Interns' identification of patients' health risks in a casualty department

This study examined whether the interns who staffed a hospital casualty department identified correctly four common health risks among their patients. When compared with patients who were attending general practitioners, patients who attended the casualty department were more likely to be cigarette smokers. They were also more likely to be heavy drinkers of alcohol and to score highly on a standardized measure of psychological disturbance. Women were less likely to have undergone a Papanicolaou smear-examination within the previous two years. The interns, who were the subjects in this study, failed to identify 56% of the smokers, 84% of the heavy drinkers, 35% of the psychologically-disturbed patients and 95% of the women who had not undergone a Papanicolaou smear-test in the last two years. The findings were in contrast with the interns' own opinions on what would constitute good-quality care in this setting. The subjects were just beginning their internship at the time of the study. Their failure to integrate important questions about common health risks suggests that their undergraduate training has been deficient in this area. The internship is the last formal opportunity to correct this deficiency before these doctors are registered for independent medical practice.     

General practitioners and the provision of Papanicolaou smear-tests: current practice, knowledge and attitudes

General practitioners are the main providers of Papanicolaou smear-tests yet, given the current suboptimal rates of cervical screening, it is clear that their full potential as screening providers is not being realized. To date, no information has been available concerning the possible barriers to the provision of Papanicolaou smear-tests by general practitioners. The present study assessed the views of a random sample of NSW general practitioners regarding the value of smear-tests, the most appropriate providers, the recommended screening protocol, and factors that were thought to influence both practitioners' provision and women's utilization of screening. The results indicate a number of changes to the current system which could counter screening barriers such as educational programmes for general practitioners, more female providers and the investigation of alternative services, consensus screening guide-lines, and screening registers and recall systems.     

全面放开二孩政策后生殖医学在全科医疗中的意义和应用

人口问题是我国发展的关键问题。随着全面二孩政策的实施,有再生育需求的妇女不断增多,但随着社会压力等多种因素的影响,有再生育需求的妇女不断高龄化,而女性不孕的比例随年龄增长而上升,因此高龄不育女性成为不孕女性中最重要的组成部分。如何落实全面二孩政策,帮助不孕夫妇(尤其是高龄不孕夫妇)实现再生育愿望成为一个新的挑战。专科医院由于地域及数量限制,已然无法满足不孕症患者的咨询及诊疗需求。而全科医生立足社区,是为个人、家庭与社区提供全面服务的医生,在维护社区人民健康中起到举足轻重的作用。但目前有关不孕及辅助生殖技术(assisted reproductive technology,ART)的知识及技术还局限于专科医院,服务社区的全科医生所掌握的该方向的知识及技术不足,不能满足不孕患者需求。如果全科医生能了解有关不孕及辅助生殖技术知识,及时对患者状况进行有效监测,提供相关咨询服务,同时疏导患者心理,并将患者推荐至专业的生殖医学机构接受更有效的治疗,便可以在全面二孩政策的执行中充当重要角色,为全面二孩政策的推广及实施打下坚实的基础。本综述系统性地探讨了临床实用的不孕及辅助生殖技术,并梳理出相关知识,目的是使全科医生重视并了解生殖医学,满足社区中不孕患者诊疗及咨询需求。      

Factors affecting compliance in colorectal cancer screening. Results of a study performed in Ballarat

Non-compliance in screening programmes for colorectal cancer is likely to be the most important factor limiting the impact of screening on mortality. This study aimed to determine risk factors and correlates of compliance that could be readily identified by general practitioners. A total of 581 eligible subjects aged 40 to 75 years completed a questionnaire that covered demographic factors, personal medical history, family history of colorectal cancer and smoking status. Faecal occult blood tests were then offered by the general practitioner and compliance correlated with responses. The over-all compliance was 44% and increased to 51% for those who accepted the self-testing kit at consultation. For men, compliance increased with increasing level of education and was significantly greater for non-smokers than for smokers. For women, compliance increased with increasing age, and was greater for those with either symptoms and/or a family history of colorectal cancer. A doctor group-practice factor appeared to influence acceptance versus refusal of the test kit from the doctor. A triage approach to screening in general practice may improve over-all compliance and the yield of tumours. With this strategy, patients at high risk (for example, those with a family history of colorectal cancer or in older age groups) are identified first. Particular attention should be given during consultation to those at high risk who have poor compliance profiles (for example male smokers with a family history of colorectal cancer). High-risk subjects with high compliance profiles would need less attention and low-risk individuals would need least attention.     

