Cancer suspicion in general practice: the role of symptoms and patient characteristics,and their association with subsequent cancer

Background

Awareness of detail in ambiguous complaints may help GPs suspect cancer when a malignancy is present.

Aim

To study the contribution of symptoms and patient characteristics to GPs’ suspicions of cancer being present, and to what degree these suspicions were confirmed.

Design and setting

Prospective cohort study of patients in 283 rural and urban general practices throughout Norway.

Method

During patient consultations (over a period of 10 days) GPs registered whether there was a suspicion of cancer when a patient presented with at least one of seven focal symptoms and three general symptoms commonly considered to be warning signs of cancer. Follow-up questionnaires were sent to GPs 6–7 months later, requesting information on any subsequent diagnosis of cancer in these patients.

Results

Out of 51 073 patients, 6321 presented with warning signs of cancer; of these, 106 had a subsequent cancer diagnosis. Of the patients presenting with warning signs, 1515 (24%) patients were suspected of having cancer; this was correct for 3.8% of suspected cases. Of the 106 patients diagnosed with cancer who presented with warning signs, cancer was suspected in 58 (54.7%). GPs’ correct cancer suspicions were six times more frequent than their erroneous lack of suspicion. Multiple symptoms, previous cancer, comorbidity, and multiple consultations increased the probability of cancer, but only multiple symptoms and previous cancer increased suspicion. Suspicion led to an increase in the number of diagnostic procedures undertaken. The proportion of cancer cases where GPs recorded a lack of suspicion was relatively small, but important.

Conclusion

Selected symptoms appropriately resulted in GPs suspecting cancer. Comorbidity and multiple consultations were underestimated by GPs as factors associated with cancer. Cancer suspicion should rely on symptoms in combination with other relevant information.     

Diagnosing headache in primary care: a qualitative study of GPs’ approaches

Background

Headache is one of the most common symptoms in primary care. Most headaches are due to primary headaches and many headache sufferers do not receive a specific diagnosis. There is still a gap in research on how GPs diagnose and treat patients with headache.

Aim

To identify GPs’ diagnostic approaches in patients presenting with headache.

Design and setting

Qualitative study with 15 GPs in urban and rural practices.

Method

Interviews (20–40 minutes) were conducted using a semi-structured interview guideline. GPs described their individual diagnostic strategies by means of patients presenting with headache that they had prospectively identified during the previous 4 weeks. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters.

Results

Regarding GPs’ general diagnostic approach to patients with headache, four broad themes emerged during the interviews: ‘knowing the patient and their background’, ‘first impression during consultation’, ‘intuition and personal experience’ and ‘application of the test of time’. Four further themes were identified regarding the management of diagnostic uncertainty: ‘identification of red flags’, ‘use of the familiarity heuristic’, ‘therapeutic trial’, and ‘triggers for patient referral’.

Conclusion

GPs apply different strategies in the early diagnostic phase when managing patients with headache. Identification of potential adverse outcomes accompanied by other strategies for handling uncertainty seem to be more important than an exact diagnosis. Established guidelines do not play a role in the diagnostic workup.     

Exception reporting in the Quality and Outcomes Framework: views of practice staff �C a qualitative study

Background

Exception reporting allows practices to exclude eligible patients from indicators or an entire clinical domain of the Quality and Outcomes Framework (QOF). It is a source of contention, viewed by some as a ‘gaming’ mechanism.

Aim

To explore GP and practice staff views and experiences of exception reporting in the QOF.

Design of study

Qualitative semi-structured interviews.

Setting

Interviews with 24 GPs, 20 practice managers, 13 practice nurses, and nine other staff were conducted in 27 general practices in the UK.

Method

Semi-structured interviews, analysed using open explorative thematic coding.

Results

Exception reporting was seen as a clinically necessary part of the QOF. Exempting patients, particularly for discretionary reasons, was seen as an ‘exception to the rule’ that was justified either in terms of practising patient-centred care within a framework of population-based health measures or because of the poor face validity of the indicators. Rates in all practices were described as minimal and the threat of external scrutiny from primary care trusts kept rates low. However, GPs were happy to defend using discretionary exception codes for individual patients. Exception reporting was used, particularly at the end of the payment year, to meet unmet targets and to prevent the practice being penalised financially. Overt gaming was seen as something done by ‘other’ practices. Only two GPs admitted to occasional inappropriate exception reporting.

Conclusion

Exception reporting is seen by most GPs and practice staff as an important and defensible safeguard against inappropriate treatment or over-treatment of patients. However, a minority of practitioners also saw it as a gaming mechanism.     

