational context were more equivocal. Choice of general practice as a career was often based on negative judgements. CONCLUSIONS: Junior doctors' perceptions of general practice are expressions of a hospital-centric culture. Criteria for career choice are diffuse and complex. There was no evidence that the 1990 GP Contract deterred recruitment. The compromise between intrinsic satisfaction and lifestyle may be significant for GP morale.      

普外科常见护理纠纷的原因分析及对策

随着我国法制建设的健全完善和人民群众法律保护意识的增强,医疗纠纷事故的发生率也逐年上升。普外科作为高风险科室,护理纠纷发生情况更难避免。如何有避免护理纠纷,是摆在广大护理人员面前的重要研究课题。本文结合临床实践,分析普外科特点和常见的护理纠纷原因,重点探究解决处理纠纷的相关策略。     

Sex, pain and cranberries - ideas from the 2006 Registrar Research Workshop

The Registrar Research Workshop has been a feature of Australian general practice training since 1994. Twenty five general practice registrars attend the annual 3 day event, which aims to develop registrars' understanding of the research process. Presenters and facilitators are drawn from the academic general practitioner and primary health care research community. Presentations alternate with small group sessions, where groups of five registrars are guided through the process of developing a research question, identifying appropriate research methods, and addressing ethical and funding concerns, before preparing a presentation about their research proposal for their peers. Research questions are developed from unanswered questions that have arisen in registrars' clinical practice.