Gynaecological cytology screening in South Australia: a 23-year experience

The Cytology Laboratory at The Queen Elizabeth Hospital, Adelaide, processed 630,131 gynaecological smears from 347,389 patients between September 1, 1959 and July 31, 1982. The data suggested a lack of compliance with the recommendations of screening frequency, with an average of only 1.8 smear-tests per woman being performed during the 23-year study period. There was a two-fold increase in the incidence of histologically-confirmed cervical dysplasia and carcinoma-in-situ from 1977, but no increase in the incidence of invasive carcinoma. The age distributions of the incidence of dysplasia and carcinoma-in-situ moved towards younger age-groups during the study period. By the end of the study period (1977-1981), the incidence peaks of dysplasia and carcinoma-in-situ were both at ages 25 to 34 years compared with 30 to 39 years of age and 35 to 44 years of age, respectively, in 1962-1966. Invasive carcinoma had a much broader age distribution, with two incidence peaks, and the distribution shifted towards older age groups. The first peak had moved from 40 to 49 years of age (1962-1966) to 50 to 59 years of age (1977-1981) and the second peak moved from 60 to 69 years of age to 75 to 84 years of age. Error rates in cytological assessment were determined by comparing the histological diagnosis with the result of the most recent smear-test. By means of this method the sensitivity was 84.6%. The sensitivity was increased to 91.4% if the estimate were based on the most abnormal result of a smear-test before the histological diagnosis. A poor correlation was found between a mildly-atypical (inflammatory) cytological result (class 2) and a benign histological diagnosis: 48% of class-2 smears were diagnosed histologically as dysplasia or worse. In very few of these cases had an elapsed time of more than five years occurred between the class-2 result of a smear-test and the subsequent diagnosis of neoplasia. Thus, the majority of these cases were either underdiagnosed by cytology or had developed within five years, which indicates the importance of the careful follow-up of women with class-2 smears. Finally, the data illustrate the ability of gynaecological cytology screening to assist in the detection of extracervical gynaecological neoplasms of the uterus, ovary, vagina and vulva, as 132 such cases were diagnosed during the study period after positive results of a smear-test led to further investigations.     

Encouraging attendance at screening mammography: knowledge, attitudes and intentions of general practitioners

We surveyed a random sample of 200 general practitioners from the Sydney metropolitan area about their attitudes to and knowledge of screening mammography. General practitioners' knowledge about some aspects of screening mammography was found to be limited; only 25% of the sample knew that the risk of breast cancer increases with age and only 30% of the sample knew that the evidence for a reduction in mortality as a result of mammographic screening is weakest for women of less than 50 years of age. Ninety-five per cent of general practitioners were of the opinion that breast self-examination and clinical examination were important for asymptomatic women of more than 45 years of age compared with the 75% of respondents who viewed mammography in the same way. Scores on a scale that was constructed to measure attitudes to mammographic screening showed that 20% of general practitioners had a "very favourable" attitude, and that a further 67% of general practitioners had a "favourable" attitude. No general practitioners had a "very unfavourable" attitude. Eighty-four per cent of general practitioners indicated that they would recommend that their patients attend a free screening-mammography service. Willingness to recommend mammographic screening was predicted by a general practitioner's attitude score. The strongest component of this prediction was a belief that the benefits of screening mammography outweighed the radiation risks. General practitioners need to be supplied with correct information about target groups for screening, so that women in the appropriate age-groups are encouraged to attend screening programmes.     

