Diagnostic uncertainty in general practice. A unique opportunity for research?

General practice encounters often involve vague symptoms, potentially representing illness in its early stage. Managing such undifferentiated symptoms is difficult, but one of the key tasks of the general practitioner is to discover serious disease at an appropriate stage whilst also minimising over-investigation. Although the diagnostic process and methods of coping with uncertainty in general practice have been described, the early course of disease, especially undifferentiated presentations, is poorly understood. There is still much to learn about diagnosis in general practice, and important contributions could be made by researchers in any primary care setting.     

Exposure time and place: do COPD patients differ from the general population?

Time-activity patterns in a panel of 70 patients with COPD (35 males) are compared to an age-matched subgroup from the randomly sampled Canadian Human Activity Pattern Survey. Total time indoors and outdoors were similar in both groups but significantly more indoor time in COPD subjects was spent at home than the indoor time of controls, who were more often indoors elsewhere. As part of improving their indoor air at home, COPD subjects were significantly more likely to have air conditioning at home. These results suggest that while outdoor air exposure strategies need not differ in COPD subjects from normals, indoor mitigation strategies should emphasize source pollutant control in the patient's home.     

Social Support and the ‘Left Behind’ Elderly in Rural China: A Case Study from Jiangxi Province

This study examines the living situation of elderly people in rural China whose children have left to work in other areas [the ‘left behind’ elderly (LBE)] and explores policy implications associated with their care. Based on survey data and interviews conducted in three villages in Jiangxi Province, China, we compare the living situation of the LBE and the ‘non-left behind’ elderly (NLBE). The data reveal that the LBE are relatively more isolated and that they spend less time interacting with neighbors and more time watching television. The study shows that the LBE have a much greater need for care services than income maintenance. Also, the LBE group has less social capital than the NLBE group. Based on our findings, it is clear that the proposal to use social capital and informal care cannot effectively meet all the needs of the LBE group. Instead, it is recommended that a comprehensive system of social support is developed.     

Falls prevention in rural general practice: what stands the test of time and where to from here?

OBJECTIVE: General practitioner recall of the 1992-96 'Stay on Your Feet' (SOYF) program and its influence on practice were surveyed five years post-intervention to gauge sustainability of the SOYF General Practice (GP) component. METHODS: A survey assessed which SOYF components were still in existence, current practice related to falls prevention, and interest in professional development. All general practitioners (GPs) situated within the boundaries of a rural Area Health Service were mailed a survey in late 2001. RESULTS: Response rate was 66.5% (139/209). Of 117 GPs in practice at the time of SOYF, 80.2% reported having heard of SOYF and 74.4% of those felt it had influenced practice. Half (50.9%) still had a copy of the SOYF GP resource and of those, 58.6% used it at least 'occasionally'. Three-quarters of GPs surveyed (75.2%) checked medications 'most/almost all' of the time with patients over 60 years; 46.7% assessed falls risk factors; 41.3% gave advice; and 22.6% referred to allied health practitioners. GPs indicated a strong interest in falls prevention-related professional development. There was no significant association between use of the SOYF resource package and any of the current falls prevention practices (all chi2 > 0.05). CONCLUSIONS AND IMPLICATIONS: There was high recall of SOYF and a general belief that it influenced practice. There was little indication that use of the resource had any lasting influence on GPs' practices. In future, careful thought needs to go into designing a program that has potential to affect long-term change in GPs' falls prevention practice.     

Occupational health and general practice: from opportunities lost to opportunities capitalised?

