Practice nurses and clinical guidelines in a changing primary care context: an empirical study

BACKGROUND: Practice Nurses form an increasingly large proportion of the English National Health Service primary care workforce and the delegation to them of clinical work from General Practitioners has attracted some academic attention. Central to this process are clinical guidelines, which provide the interface between the movement towards 'evidence-based practice' and a range of government-driven policy developments in primary care. AIMS: To identify the attitudes of practice nurses to clinical guidelines; to investigate the impact of guidelines on nurse/physician relationships; and to describe the impact of the changing primary care context on nurses. METHODS: We interviewed a sample of 29 Practice Nurses three times during a 16-month period to clarify their attitudes towards guidelines, their use of guidelines in practice and their assessment of guidelines' importance. We gathered further data on organizational culture and perceptions of national reforms of primary care structures. RESULTS: We found that practice nurses are generally supportive of clinical guidelines. Moreover, nurses' role and influence within primary care is in a process of transition to one in which they may undertake responsibility for influencing General Practitioners' clinical behaviour so as to adhere to guidelines. Practice nurses themselves recognize and welcome this, though with some reservations. CONCLUSIONS: Our findings support the proposal that explicit codification of the scientific basis of the work of lower paid groups may enhance their relative professional status.     

Using Standardized Oral Examinations to Evaluate General Competencies

Emergency medicine residency programs are required by the Accreditation Council for Graduate Medical Education (ACGME) to formally evaluate each resident with oral and written examinations. The Michigan State University Emergency Medicine Residency Program in Lansing conducts monthly standardized oral examinations (SOEs) as part of each resident's evaluation. Recently, the ACGME has advanced six areas, termed "general competencies," that should be acquired during graduate medical education. According to the ACGME, these competencies should be included in the educational process of all residency programs. In promulgating these competencies, the ACGME did not provide examples of core content, strategies for implementation, or methods of evaluation; rather, individual residency programs are required to develop their own methods. The authors describe a modification of an existing SOE strategy that assesses residents' knowledge, skills, experiences, and attitudes as reflected in the general competencies.     

General practitioners' diagnostic skills and referral practices in managing patients with drug and alcohol-related health problems: implications for medical training and education programmes

The aim of this study was to determine the current practices of established general practitioners in managing patients with drug and alcohol-related problems and identify gaps in training. A random sample of general practitioners completed a survey assessing diagnostic skills and referral practices concerning alcohol and illicit drug use in general practices in February 1999, comprising 110 general practitioners registered with the Central Sydney Division of General Practice. The main outcome measures were competent skills and knowledge, willingness to treat. The majority (96%) of GPs provided clinically appropriate responses for at least one drug category, although none received this rating for all six. Most general practitioners reported that they were unwilling to treat heroin and cocaine problems themselves but expressed willingness to refer patients appropriately. More than a quarter of general practitioners were unaware of the safe drinking levels for men and women or the appropriate treatment for patients consuming above such levels. Age, years in practice, type of practice, willingness to obtain drug use histories and post-graduate training were all significantly associated with general practitioners' willingness to treat and competence in managing drug and alcohol-related problems. In this study, general practioners reported low levels of skills and referrals for treatment of illicit drug use and suboptimal skills in the management of alcohol problems. The results suggest that a more comprehensive approach to education and training is required to bring about a change in practice behaviour. [Fucito LM, Gomes BS, Murnion B, Haber PS. General practitioners' diagnostic skills and referral practices in managing patients with drug and alcohol-related health problems: implications for medical training and education programmes. Drug Alcohol Rev 2003;22:417 - 424]     

The natural course of bulimia nervosa and eating disorder not otherwise specified is not influenced by personality disorders

OBJECTIVE: To examine prospectively the natural course of bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) and to test the effects of personality disorder (PD) comorbidity on the outcomes. METHOD: Ninety-two female patients with current BN (N=23) or EDNOS (N=69) were evaluated at baseline enrollment in the Collaborative Longitudinal Personality Disorders Study (CLPS). Eating disorders (EDs) were assessed with the Structured Clinical Interview for DSM-IV Axis I Disorders. Personality disorders (PDs) were assessed with the Diagnostic Interview for DSM-IV PD (DIPD-IV). The course of BN and EDNOS was assessed with the Longitudinal Interval Follow-up Evaluation and the course of PDs was evaluated with the Follow-Along version of the DIPD-IV at 6, 12, and 24 months. RESULTS: Probability of remission at 24 months was 40% for BN and 59% for EDNOS. To test the effects of PD comorbidity on course, ED patients were divided into groups with no, one, and two or more PDs. Cox proportional regression analyses revealed that BN had a longer time to remission than EDNOS (p<.05). The number of PDs was not a significant predictor of time to remission, nor was the presence of Axis I psychiatric comorbidity or Global Assessment of Functioning scores. Analyses using proportional hazards regression with time-varying covariates revealed that PD instability was unrelated to changes in ED. CONCLUSIONS: BN has a worse 24-month course (longer time to remission) than EDNOS. The natural course of BN and EDNOS is not influenced significantly by the presence, severity, or time-varying changes of co-occurring PDs, co-occurring Axis I disorders, or by global functioning.     