When to intervene for male and female patients' alcohol consumption: what general practitioners say

Results of a telephone survey of 103 Sydney general medical practitioners are reported. General practitioners were asked to indicate how much alcohol male and female patients would need to be consuming to warrant their intervention. The mean levels at which general practitioners stated they would intervene were 5.1 drinks per day for male patients and 3.8 drinks per day for female patients. These mean scores fall within the consumption ranges identified by the National Health and Medical Research Council (NHMRC) as being hazardous and are below the levels specified as harmful. While the results of the present study indicate some consistency between general practitioners' views and NHMRC recommended levels for low-risk alcohol consumption, there were important discrepancies. For instance, using NHMRC categories of risk, general practitioners would intervene for female patients at significantly higher levels (P less than 0.05) of associated risk than they would for male patients. In addition, many general practitioners did not differentiate between the quantities of alcohol consumed for which they would intervene for male and female patients; this is an area needing attention. While the results indicate that some general practitioners have the basic knowledge required for involvement in detection and early intervention activities for alcohol-related problems, future training programmes should address the fact that two-thirds of general practitioners either overestimate or underestimate the level of patient alcohol consumption at which it is appropriate to intervene.     

Randomised trial of compliance with screening for colorectal cancer

A randomised trial of compliance with screening for colorectal cancer by means of the haemoccult test was conducted in Farnborough and Basingstoke districts. In each of the 14 participating practices (41 general practitioners) 25 852 men and women aged between 40 and 70 years were randomly allocated by household to one of six groups. The group determined the method of invitation to screening: a letter and the test were sent to the patient, or a letter with an appointment to attend the surgery was sent, or during a routine consultation the general practitioner invited patients to participate, and some patients received an educational booklet about bowel disorders and screening. Of the 17 824 people who were offered screening, 7545 (42%) complied. Compliance was significantly affected by the method of invitation, but not by whether an educational booklet was received, and was highest (57%) in the group that was offered the haemoccult test during a routine consultation (the "opportunistic" approach). In this group the compliance rate achieved by individual general practitioners ranged from 26% to 82%. Compliance was significantly higher in Farnborough, in the older (55-70) age group, in women, and in households in which two or more people were offered screening. The higher compliance in Farnborough may be explained by the higher proportion of older people and by the higher proportion of people living in households of two or more in the population that was offered screening. The fact that the screening programme in Farnborough was offered to the whole community and that the researcher may have acted as a facilitator were probably also important. One per cent of the patients screened had a positive test, and 24 (38%) of the 63 patients who were positive and were investigated in hospital had neoplastic disease. The yield was 1.2 cancers and 1.2 benign adenomas (1 cm or larger in size) per 1000 people screened. This low yield is likely to be a consequence of the relatively young age group screened.     

Paediatric consultation patterns in general practice and the accident and emergency department.

The age, sex, source of referral and diagnosis of children brought to a paediatric accident and emergency department by their parents were compared to those consulting their general practitioner. A simultaneous, prospective review of these consultations was carried out over a six-week period in an inner-city paediatric teaching hospital and a group practice in a socially deprived urban area. 730 children less than 13 years of age who presented for a new consultation were seen. 629 (86%) presented initially to the general practitioner, who dealt with all but 25 (4.0%) without onward referral to the accident and emergency department. 127 consultations took place at the accident and emergency department, of which 104 (82%) were parental referrals. There was no sex difference in children seen by the general practitioner. There was a decreasing trend with increasing age in the proportion of children who consulted the general practitioner, perhaps due to the higher frequency of injury in the older children. Over three quarters (77%) of injured children were brought directly to the accident and emergency department, compared with only 4% of children without injuries (p < 0.001). Of 22 children with injuries who presented to the general practitioner, only 4 (18%) required onward referral. General practitioners met the great majority of the paediatric workload generated by the practice. Audit between primary and secondary care gives a more reliable picture than data from only one source. Injured children are more likely to be taken to the accident and emergency department. Further study of the severity of injury in children is required to determine if there is potential to reduce parental referrals to accident and emergency departments.     

Sources of primary health care for women in an urban centre

Family or general practitioners and obstetrician-gynecologists have the opportunity to provide primary health care to women. Who actually gives this care in a large urban setting was the focus of this study. In the Montreal area 297 women were asked by telephone whether they had an obstetrician-gynecologist and whether they would see another type of doctor for a cold that was not getting better. Overall, 88% of all the women indicated that they would go to a family or general practitioner for such a problem, and of the women who reported receiving some care from an obstetrician-gynecologist 78% also received care from another physician. Of the respondents seeking health care from only one type of doctor, women with English as the mother tongue were significantly more likely to attend an obstetrician-gynecologist, whereas French-speaking women much more often were cared for by family or general practitioners.     