Motivation and satisfaction in GP training: a UK cross-sectional survey

Background

Recruitment to general practice has had periods of difficulty, but is currently going through a phase of relative popularity in the UK.

Aim

To explore motivators for career choice and career satisfaction among UK GP trainees and newly qualified GPs.

Design and setting

Cross-sectional web-based questionnaire of GP trainees and GPs within the first 5 years of qualification in the UK.

Method

All 9557 UK GP trainees and 8013 GPs who were within the first 5 years of qualification were invited to participate by email. Further publicity was conducted via general practice publications and the internet.

Results

Overall, there were 2178 responses to the questionnaire (12.4% response rate, 61.5% women, 61.8% trainees). Levels of satisfaction were high, with 83% of responders stating that they would choose to be a doctor again; of these, 95% would choose to be a GP again. The most frequently cited reason for choosing general practice was ‘compatibility with family life’, which was chosen by 76.6% of women and 63.2% of men (P<0.001). Other reasons given were: ‘challenging medically diverse discipline’ (women 59.8%, men 61.8%, P = 0.350), ‘the one-to-one care general practice offers’ (women 40.0%, men 41.2%, P = 0.570), ‘holistic approach’ (women 41.4%, men 30.1%, P<0.001), ‘autonomy and independence’ (women 18.0%, men 34.8%, P<0.001), ‘communication’ (women 20.6%, men 12.2%, P<0.001), ‘negative experiences in hospital’ (women 12.8%, men 9.8%, P= 0.036), and ‘good salary’ (women 7.8%, men 14.9%, P<0.001).

Conclusion

The most important reason for both women and men choosing general practice as a career in the UK is its compatibility with family life. As such, changes to UK primary care that decrease family compatibility could negatively impact on recruitment.     

Placebo interventions in practice: a questionnaire survey on the attitudes of patients and physicians

Background

Few studies have investigated whether patients and physicians differ in their attitudes regarding placebo interventions in medical practice.

Aim

To compare the proportions of patients and physicians who would accept therapies that do not work through specific pharmacological or physiological action but by enhancing self-healing capacities and by exploiting contextual factors.

Design of study

Survey of a random sample of GPs and patients consecutively attending in primary care practices.

Setting

Four hundred and seventy-seven patients and 300 GPs from primary care practices of the Canton Zurich of Switzerland were approached.

Method

Two questionnaires on responders'' attitudes regarding non-specific therapies.

Results

The response rates were 87% for patients and 79% for GPs. Eighty-seven per cent of patients and 97% of GPs thought that physical complaints can get better by believing in the effectiveness of the therapy. Overall there was more support for placebo interventions among patients than among GPs, yet 90% of the physicians admitted to actively proposing treatments intended to take advantage of non-specific effects. Seventy per cent of the patients wanted to be explicitly informed when receiving a non-specific intervention, whereas physicians thought this was the case for only 33% of their patients. Fifty-four per cent of patients would be disappointed when learning they had unknowingly been treated with pure placebo (‘sugar pill’), while only 44% would feel that way after treatment with impure placebo (for example, herbal medicine).

Conclusion

GPs rather underestimate the openness of their patients to non-specific therapies. However, patients want to be appropriately informed. Developing specific professional standards could help physicians to harness the ‘power of the placebo’, while remaining authentic and credible.     

��I didn't want her to panic��: unvoiced patient agendas in primary care consultations when consulting about antidepressants

Background

Patient participation in primary care treatment decisions has been much debated. There has been little attention to patients'' contributions to primary care consultations over a period of time, when consulting about depression and its treatment with antidepressants.

Aim

To explore: (1) what issues remain unsaid during a primary care consultation for depression but are later raised by the patient as important during a research interview; (2) patients'' reasons for non-disclosure; (3) whether unvoiced agendas are later voiced; and (4) the nature of the GP–patient relationship in which unvoiced agendas occur.

Design of study

Qualitative interview study.

Setting

Primary health care.

Method

Patients were recruited through six general practices in the south west of England. Qualitative interviews were carried out with 10 ‘pairs’ of GPs and patients who presented with a new or first episode of moderate to severe depression and were prescribed antidepressants. Follow-up patient interviews were conducted at 3 and 6 months. Throughout the 6-month period, patients were invited to record subsequent consultations (with GPs'' consent), using a patient-held tape recorder.

