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1.
Stefan B?sner Simone Hartel Judith Diederich Erika Baum 《The British journal of general practice》2014,64(626):e532-e537
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. 相似文献2.
John Campbell Martin Roland Suzanne Richards Andy Dickens Michael Greco Peter Bower 《The British journal of general practice》2009,59(558):e8-e15
Background
National standards for delivery of out-of-hours services have been refined. Health service users'' preferences, reports, and evaluations of care are of importance in a service that aims to be responsive to their needs.Aim
To investigate NHS service users'' reports and evaluations of out-of-hours care in the light of UK national service quality requirements.Design
Cross sectional survey.Setting
Three areas (Devon, Cornwall, Sheffield) of England, UK.Method
Participants were 1249 recent users of UK out-of-hours medical services. Main outcome measures were: users'' reports and evaluations of out-of-hours services in respect of the time waiting for their telephone call to the service to be answered; the length of time from the end of the initial call to the start of definitive clinical assessment (‘call back time’); the time waiting for a home visit; and the waiting time at a treatment centre.Results
UK national quality requirements were reported as being met by two-thirds of responders. Even when responders reported that they had received the most rapid response option for home visiting (waiting time of ‘up to an hour’), only one-third of users reported this as ‘excellent’. Adverse evaluations of care were consistently related to delays encountered in receiving care and (for two out of four measures) sex of patient. For 50% of users to evaluate their care as ‘excellent’, this would require calls to be answered within 30 seconds, call-back within 20 minutes, time spent waiting for home visits of significantly less than 1 hour, and treatment centre waiting times of less than 20 minutes.Conclusion
Users have high expectations of UK out-of-hours healthcare services. Service provision that meets nationally designated targets is currently judged as being of ‘good’ quality by service users. Attaining ‘excellent’ levels of service provision would prove challenging, and potentially costly. Delivering services that result in high levels of user satisfaction with care needs to take account of users'' expectations as well as their experience of care. 相似文献3.
Clare McDermott Richard Coppin Paul Little Geraldine Leydon 《The British journal of general practice》2012,62(601):e538-e545
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 decisionsAim
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. 相似文献4.
Fiona Fox Michael Harris Gordon Taylor Karen Rodham Jane Sutton Brian Robinson Jenny Scott 《The British journal of general practice》2009,59(568):811-818
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 analysisResults
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. 相似文献5.
Paul Little Peter White Joanne Kelly Hazel Everitt Shkelzen Gashi Annemieke Bikker Stewart Mercer 《The British journal of general practice》2015,65(635):e357-e365
Background
Few studies have assessed the importance of a broad range of verbal and non-verbal consultation behaviours.Aim
To explore the relationship of observer ratings of behaviours of videotaped consultations with patients’ perceptions.Design and setting
Observational study in general practices close to Southampton, Southern England.Method
Verbal and non-verbal behaviour was rated by independent observers blind to outcome. Patients competed the Medical Interview Satisfaction Scale (MISS; primary outcome) and questionnaires addressing other communication domains.Results
In total, 275/360 consultations from 25 GPs had useable videotapes. Higher MISS scores were associated with slight forward lean (an 0.02 increase for each degree of lean, 95% confidence interval [CI] = 0.002 to 0.03), the number of gestures (0.08, 95% CI = 0.01 to 0.15), ‘back-channelling’ (for example, saying ‘mmm’) (0.11, 95% CI = 0.02 to 0.2), and social talk (0.29, 95% CI = 0.4 to 0.54). Starting the consultation with professional coolness (‘aloof’) was helpful and optimism unhelpful. Finishing with non-verbal ‘cut-offs’ (for example, looking away), being professionally cool (‘aloof’), or patronising, (‘infantilising’) resulted in poorer ratings. Physical contact was also important, but not traditional verbal communication.Conclusion
These exploratory results require confirmation, but suggest that patients may be responding to several non-verbal behaviours and non-specific verbal behaviours, such as social talk and back-channelling, more than traditional verbal behaviours. A changing consultation dynamic may also help, from professional ‘coolness’ at the beginning of the consultation to becoming warmer and avoiding non-verbal cut-offs at the end. 相似文献6.