BACKGROUND AND AIM: Western populations are in the middle of the epidemiological transition of chronic diseases. Care of patients with chronic disease is directed at optimising life expectancy and quality of life. Daily and social functioning, including paid work are part of the treatment objectives. Yet, advice for and support in work related coping with chronic diseases, and collaboration with occupational health are not--yet--part of routine curative medical care procedures. This is also the case in general practice, where most patients with chronic conditions are treated. This 'blind spot' signals a generic lost opportunity in optimizing the care of patients with chronic disease. This paper analyses from empirical data the importance of integrating work-related advice and support in general practice and explores potential evidence of the benefits this provides for patients: the opportunities that can be capitalised through better interaction between occupational physicians (OP) and general practitioners (GP). METHODS: The paper is based on a review of three sources: (i) Epidemiology of chronic diseases: the Nijmegen Continuous Morbidity Registration; (ii) The relevant guidelines of the Dutch College of General Practitioners; (iii) Studies of work-related implications of asthma and COPD management of GPs of the Nijmegen centre of Evidence-Based Practice. RESULTS: Chronic diseases like cardiovascular disease, diabetes mellitus, COPD and asthma dominate general practice and lead annually to a large number of consultations. Although a majority of patients are 65 years or older--in particular for the first three diseases--GPs also care for a substantial number of under-65 years old. General practice guidelines for these disorders advocate care directed at normal functioning but do not systematically address functioning in the working place. Analysis of work-related functioning in case of chronic respiratory diseases, however, highlight that work-related factors and circumstances play an important role in patients' coping strategies. Patients tend to ignore negative effects of their workplace on their physical condition and as a consequence suffer undue limitations. Despite these work related risks, COPD patients who were in paid employement perceived higher quality of life than COPD patients who were disabled for work, but had similar disease severity (airway obstruction). Interestingly, a programme of patients' self-management of asthma resulted, in comparison to GP-supervised usual care in a substantial and lasting reduction of asthma related absence from work and other social-daily activities. CONCLUSIONS AND DISCUSSION: All consultations with employees with a chronic (respiratory) disease can be considered as opportunities to supervise work-related implications of the disease. Patients value their ability to work but frequently apply inefficient coping through ignoring the implications of their circumstances for their disease. A more efficient coping can probably be achieved through a more active involvement of patients in managing their own disease. Guidelines--like the Dutch College of General Practitioners'--have developed into a sophisticated and generally respected system of guidance of patient care. Explicit emphasis of management in relation to the workplace may present a logical opportunity to capitalise on.     

Practice guidelines, CME and epidemiologic research in general practice: a consistent triad?

A multidisciplinary effort involving epidemiologists, general practitioners and specialists is critical for finding valid and feasible answers, by asking the right questions through observational and experimental studies. Clinical practice guidelines may represent a good starting point of this research process, highlighting which information needs exist in everyday practice; logically, guidelines also represent an ideal end, as a means of transferring any useful knowledge produced into practice. In between, this research process may have an added educational value and represent an active and valuable means of achieving continuing medical education credits. Consistency of the research-education-guidelines triad is discussed in this paper by describing methods and results of a practical research experience--a cohort study for evaluating prevalence, incidence, chronicity and management of digestive disorders--involving epidemiologists, gastroenterologists and thirty-five general practitioners of the Emilia-Romagna region.     

Comorbidity and coexisting symptoms and infections presented in general practice by COPD patients: Does livestock density in the residential environment play a role?

Objectives

Patients with chronic obstructive pulmonary disease (COPD) constitute a potentially susceptible group towards environmental exposures such as livestock farm emissions, given their compromised respiratory health status. The primary aim of this study was to examine the association between livestock exposure and comorbidities and coexisting symptoms and infections in COPD patients.

Knee pain and osteoarthritis in the general population: what influences patients to consult?

BACKGROUND: We examined the relationship between predisposing factors, enabling factors and need-related factors with consultation for knee pain in general practice. METHODS: This was a retrospective review of computerized medical records for knee-related consultations in the 18 months before baseline assessment of individuals aged over 50 years reporting knee pain in the previous 12 months. The association between each factor and consultation for consulters compared to non-consulters was summarized using odds ratios (ORs). Interaction between each variable and chronic pain grade was investigated. The association between knee-related consultation and the number and type of other co-morbid consultations was then determined. RESULTS: In total, 742 participants were assessed. Of these, 209 (28%) had a knee-related consultation in the previous 18 months. Recent onset of pain [OR 3.2; 95% confidence interval (95% CI) 1.8, 5.7] and severity of pain, Grade III/IV (OR 3.4; 95% CI 2.1, 5.6), were associated with knee-related consultation. Those rating their knee problem as a health priority were more likely to consult (OR 3.2; 95% CI 1.6, 6.7). Irrespective of knee pain severity, there was no difference in the median number of co-morbid consultations between knee consulters and knee non-consulters. CONCLUSIONS: Need-related factors appeared to be associated with the decision to consult about knee pain. Neither the presence of self-reported selected co-morbid conditions nor the total number of co-morbid conditions was related to consultations for knee pain. Nevertheless, 50% of those with severely disabling knee pain still did not consult for it. Further investigation of this is important in order to optimize care for patients with knee pain and co-morbid disease.     