Results

Twenty-three unvoiced agendas were revealed, often within decision-making relationships that were viewed in positive terms by patients. Unvoiced agendas included: a preference for immediate treatment, a preference to increase dosage, and the return or worsening of suicidal thoughts. In some cases, patients were concerned that they were ‘letting the GP down’ by not being able to report feeling better.

Conclusion

Unvoiced agendas are not necessarily an indication that ‘shared decision making’ is absent but may in some cases represent patients'' attempts to ‘protect’ their GPs.     

Reasons why doctors choose or reject careers in general practice: national surveys

Background

Less than one-third of newly qualified doctors in the UK want a career in general practice. The English Department of Health expects that half of all newly qualified doctors will become GPs.

Aim

To report on the reasons why doctors choose or reject careers in general practice, comparing intending GPs with doctors who chose hospital careers.

Design and setting

Questionnaire surveys in all UK medical graduates in selected qualification years.

Method

Questions about specialty career intentions and motivations, put to the qualifiers of 1993, 1996, 1999, 2000, 2002, 2005, 2008, and 2009, 1 year after qualification, and at longer time intervals thereafter.

Results

‘Enthusiasm for and commitment to the specialty’ was a very important determinant of choice for intending doctors, regardless of chosen specialty. ‘Hours and working conditions’ were a strong influence for intending GPs (cited as having had ‘a great deal’ of influence by 75% of intending GPs in the first year after qualification), much more so than for doctors who wanted a hospital career (cited by 30%). Relatively few doctors had actually considered general practice seriously but then rejected it; 78% of the doctors who rejected general practice gave ‘job content’ as their reason, compared with 32% of doctors who rejected other specialties.

Conclusion

The shortfall of doctors wanting a career in general practice is not accounted for by doctors considering and rejecting it. Many do not consider it at all. There are very distinctive factors that influence choice for, and rejection of, general practice.     

Do doctors and patients agree on cardiovascular-risk management recommendations post-consultation? The INTERMEDE study

Background

Understanding interactions between patients and GPs may be important for optimising communication during consultations and improving health promotion, notably in the management of cardiovascular risk factors.

Aim

To explore the agreement between physicians and patients on the management of cardiovascular risk factors, and whether potential disagreement is linked to the patient''s educational level.

Design of study

INTERMEDE is a cross-sectional study with data collection occurring at GPs'' offices over a 2-week period in October 2007 in France.

Method

Data were collected from both patients and doctors respectively via pre- and post-consultation questionnaires that were ‘mirrored’, meaning that GPs and patients were presented with the same questions.

Results

The sample consisted of 585 eligible patients (61% females) and 27 GPs. Agreement between patients and GPs was better for tangible aspects of the consultation, such as measuring blood pressure (κ = 0.84, standard deviation [SD] = 0.04), compared to abstract elements, like advising the patient on nutrition (κ = 0.36, SD = 0.04), and on exercise (κ = 0.56, SD = 0.04). Patients'' age was closely related to level of education: half of those without any qualification were older than 65 years. The statistical association between education and agreement between physicians and patients disappeared after adjustment for age, but a trend remained.

Conclusion

This study reveals misunderstandings between patients and GPs on the content of the consultation, especially for health-promotion outcomes. Taking patients'' social characteristics into account, notably age and educational level, could improve mutual understanding between patients and GPs, and therefore, the quality of care.     

The ‘added value’ GPs bring to commissioning: a qualitative study in primary care

Background

The 2012 Health and Social Care Act in England replaced primary care trusts with clinical commissioning groups (CCGs) as the main purchasing organisations. These new organisations are GP-led, and it was claimed that this increased clinical input would significantly improve commissioning practice.

Aim

To explore some of the key assumptions underpinning CCGs, and to examine the claim that GPs bring ‘added value’ to commissioning.

Design and setting

In-depth interviews with clinicians and managers across seven CCGs in England between April and September 2013.

Method

A total of 40 clinicians and managers were interviewed. Interviews focused on the perceived ‘added value’ that GPs bring to commissioning.

Results

Claims to GP ‘added value’ centred on their intimate knowledge of their patients. It was argued that this detailed and concrete knowledge improves service design and that a close working relationship between GPs and managers strengthens the ability of managers to negotiate. However, responders also expressed concerns about the large workload that they face and about the difficulty in engaging with the wider body of GPs.

Conclusion

GPs have been involved in commissioning in many ways since fundholding in the 1990s, and claims such as these are not new. The key question is whether these new organisations better support and enable the effective use of this knowledge. Furthermore, emphasis on experiential knowledge brings with it concerns about representativeness and the extent to which other voices are heard. Finally, the implicit privileging of GPs’ personal knowledge ahead of systematic public health intelligence also requires exploration.     