Isobel M Cameron Kenneth Lawton Ian C Reid 《The British journal of general practice》2009,59(566):644-649
Background
Since the 1990s, Scottish community-based antidepressant prescribing has increased substantially.Aim
To assess whether GPs prescribe antidepressants appropriately.Design of study
Observational study of adults (aged ≥16 years) screened with the Hospital Anxiety and Depression Scale (HADS) attending a GP.Setting
Four practices in Grampian, Scotland.Method
Patients (n = 898) completed the HADS, and GPs independently estimated depression status. Notes were scrutinised for evidence of antidepressant use, and the appropriateness of prescribing was assessed.Results
A total of 237 (26%) participants had HADS scores indicating ‘possible’ (15%) or ‘probable’ (11%) depression. The proportion of participants rated as depressed by their GP differed significantly by HADS depression subscale scores. Odds ratio for ‘possible’ versus ‘no’ depression was 3.54 (95% confidence interval [CI] = 2.17 to 5.76, P<0.001); and for ‘probable’ versus ‘possible’ depression was 3.59 (95% CI = 2.06 to 6.26, P<0.001). Similarly, the proportion of participants receiving antidepressants differed significantly by HADS score. Odds ratio for ‘possible’ versus ‘no’ depression was 2.79 (95% CI = 1.70 to 4.58, P<0.001); and for ‘probable’ versus ‘possible’ was 2.12 (95% CI = 1.21 to 3.70, P = 0.009). In 101 participants with ‘probable’ depression, GPs recognised 53 (52%) participants as having a clinically significant depression. Inappropriate initiation of antidepressant treatment occurred very infrequently. Prescribing to participants who were not symptomatic was accounted for by the treatment of pain, anxiety, or relapse prevention, and for ongoing treatment of previously identified depression.Conclusion
There was little evidence of prescribing without relevant indication. Around half of patients with significant symptoms were not identified by their GP as suffering from a depressive disorder: this varied inversely with severity ratings. Rather than prescribing indiscriminately (as has been widely assumed), it is likely that GPs are initiating antidepressant treatment conservatively. 相似文献7.
Chris Shiels Mark Gabbay Jim Hillage 《The British journal of general practice》2014,64(620):e137-e143
Background
The ‘fit note’, with the opportunity for the GP to advise that a patient ‘may be fit’ to do some work, was introduced in April 2010.Aim
To estimate numbers of fit notes with ‘may be fit’ advice, the types of advice, and factors associated with any inclusion of such advice in the fit note.Design and setting
Cross-sectional analysis of fit note data from 68 general practices in eight regions of England, Wales and Scotland.Method
Collection of practice fit note data via GP use of carbonised pads of fit notes for a period of 12 months.Results
The ‘may be fit’ box was ticked on 5080 fit notes (6.4% of all fit notes in study). But there was a wide variation in completion rates across the 68 practices (from 1% to 15%). The most prevalent individual item of advice was to ‘amend duties’ of patient as a prerequisite for return to work (included in 42% of all notes containing any ‘may be fit’ advice). Advice was often incomplete or irrelevant, with some GPs failing to comply with official guidance. Inclusion of any ‘may be fit’ advice was independently associated with the patient being female, less socially deprived and having a physical health reason for receiving a fit note.Conclusion
Unlike other studies that have relied upon eliciting opinion, this study investigates how the fit note is being used in practice. Findings provide some evidence that the fit note is not yet being used to the optimum benefit of patients (and their employers). 相似文献8.