Cervical cytology in Western Australia. Frequency, geographical and socioeconomic distributions and providers of the service

Basic data were obtained from the records of 16,069 women who had smears taken for cervical cytological examination in Western Australia during an eight-week period in 1983. The peak smear rate was 340.7 per 1000 at 25-29 years of age and fell thereafter with age. The estimated peak frequency of smears that were designated as "screening" smears was 178.3 per 1000 at 30-34 years of age. Screening smears comprised 39% to 66% of the total number of smears, depending on age. After correction for the estimated prevalence of past hysterectomy, only in the age range 20-34 years did the rate of all smears approach the rate of screening smears that would be obtained under a recommended frequency of once every three years. The frequency of screening smears was 20% less in rural areas of Western Australia than in the capital city, Perth. In Perth it fell with decreasing socioeconomic status. General practitioners took 62.4% of all smears and 70.3% of screening smears. On average, female general practitioners took twice as many smears than did male general practitioners.     

Promotion of attendance for mammographic screening through general practice: a randomised trial of two strategies.

OBJECTIVE: To compare the effectiveness of two strategies--patient education and practitioner recommendation--in encouraging women to attend for mammographic screening. DESIGN: The study was a prospective randomised controlled trial. Women aged between 40 and 70 years attending a general practitioner participated in the study. Consenting, eligible women were randomly allocated to one of the two strategy groups. SETTING: The study was conducted in private general practice in Newcastle, New South Wales. PARTICIPANTS: The general practitioners who took part in the study were a non-random sample of practitioners: 20 were approached, two declined to participate, and five failed to begin recruitment, leaving 13 practitioners who took part in the study. A total of 302 women aged 40-69 were recorded as attending the surgeries during recruitment sessions. Twenty women did not consent to the study and 73 were ineligible. Thirty-four women were not given the intervention because the general practitioner forgot or did not have time. There were 92 women in the simple recommendation group and 83 women in the patient education group. INTERVENTIONS: An intensive patient education approach based on health belief principles was compared with a simple recommendation by the general practitioner that the woman have a mammogram. MAIN OUTCOME MEASURE: Attendance rates were calculated from screening service attendance records. RESULTS: No significant difference in attendance rates was observed between the two groups, 82% of the simple recommendation group and 91% of the patient education group attended for screening. CONCLUSIONS: These results suggest that mammographic screening can be effectively promoted in general practice without extensive patient education.     

The haematuria clinic--referral patterns in Northern Ireland.

One hundred consecutive patients with haematuria were seen over a three month period at the haematuria clinic, Belfast City Hospital. 14% of patients were found to have transitional cell carcinoma of the urinary bladder; all of these presented with frank haematuria and were over 50 years of age. No malignancy was detected in the microscopic haematuria group. 14% of patients with macroscopic haematuria held back for longer than one month before seeking advice from their general practitioner. 23% with macroscopic and 30% with microscopic haematuria had their symptoms noted by the general practitioner for more than a month before they were referred for investigation. The waiting time for initial investigation at the haematuria clinic took longer than six weeks in 52% with macroscopic and 39% with microscopic haematuria. Our study has identified a high-risk group who need immediate referral and investigation. The importance of patient education, rapid referral by general practitioners and also the need to increase the capacity of the haematuria clinic are emphasized.     

Screening for Chlamydia trachomatis at the time of routine Pap smear in general practice: a cluster randomised controlled trial

OBJECTIVE: To determine whether asking general practitioners to offer chlamydia screening at the same time as Pap screening increases chlamydia screening rates. DESIGN: A pragmatic cluster randomised controlled trial. PARTICIPANTS AND SETTING: Doctors from 31 general practices in the Australian Capital Territory performing more than 15 Pap smear screens per year, and all women aged 16-39 years attending those practitioners between 1 November 2004 and 31 October 2005. INTERVENTION: Doctors in the intervention practices were asked to routinely offer combined chlamydia and Pap screening to eligible women; doctors in the control practices were asked to implement screening guidelines based on a risk assessment of the individual patient (ie, usual practice). MAIN OUTCOME MEASURE: Chlamydia screening rate per visit. RESULTS: There were 26 876 visits by eligible women during the study period: 16 082 to intervention practices and 10 794 to control practices. Chlamydia screening occurred during 6.9% (95% CI, 6.5%-7.3%) of visits to intervention practices and 4.5% (95% CI, 4.1%-4.9%) of visits to control practices. After controlling for clustering and potential confounders, there were twofold greater odds of chlamydia screening occurring during a visit by an eligible woman to an intervention practice than to a control practice (adjusted odds ratio, 2.1 [95% CI, 1.3-3.4]). CONCLUSION: Combining chlamydia and Pap screening increases the rate of chlamydia screening in general practice. Implementing this approach would require little additional infrastructure support in settings where a cervical screening program already exists.     