Advance care planning for cancer patients in primary care: a feasibility study

Background

Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging.

Aim

To assess the feasibility of implementing advance care planning in UK primary care.

Design of study

Mixed methods evaluation of a pilot educational intervention.

Setting

Four general practices in south-east Scotland.

Method

Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK.

Results

End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a ‘good death’. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of ‘tick-box’ approach. Following the workshop, participants'' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care.

Conclusion

A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes.     

What happens when doctors are patients? Qualitative study of GPs

Background

Current evidence about the experiences of doctors who are unwell is limited to poor quality data.

Aim

To investigate GPs'' experiences of significant illness, and how this affects their own subsequent practice.

Design of study

Qualitative study using interpretative phenomenological analysis to conduct and analyse semi-structured interviews with GPs who have experienced significant illness.

Setting

Two primary care trusts in the West of England.

Method

A total of 17 GPs were recruited to take part in semi-structured interviews which were conducted and analysed using interpretative phenomenological analysis

Results

Four main categories emerged from the data. The category, ‘Who cares when doctors are ill?’ embodies the tension between perceptions of medicine as a ‘caring profession’ and as a ‘system’. ‘Being a doctor–patient’ covers the role ambiguity experienced by doctors who experience significant illness. The category ‘Treating doctor–patients’ reveals the fragility of negotiating shared medical care. ‘Impact on practice’ highlights ways in which personal illness can inform GPs'' understanding of being a patient and their own consultation style.

Conclusion

Challenging the culture of immunity to illness among GPs may require interventions at both individual and organisational levels. Training and development of doctors should include opportunities to consider personal health issues as well as how to cope with role ambiguity when being a patient and when treating doctor–patients. Guidelines about being and treating doctor–patients need to be developed, and GPs need easy access to an occupational health service.     

Hospital admissions from nursing homes: a qualitative study of GP decision making

Background

Decisions regarding the hospitalisation of nursing home residents may present a difficult dilemma for GPs. There are pressures to admit very frail patients with exacerbations of illness even though such frailty may limit the possible health gains. As ‘gatekeepers’ to NHS, GPs are expected to make best use of resources and may be criticised for ‘inappropriate’ admissions. Little is understood about the influences on GPs as they make such decisions

Aim

To explore GPs views on factors influencing decisions on admitting frail nursing home residents to hospital.

Design and setting

A purposive sample of 21 GPs from two counties in the South of England.

Method

Data from semi-structured, one-to-one interviews with GPs were analysed using thematic analysis following principles of the constant comparative method.

Results

This study suggests that while clinical assessment, perceived benefits and risks of admission, and patients’ and relatives’ preferences are key factors in determining admissions, other important factors influencing decision making include medico-legal concerns, communications, capability of nursing homes and GP workload. These factors were also perceived by GPs as influencing the feasibility of keeping patients in the nursing home when this was clinically appropriate. Key areas suggested by GPs to improve practice were improving communication (particularly informational continuity), training and support for nursing staff, and peer support for GPs. Local initiatives to address these issues were very variable.

Conclusion

Developing a systematic palliative care approach to address poor documentation and communication, the capability of nursing homes, and medico-legal concerns has the potential to improve decision-making regarding hospital admissions.     

Integrating preconception care for women with diabetes into primary care: a qualitative study

Background

National guidelines emphasise the need to deliver preconception care to women of childbearing age. However, uptake of the services among women with diabetes in the UK is low. Questions arising include how best to deliver preconception care and what the respective roles of primary versus secondary caregivers might be.

Aim

To explore the perspective of GPs and secondary care health professionals on the role of GPs in delivering preconception care to women with diabetes.

Design of study

Qualitative, cross-sectional study.

Setting

A London teaching hospital and GP practices in the hospital catchment area.

Method

Semi-structured interviews with GPs and members of the preconception care team in secondary care. Thematic analysis using the framework approach.

Results

GPs and secondary care professionals differ in their perception of the number of women with diabetes requiring preconception care and the extent to which preconception care should be integrated into GPs'' roles. Health professionals agreed that GPs have a significant role to play and that delivery of preconception care is best shared between primary and secondary care. However, the lack of clear guidelines and shared protocols detailing the GP''s role presents a challenge to implementing ‘shared’ preconception care.