GPs' perspectives on managing time in consultations with patients suffering from depression: a qualitative study

BACKGROUND: Although there is widespread concern that general practice consultations are too short for doctors to provide a high quality of care for patients, the relationship between the length and outcome of these consultations remains unclear. Research to date has neglected the subjective experience of consultation time of both patients and GPs. OBJECTIVES: Our aim was to investigate GP perspectives on consultation time and the management of depression in general practice. METHOD: A qualitative interview-based study was carried out of 19 GPs from eight West Midlands general practices. RESULTS: The GPs in this study acknowledged the pressure of work and resource constraints in general practice. However, they did not feel these prevented them from providing good support and treatment for depression. They were confident in the effectiveness of antidepressants and their own skills in providing counselling support, and were able to utilize time flexibly in responding to patients' variable needs. Depression was viewed as a relatively straightforward problem that usually could be managed within the resources available to general practice. CONCLUSION: The doctors generally did not experience time to be a limiting factor in providing care for patients with depression. This is in contrast to the more acute sense of time pressure commonly reported by patients which they felt undermined their capacity to benefit from the consultation. GPs need to be more aware of patient anxieties about time, and to devise effective means of raising patients' sense of time entitlement in general practice consultations.     

GP and patient predictors of PSA screening in Australian general practice

OBJECTIVE: We determined GP and patient variables associated first with men's prior uptake of prostate-specific antigen (PSA) screening and, subsequently, its initiation during an 'index consultation' in Australian general practice. METHODS: From the practices of 60 GPs, we recruited a sample of 423 male patients aged 40-70 years. In a waiting room questionnaire completed before their 'index consultation' (retrospective component), men reported their previous PSA screening status. We obtained demographic and clinical data, including the presence of lower urinary tract symptoms (LUTS). Men also were mailed a questionnaire 2 days after their 'index consultation' to ascertain whether the GP had discussed PSA screening (prospective component) for prostate cancer and other behaviours. GPs themselves completed questionnaires eliciting demographic and practice characteristics as well as their propensity to screen and understanding of the evidence about PSA testing. GP and patient study variables were modelled simultaneously in analyses. RESULTS: Of those 348 men consulting with their regular GP, 80 (23.0%) reported previously having had a PSA screening test. Men were significantly and independently more likely ever to have had PSA screening if their regular GP reported a propensity to initiate screening [adjusted odds ratio (AOR) = 2.27, 95% confidence interval (CI) 1.23-4.20; P = 0.009]. GP age also was independently associated with men's PSA screening status [chi-squared (3) P < 0.0001] as was men's age and severity of LUTS (AOR = 2.38, 95% CI 1.58-3.57, P < 0.0001 and AOR = 1.79, 95% CI 1.00-3.19, P = 0.004, respectively). Current smokers were less likely ever to have had a PSA screening test (AOR = 0.34, 95% CI 0.16-0.69; P = 0.003). Discussion of PSA screening in their 'index consultation' was recalled independently more often by older men (AOR = 1.46, 95% CI 1.00-2.13; P = 0.04), those with moderate/severe LUTS (AOR = 1.94, 1.07-3.49; P = 0.04), those whose GP had performed or discussed a cholesterol test (AOR = 2.26, 95% CI 1.03-4.92; P = 0.04) and those whose GP had postgraduate training in family medicine (AOR = 3.13, 95% CI 1.23-8.00; P = 0.02). CONCLUSION: In the absence as yet of compelling evidence that PSA screening will prolong life or enhance its quality, our findings identify GP and patient factors that could be targeted to modify PSA screening.     

Understanding variation in quality improvement: the treatment of sore throats in primary care

BACKGROUND: In 1988, two practices attempted to improve the prescribing of antibiotics for sore throat. The initiative produced only modest improvements in prescribing practice, a finding the authors found difficult to explain. This paper reanalyses the data from an audit of antibiotic prescribing for sore throat in general practice. OBJECTIVE: Our aim was to demonstrate the use of Shewhart control charts and to obtain fresh insight into the variations in clinical practice revealed in clinical audit data. METHODS: We use Shewhart control charts to explore variation in antibiotic prescribing between GPs and to suggest the action most likely to result in improvement. RESULTS: Using control charts, it is possible to distinguish two categories of GPs: low prescribers of antibiotics and high prescribers of antibiotics. Low prescribers of antibiotics show common cause variation, indicating that their prescribing is a stable process. Among low prescribers, improvement can best be achieved by changing the common underlying process. One high prescriber of antibiotics is affected by special cause variation. Among high prescribers, improvement can best be achieved by investigating the special causes affecting this GP and learning lessons from the findings. CONCLUSION: The original improvement effort took the same action on all GPs in both practices. Our analysis suggests that such an approach was unlikely to be successful and that different actions were needed for high and low prescribers. The control charts provide fresh insights on the original data and guide improvement efforts.     

A framework for clinical general practice and for research and teaching in the discipline

This paper uses three typical case stories from general practice to demonstrate that a GP simultaneously considers four dimensions when making a diagnosis and planning subsequent treatment of a patient in the consultation: (i). a biomedical dimension; (ii). a culture and context dimension; (iii). a medico-psychological dimension; and (iv). a network and social dimension. By taking this diagnostic and therapeutic approach, the GP adds value to the total performance of the health care system. It is demonstrated that a GP needs theoretical, research-based knowledge and skills within all four dimensions, and that it is necessary for a GP to work together with both medical and non-medical disciplines when defining the research and teaching agenda. It is stressed that consultation and communication skills are important tools for any doctor, and the value of continuity of care is discussed. Finally, the implications of the diagnostic approach with respect to planning research and teaching programmes are discussed, and the need for a better balance is stressed.