Shamil Haroon Peymane Adab Carl Griffin Rachel Jordan 《The British journal of general practice》2013,63(606):e55-e62
Background
Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality. However, much of the disease burden remains undiagnosed.Aim
To compare the yield and cost effectiveness of two COPD case-finding approaches in primary care.Design and setting
Pilot randomised controlled trial in two general practices in the West Midlands, UK.Method
A total of 1634 ever-smokers aged 35–79 years with no history of COPD or asthma were randomised into either a ‘targeted’ or ‘opportunistic’ case-finding arm. Respiratory questionnaires were posted to patients in the ‘targeted’ arm and provided to patients in the ‘opportunistic’ arm at routine GP appointments. Those reporting at least one chronic respiratory symptom were invited for spirometry. COPD was defined as pre-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC)<0.7 and FEV1<80% of predicted. Primary outcomes were the difference in the proportion of patients diagnosed with COPD and the cost per case detected.Results
Twenty-six per cent (212/815) in the ‘targeted’ and 13.6% (111/819) in the ‘opportunistic’ arm responded to the questionnaire and 78.3% (166/212) and 73.0% (81/111), respectively, reported symptoms; 1.2% (10/815) and 0.7% (6/819) of patients in the ‘targeted’ and ‘opportunistic’ arms were diagnosed with COPD (difference in proportions = 0.5% [95% confidence interval {CI} = –0.5% to 3.08%]). Over a 12-month period, the ‘opportunistic’ case-finding yield could be improved to 1.95% (95% CI = 1.0% to 2.9%). The cost-per case detected was £424.56 in the ‘targeted’ and £242.20 in the ‘opportunistic’ arm.Conclusion
Opportunistic case finding may be more effective and cost effective than targeting patients with a postal questionnaire alone. A larger randomised controlled trial with adequate sample size is required to test this. 相似文献9.
Mark Ashworth Peter Schofield Stevo Durbaba Sanjiv Ahluwalia 《The British journal of general practice》2014,64(620):e168-e177
Background
Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care.Aim
The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care.Design and setting
Retrospective cross-sectional study in general practices in England.Method
Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. Outcome measures: multilevel regression models adjusted for clustering.Results
GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the ‘doctor care’ (n = 6) and ‘overall satisfaction’ (n = 2) domains but not to any of the ‘nurse care’ or ‘out-of-hours’ domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients.Conclusion
Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as ‘listening’ or ‘care and concern’. 相似文献10.
11.
Jonathan Hammond Katja Gravenhorst Emma Funnell Susan Beatty Derek Hibbert Jonathan Lamb Heather Burroughs Marija Kovand?i? Mark Gabbay Christopher Dowrick Linda Gask Waquas Waheed Carolyn A Chew-Graham 《The British journal of general practice》2013,63(608):e177-e184
Background
General practice receptionists fulfil an essential role in UK primary care, shaping patient access to health professionals. They are often portrayed as powerful ‘gatekeepers’. Existing literature and management initiatives advocate more training to improve their performance and, consequently, the patient experience.Aim
To explore the complexity of the role of general practice receptionists by considering the wider practice context in which they work.Design and setting
Ethnographic observation in seven urban general practices in the north-west of England.Method
Seven researchers conducted 200 hours of ethnographic observation, predominantly in the reception areas of each practice. Forty-five receptionists were involved in the study and were asked about their work as they carried out their activities. Observational notes were taken. Analysis involved ascribing codes to incidents considered relevant to the role and organising these into related clusters.Results
Receptionists were faced with the difficult task of prioritising patients, despite having little time, information, and training. They felt responsible for protecting those patients who were most vulnerable, however this was sometimes made difficult by protocols set by the GPs and by patients trying to ‘play’ the system.Conclusion
Framing the receptionist–patient encounter as one between the ‘powerful’ and the ‘vulnerable’ gets in the way of fully understanding the complex tasks receptionists perform and the contradictions that are inherent in their role. Calls for more training, without reflective attention to practice dynamics, risk failing to address systemic problems, portraying them instead as individual failings. 相似文献12.