Conclusion

GPs should be more effectively involved in providing preconception care to women with diabetes. Organisational and policy developments are required to support GPs in playing a role in preconception care. This study''s findings stress the importance of providing an integrated approach to ensure continuity of care and optimal pregnancy preparation for women with diabetes.     

Therapeutic decisions by number needed to treat and survival gains: a cross-sectional survey of lipid-lowering drug recommendations

Background

Previous studies suggest that lay people have difficulties with evaluating effect size in terms of number needed to treat (NNT), but theyare sensitive to effect size in terms of survival gains.

Aim

To explore whether GPs and internists are sensitive to NNT and survival gains when considering a lipid-lowering drug therapy.

Design and setting

Cross-sectional survey of primary prevention of cardiovascular disease with random allocation to different scenarios.

Method

GPs (n = 450) and internists (n = 450) were posted a vignette presenting a high-risk patient and a novel drug, ‘neostatin’. The benefit was described in terms of NNT or mean gain in disease-free survival. Each physician was randomly allocated to one version of the vignette. Outcome measures were evaluation of ‘neostatin’ on a Likert scale (0: very poor choice, 10: very good choice) and the proportion recommending ‘neostatin’.

Results

A total of 477 responses (53%) were received. Among responders to NNT scenarios, 26%, 31%, and 43% recommended ‘neostatin’ for NNT values of 34, 17, and 9 respectively. With equivalent disease-free survival gains of 9, 17, and 32 months, 40%, 49%, and 52% respectively recommended the drug. On the rating scale, mean values were 4.7, 5.0, and 5.5 across the respective NNT scenarios and 5.2, 6.2, and 6.1 across the scenarios presenting survival gains. Differences in trends between the two formats were not statistically significant. In total, 33% recommended ‘neostatin’ when presented with NNT values, compared to 47% when presented with survival gain (χ² = 9.2, P= 0.002).

Conclusion

Physicians presented with survival gains were more likely to recommend the therapy than those presented with NNT. Sensitivity to effect size was similarfor both effect formats.     

Risk taking in general practice: GP out-of-hours referrals to hospital

Background

Emergency admissions to hospital at night and weekends are distressing for patients and disruptive for hospitals. Many of these admissions result from referrals from GP out-of-hours (OOH) providers.

Aim

To compare rates of referral to hospital for doctors working OOH before and after the new general medical services contract was introduced in Bristol in 2005; to explore the attitudes of GPs to referral to hospital OOH; and to develop an understanding of the factors that influence GPs when they refer patients to hospital.

Design of study

Cross-sectional comparison of admission rates; postal survey.

Setting

Three OOH providers in south-west England.

Method

Referral rates were compared for 234 GPs working OOH, and questionnaires explored their attitudes to risk.

Results

There was no change in referral rates after the change in contract or in the greater than fourfold variation between those with the lowest and highest referral rates found previously. Female GPs made fewer home visits and had a higher referral rate for patients seen at home. One-hundred and fifty GPs responded to the survey. Logistic regression of three combined survey risk items, sex, and place of visit showed that GPs with low ‘tolerance of risk’ scores were more likely to be high referrers to hospital (P<0.001).

Conclusion

GPs'' threshold of risk is important for explaining variations in referral to hospital.     

Work-related sickness absence negotiations: GPs' qualitative perspectives

Background

GPs can find their role as issuers of sickness certification problematic, particularly in trying to maintain a balance between certifying absence and preserving the doctor–patient relationship. Little research has been published on consultations in which sickness absence has been certified.

Aim

To explore negotiations between GPs and patients in sickness absence certification, including how occupational health training may affect this process.

Method

A qualitative study was undertaken with GPs trained in occupational health who also participate in a UKwide surveillance scheme studying work-related ill-health. Telephone interviews were conducted with 31 GPs who had reported cases with associated sickness absence.

Results

Work-related sickness absence and patients'' requests for a ‘sick note’ vary by diagnosis. Some GPs felt their role as patient advocate was of utmost importance, and issue certificates on a patient’s request, whereas others offer more resistance through a greater understanding of issues surrounding work and health aquired through occupational health training. GPs felt that their training helped them to challenge beliefs about absence from work being beneficial to patients experiencing ill-health; they felt better equipped to consider patients’ fitness for work, and issued fewer certificates as a result of this.

Conclusion

Complex issues surround GPs'' role in the sickness-certification process, particularly when determining the patient''s ability to work while maintaining a healthy doctor–patient relationship. This study demonstrates the potential impact of occupational health training for GPs, particularly in light of changes to the medical statement introduced in 2010.