Cancer detection in working women: a report on 7450 subjects

A cancer detection programme for women was devised in 1964 by the writer, who attended an increasing number of work centres, mostly on an annual basis. During 12 years 7450 women were examined, some of them more than once. There were 237 abnormal Papanicolaou smears (in 112 of which the histological diagnosis was carcinoma or moderate to severe dysplasia), and 18 carcinomas of the breast. Education about cancer, teaching of breast self-examination and general counseling were also carried out. The high detection rate of cancer emphasizes the need for such services to be taken to the women at risk, and suggests that annual Papanicolaou smears are still the ideal.     

Effectiveness of a call/recall system in improving compliance with cervical cancer screening: a randomized controlled trial

OBJECTIVE: To determine the effectiveness of a simple call/recall system in improving compliance with cervical cancer screening among women not screened in the previous 3 years. DESIGN: Prospective randomized controlled study. SETTING: Two family medicine clinics (1 urban, 1 rural) affiliated with Memorial University of Newfoundland, St. John's. PARTICIPANTS: A sample of women aged 18-69 years who were listed as patients of the clinics but who had not had a Papanicolaou test (Pap test) within the 3 years before the start of the study. Of 9071 women listed as patients 1360 (15.0%) had not undergone screening in the previous 3 years. A random sample of 650 were selected, 209 of whom were excluded because they had had a hysterectomy, had had a recent Pap test, had moved or had records containing clerical errors. This left 441 women for the study. INTERVENTION: The 221 women in the intervention group were sent a letter asking them to seek a Pap test and a reminder letter 4 weeks later. The 220 in the control group were sent no letters. MAIN OUTCOME MEASURES: Number of women who had a Pap test within 2 months and 6 months after the first letter was sent. RESULTS: Within 2 months, more women in the intervention group than in the control group had been screened (2.8% [5/178] and 1.9% (4/208] respectively). There was also a difference between the overall proportions at 6 months (10.7% [19/178] and 6.3% [13/208] respectively). None of the differences was statistically significant. CONCLUSION: A letter of invitation is not sufficient to encourage women who have never or have infrequently undergone a Pap test to come in for cervical cancer screening. The effectiveness of added recruitment methods such as opportunistic screening by physicians, follow-up by telephone and the offer of a specific appointment should be evaluated.     

Sources and patterns of referrals of oral cancer: role of general practitioners

Referrals of patients with oral squamous cell carcinomas to an oral medicine clinic were assessed with regard to the sources, delays, and pattern of referrals from general medical practitioners and general dental practitioners. Slightly more patients were referred by dental practitioners than by medical practitioners, but general medical practitioners were far more likely to see advanced tumours and to request an urgent second opinion or suggest a diagnosis of malignant disease. The greatest delay overall was caused by the patients in seeking advice from their practitioner, particularly those who attended a general medical practitioner. Both groups of practitioners requested a hospital opinion within roughly a month--a reasonable interval. Subsequent delays were minimal. Delays occur mainly because the patients are slow in seeking professional advice and, in general, do not appear to have been reduced over the decade since a previous British study on referral patterns was carried out. This study emphasises the importance of educating patients about oral cancer since it is they who appear to be mainly responsible for the delays in diagnosis. The results also help to dispel the myth that general medical practitioners might be less competent at diagnosis and referral of patients with oral cancer than are dental practitioners, though we are aware of misdiagnoses from both groups.     

