Paternalism and the doctor-patient relationship in general practice.

This paper is a brief introduction to the subject of paternalism as it occurs in general practice. A definition of paternalism is provided and the four main types of doctor-patient relationship within the paternalistic spectrum are described. These relationships are illustrated with examples from general practice. Some of the extensive literature on paternalism is reviewed. It is concluded that paternalism is rarely justified when treating patients of sound mind and then only where restoration of the patients' autonomy is the main aim.     

Evaluation of a direct doctor-patient telephone advice line in general practice.

A general practitioner-staffed direct access telephone advice line was made available for 30 minutes every morning at an inner-London practice to advise patients with urgent problems. Users valued the service, but the impact on surgery consultations was too small for this to be advocated as an alternative to emergency consultations.     

Salaried general practice in Czechoslovakia: personal observations and impressions.

In 1991, a visit was undertaken, to the former Czechoslovakia, during which discussions were held with general practitioners. Some personal observations and impressions from the visit are presented. For four decades, salaried general practice was a feature of the Czechoslovakian health care system. Primary health care comprised three strands: paediatric services, an occupational health service and community general practitioner care. The main point of service delivery was the polyclinic which, although being large and impersonal, provided easy access to other primary and secondary services. General practitioners, over half of whom were women, had regular leave entitlement and predictable hours of work, out of hours work being provided through separate contracts based on primary care emergency centres. However, doctors were poorly paid compared with industrial workers. Following the 'velvet revolution' in 1989, all aspects of the health service have been subject to major review, and salaried general practice is likely to give way to a more entrepreneurial system.     

Clinical value of microbiological investigations in general practice.

The clinical value of many laboratory tests has frequently been queried. A short questionnaire was attached to individual microbiology reports issued to general practitioners in Bradford for an eight week period. Of the 2386 questionnaires sent out 1847 (77%) were returned. The general practitioners indicated that 34% of reports gave unexpected findings, 28% resulted in a change of therapy and most of the investigations (83%) were seen as beneficial to the patients. The majority of the specimens (56%) were mid-stream urine samples of which 77% gave negative findings. This study indicates that conventional microbiology test results are more valuable in general practice than previous hospital based surveys might suggest. Alternative strategies for investigation to reduce the number of tests of low value are discussed.     

Organized personal care--an effective choice for managing diabetes in general practice.

A system of diabetic review was introduced in two Southampton training practices in March 1985. Each partner, with the help of the practice nurse, retained responsibility for review of their own diabetic patients. During the study period (1984-86) 213 diabetics remained with the practices. In 1984 there were 94 non-insulin dependent patients who were not receiving hospital outpatient care. Over the study period there was an increase in the surveillance of blood glucose, blood pressure, weight, urine (for protein), fundi, visual acuity and feet for this group so that in 1986 between 79% and 89% of patients were having these parameters checked at least annually. More complications were found and more referrals for specialist evaluation were made. There was a trend towards transfer of care from the hospital to the general practitioner, and the proportion of non-insulin dependent diabetic patients receiving their care entirely from general practice increased from 22% to 60% over the period. There was a small increase in the workload of the general practitioners and a considerable contribution to care was made by the practice nurses. It is concluded that structured personal diabetic care based on a nurse coordinated service is a satisfactory alternative to the 'specialist' general practitioner mini-clinic model.     

Communication guidelines as a learning tool: An exploration of user preferences in general practice

Objective

To explore characteristics of written communication guidelines that enhance the success of training aimed at the application of the recommendations in the guidelines.

Methods

Seven mixed focus groups were held consisting of communication skill teachers and communication skill learners and three groups with only learners. Analysis was done in line with principles of grounded theory.

Results

Five key attributes of guidelines for communication skill training were identified: complexity, level of detail, format and organization, type of information, and trustworthiness/validity. The desired use of these attributes is related to specific educational purposes and learners’ expertise. The low complexity of current communication guidelines is appreciated, but seems ad odds with the wish for more valid communication guidelines.

Conclusions

Which guideline characteristics are preferred by users depends on the expertise of the learners and the educational purpose of the guideline.

Practice implications

Communication guidelines can be improved by modifying the key attributes in line with specific educational functions and learner expertise. For example: the communication guidelines used in GP training in the Netherlands, seem to offer an oversimplified model of doctor patient communication. This model may be suited for undergraduate learning, but does not meet the validity demands of physicians in training.     

The value of vaginal cultures in general practice

One hundred and eighty high risk cases in a hospital special treatment centre and 50 low risk cases of vaginal discharge from general practice were investigated by the cultural examination of vaginal secretion. The results show this procedure is of value in diagnosing sexually transmitted diseases.