Rebecca Lawton Paul T Seed Maria Kordowicz Peter Schofield André Tylee Mark Ashworth 《The British journal of general practice》2014,64(623):e354-e363
Background
Patients with coronary heart disease (CHD) who are depressed have an increased risk of further cardiac events and higher mortality.Aim
To use a patient generated instrument (PSYCHLOPS) to define categories of concerns in patients with CHD. To define the psychometric characteristics of patients in each category.Design and setting
Cross-sectional study set in general practices in south London.Method
Of 3325 patients on the CHD registers in 15 general practices, 655 completed six baseline psychometric and functional instruments: PSYCHLOPS, HADS-Depression, HADS-Anxiety, Clinical Interview Schedule – Revised, SF12-Mental and SF12-Physical. Content analysis was used to categorise patients based on their main problem, as elicited by PSYCHLOPS. Mean psychometric scores were adjusted for confounding by age, sex, deprivation and ethnicity and calculated for each response category.Results
Response categories were: physical problems, both non-cardiac (23.2%) and cardiac (6.0%); social problems: relationship/family (18.2%), money (7.5%), work (3.1%); functional (9.8%); psychological (6.9%); miscellaneous (7.3%); ‘no problem’ (18.2%). The highest psychological distress scores were found in ‘physical, cardiac’ and ‘psychological’ categories. The ‘no problem’ category had significantly lower psychological distress and higher functional capacity than other categories.Conclusions
PSYCHLOPS enabled the identification of subtypes of CHD patients, based on a classification of self-reported problems. A high proportion of CHD patients report social problems. Psychological distress was highest in those reporting cardiac or psychological symptoms. Services should be aligned to the reported needs of patients. 相似文献13.
Stephen Barclay Katherine Froggatt Clare Crang Elspeth Mathie Melanie Handley Steve Iliffe Jill Manthorpe Heather Gage Claire Goodman 《The British journal of general practice》2014,64(626):e576-e583
Background
Older people living in care homes often have limited life expectancy. Practitioners and policymakers are increasingly questioning the appropriateness of many acute hospital admissions and the quality of end-of-life care provided in care homes.Aim
To describe care home residents’ trajectories to death and care provision in their final weeks of life.Design and setting
Prospective study of residents in six residential care homes in three sociodemographically varied English localities: Hertfordshire, Essex, and Cambridgeshire.Method
Case note reviews and interviews with residents, care home staff, and healthcare professionals.Results
Twenty-three out of 121 recruited residents died during the study period. Four trajectories to death were identified: ‘anticipated dying’ with an identifiable end-of-life care period and death in the care home (n = 9); ‘unexpected dying’ with death in the care home that was not anticipated and often sudden (n = 3); ‘uncertain dying’ with a period of diagnostic uncertainty or difficult symptom management leading to hospital admission and inpatient death (n = 7); and ‘unpredictable dying’ with an unexpected event leading to hospital admission and inpatient death (n = 4). End-of-life care tools were rarely used. Most residents who had had one or more acute hospital admission were still alive at the end of the study.Conclusion
For some care home residents there was an identifiable period when they were approaching the end-of-life and planned care was put in place. For others, death came unexpectedly or during a period of considerable uncertainty, with care largely unplanned and reactive to events. 相似文献14.
Neil Perkins Anna Coleman Michael Wright Erica Gadsby Imelda McDermott Christina Petsoulas Kath Checkland 《The British journal of general practice》2014,64(628):e728-e734
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. 相似文献15.
16.
Trevor Lambert Raph Goldacre Fay Smith Michael J Goldacre 《The British journal of general practice》2012,62(605):e851-e858
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. 相似文献17.
Sabrina Grant Sheila M Greenfield Arie Nouwen Richard J McManus 《The British journal of general practice》2015,65(640):e776-e783
Background
Self-monitoring blood pressure (SMBP) is becoming an increasingly prevalent practice in UK primary care, yet there remains little conceptual understanding of why patients with hypertension engage in self-monitoring.Aim
To identify psychological factors or processes prompting the decision to self-monitor blood pressure.Design and setting
A qualitative study of patients previously participating in a survey study about SMBP from four general practices in the West Midlands.Method
Taped and transcribed in-depth interviews with 16 patients (6 currently monitoring, 2 used to self-monitor, and 8 had never self-monitored). Thematic analysis was undertaken.Results
Three main themes emerged: ‘self’ and ‘living with hypertension’ described the emotional element of living with an asymptomatic condition; ‘self-monitoring behaviour and medication’ described overall views about self-monitoring, current practice, reasons for monitoring, and the impact on medication adherence; and ‘the GP–patient transaction’ described the power relations affecting decisions to self-monitor. Self-monitoring was performed by some as a protective tool against the fears of a silent but serious condition, whereas others self-monitor simply out of curiosity. People who self-monitored tended not to discuss this with their nurse or GP, partly due to perceiving minimal or no interest from their clinician about home monitoring, and partly due to fear of being prescribed additional medication.Conclusion
The decision to self-monitor appeared often to be an individual choice with no schedule or systems to integrate it with other medical care. Better recognition by clinicians that patients are self-monitoring, perhaps utilising the results in shared decision-making, might help integrate it into daily practice. 相似文献18.