Does patients’ experience of general practice affect the use of emergency departments? Evidence from Australia

AS Emergency Department (ED) attendances have been growing rapidly, various strategies have been employed in Australia to improve access to General Practitioner (GP) care, particularly after normal working hours, in order to reduce the demand for ED. However, there has been little attention paid to the quality of GP care and whether that influences ED attendances. This paper investigates whether ED use is affected by patients’ experience of GP care, using the logit model to analyse data from a survey of Australian consumers (1758 individuals). Not surprisingly, we find that people with poor health status and a greater number of chronic conditions are more likely to visit the ED. We also find that, after correcting for health status and sociodemographic factors, patients with a better GP experience are less likely to visit the ED. This suggests that policies aimed at improving the quality of primary care are also important in reducing unplanned hospital use.     

Research report 'the appropriate prescribing of antidepressants in general practice': who is better served by more diagnoses and more antidepressants?

Recently a report entitled 'The appropriate prescribing of antidepressants in general practice' was published. The researchers conclude that depression and anxiety are still more under-diagnosed than over-diagnosed and that antidepressants are frequently prescribed even when they are not indicated. Why this is so remains unclear. Looking for better interventions to improve treatment and increase therapy compliance, this study reports that many types of intervention could help but it is not very specific on how this could be achieved. Improving communication and knowledge about prescribing and how and when to discontinue treatment, are among the suggestions made in the report. Many questions remain: (a) is under-diagnosis a problem in a condition that often resolves spontaneously with watchful waiting?, (b) why are antidepressants so widely prescribed when their effectiveness is controversial and they have major adverse reactions?, (c) why are other treatment options such as talking therapy and a short period psychological intervention, of which the effectiveness has been established, not more frequently applied?     

Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor-patient communication in general practice.

Mishler (The discourse of medicine. The dialectics of medical interviews. Norwood, NJ: Ablex), applying Habermas's theory of Communicative Action to medical encounters. showed how the struggle between the voice of medicine and the voice of the lifeworld fragmented and suppressed patients' multi-faceted, contextualised and meaningful accounts. This paper investigates and critiques Mishler's premise that this results in inhumane, ineffective medical care. Using a more complex data collection strategy, comprising patient interviews, doctor interviews and transcribed consultations we show more complex relations than emerged from Mishler's analysis. We found four communication patterns across 35 general practice case studies. When doctor and patient both used the voice of medicine exclusively (acute physical complaints) this worked for simple unitary problems (Strictly Medicine). When both doctor and patient engaged with the lifeworld, more of the agenda was voiced (Mutual Lifeworld) and patients were recognised as unique human beings (psychological plus physical problems). Poorest outcomes occurred where patients used the voice of the lifeworld but were ignored (Lifeworld Ignored) or blocked (Lifeworld Blocked) by doctors' use of voice of medicine (chronic physical complaints). The analysis supports the premise that increased use of the lifeworld makes for better outcomes and more humane treatment of patients as unique human beings. Some doctors switched communication strategies in different consultations, which suggests that their behaviour might be open to change. If doctors could be sensitised to the importance of dealing with the concerns of the lifeworld for patients with chronic physical conditions as well as psychological conditions, it might be possible to obtain better care for patients. This would require attention to structural aspects of the healthcare system to enable doctors to work fully within the patient-centred model.     

Socioeconomic differences in fat intake in a middle-aged population: report from the Malmö Diet and Cancer Study

BACKGROUND: The objective was to investigate whether socioeconomic differences in fat intake may explain socioeconomic differences in cardiovascular diseases. METHODS: The Malm? Diet and Cancer Study is a prospective cohort study. The baseline examinations used in the present cross-sectional study were undertaken in 1992-1994. Dietary habits were assessed using a modified diet history method consisting of a 7-day menu book and a 168-item questionnaire. A subpopulation of 11 837 individuals born 1926-1945 was investigated. This study examined high fat intake, defined as >35.9% among men and >34.8% among women (25% quartile limit) of the proportion of the non-alcohol energy intake contributed by fat. The subfractions saturated, mono-unsaturated and poly-unsaturated fatty acids and the P:S ratio (polyunsaturated/saturated fatty acids) were analysed in the same way. The uppermost quartile (75%) of total and subgroup fat intake was also studied. Socioeconomic differences before and after adjustment for low energy reporting (LER), defined as energy intake below 1.2 x Basal Metabolic Rate, were examined. RESULTS: No socioeconomic differences in fat intake were seen between the SES groups, except for self-employed men, and male and female pensioners. Approximately 20% in most SES groups were LER. The LER and body mass index were strongly related. The SES pattern of fat intake remained unchanged after adjustment for age, country of origin and LER in a logistic regression model. The results for the subfractions of fat and the P:S ratio did not principally differ from the total fat results. CONCLUSIONS: This study provides no evidence that fat intake contributes to the inverse socioeconomic differences in cardiovascular diseases.