综合医院全科门诊中乏力患者特征及就诊原因分析

背景　在国内综合性医院全科医学科因未分化疾病（如乏力等）就诊的患者占很大的比例，但针对乏力就诊患者的特点和病因等尚缺少相关的研究。目的　分析综合性医院全科门诊乏力患者特征及就诊原因。方法　选取2017-07-01至2018-06-30浙江大学医学院附属第一医院门诊电子病历系统中因乏力就诊患者301例为研究对象。收集患者的基本情况，包括性别、年龄、就诊时间、第一就诊原因、诊断；并对其当次及随后就诊记录进行分析，了解其乏力病因及最终去向。结果　301例患者因乏力就诊于全科门诊，其中男148例（49.2%），女153例（50.8%），平均年龄（48.3±13.3）岁。就诊时间上患者最多的是在2018年第二季度95例（31.6%），181例（60.1%）以乏力为第一就诊原因。26.2%（79/301）的患者可初步明确某系统疾病引起的乏力；25.3%（76/301）的患者建议其至专科进一步就诊明确病因，其中转诊最多的专科是精神卫生科〔39.5%（30/76）〕。不同性别、年龄、就诊时间患者就诊目的及去向分类比较，差异无统计学意义（P>0.05）；是否以乏力为第一就诊原因患者就诊目的及去向分类比较，差异有统计学意义（P<0.05）。结论　乏力可见于任一年龄、性别，也可见于任一时间段；既可为一种急性问题，也可为一种慢性健康问题。作为全科医师既要掌握乏力的正确评估和病因鉴别，也要对慢性乏力患者进行规范化的随访。     

新疆维吾尔自治区医师高血压防治知识掌握情况调查

目的：了解新疆维吾尔自治区医师对高血压知识的掌握情况,为高血压的防治工作提供依据。方法分别对来自新疆维吾尔自治区和田、库尔勒、伊犁等7个主要地区不同级别医院的782名医生,采用闭卷笔试形式进行高血压知识水平问卷调查,根据问卷的答对率观察新疆医师对高血压知识的掌握情况。结果除高血压诊断标准和降压治疗的最终目标外,南疆医师对高血压靶器官损害、危险因素、不同人群降压目标答对率均明显低于北疆（P＝0．000）。和田地区对高血压心、肾、血管损害、高血压危险因素（缺乏运动一项）答对率最低,均明显低于其他地区（P＜0．05）,而对老年高血压人群降压目标一项,库尔勒地区答对率最低,仅50．8％。三级医院对高血压一般知识认知情况明显优于二级和一级医院,二级医院医师对老年高血压人群降压目标答对率仅为70．4％。男性医师对高血压血管损害（93．2％ vs 85．4％,P＝0．001）、过量饮酒（92．9％ vs 86．7％,P＝0.006）及合并糖尿病或肾病人群降压目标（93．5％vs 87．7％,P＝0．008）的答对率均明显高于女性医师。“不同人群降压目标”1项,主治医师答对率最低（P＝0．019）。结论新疆地区基层医务人员对高血压病防治的基础知识掌握仍有欠缺,尤以南疆地区、一级和二级医院以及女性医师为甚,故而应以加强此地区医师高血压防治工作、强化全面正确掌握高血压防治知识为重点。     

Old people not known to the general practitioner: low risk group

The elderly patients in a large general practice aged 75 and over who lived at home (n = 877) were divided into two groups according to the general practitioner's knowledge of their risk status and were designated "risk status known" (n = 679) and "risk status not known" (n = 198). Forty-three high risk patients in the risk status known group had a functional disability score and experience of mortality that was not dissimilar to those of elderly people in institutions. The medical and social characteristics of a random sample (n = 150) of the risk status known group, after excluding the high risk patients, were compared with the risk status not known group using a Barber Wallis questionnaire. A response rate of 90% was achieved from both groups and a cumulative risk score was calculated by totalling unfavourable replies to the questions. The risk status not known group, which comprised 14% of the patients who lived at home after correcting for the number who had died and moved, had appreciably less contact with the general practitioners, had an appreciably lower cumulative risk score, were confined at home less because of ill health, were less concerned about their health, and were less in need of nursing attention. The findings of this study suggest that the elderly patients who are not known to their general practitioners are in relatively good health when compared with the patients that the general practitioner knows well.