Mei Ling Denney Adrian Freeman Richard Wakeford 《The British journal of general practice》2013,63(616):e718-e725
Background
Concern exists regarding differential performance of candidates in postgraduate clinical assessments by ethnicity, sex, and country of primary qualification. Could examiner bias be responsible?Aim
To explore whether candidate demographics affect examiners’ judgements, by investigating candidates’ case performances by candidates’ and examiners’ demographics.Design and setting
Data on 4000 candidates (52 000 cases) sitting the MRCGP clinical skills assessment in 2011–2012.Method
Univariate analyses were undertaken of subgroup performance (male/female, white/black and minority ethnic (BME), UK/non-UK graduates) by parallel examiner demographics. Due to confounding of variables, these were complemented by multivariate ANOVA and multiple regression analyses.Results
Univariate analysis showed some differences between outcomes between the same-group and other-group examiners: these were contradictory regarding examiners ‘favouring their own’, for example, males received higher marks from female examiners than from males: maximum effect size was 3.6%. A six-way ANOVA confirmed all three candidate and examiner variables as having significant effects individually, identifying one significant interaction (examiner sex by examiner ethnicity). Stepwise regression showed candidate variables predicting 12% of score variance, parallel examiner demographics adding little (approximately 0.2% of variance). One ‘transactional’ variable proved significant, explaining 0.06% of score variance.Conclusion
Examiners show no general tendency to ‘favour their own kind’. With confounding between variables, as far as the impact on candidates’ case scores, substantial effects relate to candidate and not examiner characteristics. Candidate–examiner interaction effects were inconsistent in their direction and slight in their calculated impact. 相似文献19.
Jane Roberts Ann Crosland John Fulton 《The British journal of general practice》2014,64(622):e254-e261
Background
Psychological difficulties are common in adolescents yet are not often addressed by GPs. Anxiety and uncertainty about professional practice, with a reluctance to medicalise distress, have been found among GPs. GP involvement in this clinical area has been shown to be influenced by how GPs respond to the challenges of the clinical consultation, how they view young people and their perception of their health needs, and a GP’s knowledge framework.Aim
To explore the relationship between the above three influences to develop an overarching conceptual model.Design and setting
Qualitative study based in 18 practices in the north east of England. The practices recruited included rural, urban, and mixed populations of patients predominantly living in socioeconomically disadvantaged communities.Method
Theoretical sampling was used to guide recruitment of GP participants continuing until theoretical saturation was reached. Data were analysed using the constant comparative method of grounded theory and situational analysis.Results
In total 19 GPs were recruited: 10 were female, the age range was 29–59 years, with a modal range of 40–49 years. Three levels of analysis were undertaken. This study presents the final stage of analysis. GP ‘enactment of role’ was found to be the key to explaining the relationship between the three influencing factors. Three role archetypes were supported by the data: ‘fixers’, ‘future planners’, and ‘collaborators’.Conclusion
The role of GPs in managing adolescent psychological difficulties is unclear. Policy advocates a direct role but this is unsupported by education and service delivery. GPs adopt their own position along a continuum, resulting in different educational needs. Better preparation for GPs is required with exploration of new, more collaborative models of care for troubled adolescents. 相似文献20.
Robert Fleetcroft Peter Schofield Martin Duerden Mark Ashworth 《The British journal of general practice》2012,62(605):e815-e820