The preregistration houseman in general practice.

During 1979-80 an experimental preregistration house physician post in general practice was conducted at Aldermoor Health Centre in Southampton in rotation with medical posts at Southampton General Hospital. Ten house physicians took part in the experiment that lasted for 19 months and each doctor spent two months in general practice. The house physicians settled quickly into general practice and found the experience both enjoyable and worth while. The hospital consultants, general practitioners, and the house physicians themselves thought that this was a valuable extension to preregistration education. The experiment raised several questions, some of which were specific to the type of rotation organised and others that were more fundamental to the whole concept of the preregistration house physician in general practice. If the experiment is to be repeated a longer period in general practice is strongly recommended. A full year rotation is suggested with four months each of surgery, medicine, and general practice.     

Attitudes to prescribing iron supplements in general practice.

In response to a postal questionnaire general practitioners in the Southampton and New Forest area indicated a considerable understanding of the principles of iron prescribing and use of laboratory tests to determine iron deficiency. Many respondents, however, chose slow release and compound iron preparations as first treatments for iron deficiency. The role of parenteral iron appeared to be poorly understood. The use of and response to laboratory investigations for iron deficiency were generally appropriate, but many practitioners probably do not check for a response to oral iron sufficiently early during treatment or stop prescribing supplements before iron stores have been replenished. There is scope for further education in the biology and management of iron deficiency in general practice.     

Referral routes to hospital of patients with chronic open-angle glaucoma.

An analysis of the referral routes of Southampton Eye Hospital of 191 patients who had been diagnosed as having chronic open-angle glaucoma showed that 121 patients (63.4%) were diagnosed as a result of the patient seeking advice for ocular symptoms (118) or because they had a family history of glaucoma (3). Advice had been sought from general practitioners (48), ophthalmic medical practitioners (19), and ophthalmic opticians (46). The remaining eight patients had gone directly to the casualty department. Seventy patients had been identified by chance, the majority of ophthalmic medical practitioners (26) or ophthalmic opticians (32).     

Need for open access non-screening mammography in a hospital with a specialist breast clinic service.

OBJECTIVE--Assessment of open access non-screening mammography in a hospital with a breast clinic. DESIGN--Retrospective analysis of patients sent for first mammogram to our open access service by general practitioners and breast clinic in the year April 1989 to March 1990. SETTING--District general hospital serving 200,000 people before the introduction of breast screening. SUBJECTS--361 symptomatic women referred directly by general practitioners and 226 women referred by the breast clinic for first, non-screening mammograms. MAIN OUTCOME MEASURES--Radiographic reports on all patients. Final diagnosis in patients reported as having possible or probable neoplasm. RESULTS--Of the women referred directly by general practitioners one (0.2%) was reported as showing probable malignancy (later histologically confirmed) and 15 (4%) as showing possible malignancy (on follow up none had proved malignancy). Of the women referred by the breast clinic 38 (17%) were reported as showing probable malignancy (all had confirmed carcinomas) and 35 (15%) as showing possible malignancy (19 (54%) had proved malignancy). 18 of the proved malignancies were in women under 50 years old, 26 were in women over 64 years, and 14 were in women of screening age. 54 (93%) of the 58 patients with proved breast cancer and an abnormal mammogram had a discrete breast lump. CONCLUSIONS--General practitioners accurately divided women into low and high risk groups, resulting in few abnormalities being detected in patients referred directly for mammography. This suggests that an open access non-screening mammography service for general practitioners is unnecessary in an area with a specialist breast clinic. The large proportion of cancers in women outside of screening age emphasises the need for such clinics.     

General practitioners' responsibilities to their patients.

The views of general practitioners about their responsibilities for patient care have not been canvassed. A survey of general practitioners was therefore carried out to determine their views. A postal questionnaire, in which general practitioners were asked what they saw as their responsibilities, was sent to 525 principals in Avon and completed by 424, giving a response rate of 81%. The doctors generally agreed that their responsibilities for patient care included problems related to internal medicine, such as managing diabetes and hypertension. Less consensus was found in the replies to questions about technical procedures, such as resection of ingrowing toenails, and gynaecological, orthopaedic, or psychosocial problems. The results supported the view that general practitioners are gradually abandoning technical aspects of medicine to specialists without a compensating role having been defined. In the light of this trend the responsibilities of general practitioners should be clearly defined by the profession.     

Attendance and non-attendance for breast screening at the south east London breast screening service.

OBJECTIVES--To ascertain the reasons for a low rate of response for breast screening. DESIGN--All relevant aspects of the organisational process examined, including general practitioners'' notes. Non-responders visited and interviewed. SETTING--An inner city breast screening service working on the model advocated by the Forrest report. SUBJECTS--288 Women aged 50-64 registered with several general practices and invited for screening by post. MAIN OUTCOME--Determination of factors important for success of breast screening programmes. RESULTS--After five women were excluded by their general practitioners the response rate was 129 out of 283 (46%), but 99 (35%) of the women did not receive their invitations because of inaccuracies in the family practitioner committee''s database and general practitioners failing to check women''s addresses completely. CONCLUSIONS--Increased rates of response will depend on enabling general practitioners to check addresses and on an increased awareness of the importance of information.     

Irritable bowel syndrome in the general population.

OBJECTIVE--To determine the prevalence of symptoms compatible with a clinical diagnosis of irritable bowel syndrome in the general population. DESIGN--Validated postal questionnaire sent to 2280 subjects randomly selected in 10 year age bands from the lists of eight general practitioners. The Manning criteria were used to define irritable bowel syndrome. SETTING--Urban population in Southampton and mixed urban-rural population in Andover, Hampshire. RESULTS--A response of 71% yielded 1620 questionnaires for analysis, of which 412 (25%) reported more than six episodes of abdominal pain in the preceding year, with 350 (22%) reporting symptoms consistent with the diagnosis of irritable bowel syndrome. The male: female ratio was 1:1.38. More subjects with irritable bowel syndrome had constipation and diarrhoea and 35% with the syndrome reported rectal bleeding compared with an overall prevalence of 20%. Other symptoms and conditions including heartburn, dyspepsia, flushing, palpitations, migraine, and urinary symptoms were significantly more common in the group with irritable bowel syndrome. Abdominal pain in childhood was more common in the subjects with irritable bowel syndrome (12%) than without (3%). One third of the group with irritable bowel syndrome had sought medical advice during the study period (male:female ratio 1:1.21); consultation behaviour was influenced by age and the presence of associated symptoms, varied considerably among patients registered with different general practitioners, and was poorly correlated with symptom severity. CONCLUSION--Symptoms consistent with a diagnosis of irritable bowel syndrome are present in almost one quarter of the general population and tend to be associated with a number of other complaints and conditions, some of which may reflect smooth muscle dysfunction.     

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.     

Patients' and general practitioners' satisfaction with information given on discharge from hospital: audit of a new information card.

OBJECTIVE--To determine the attitudes of patients discharged from hospital and their general practitioners to a new information card giving details about admission, diagnosis, and treatment and to assess the completeness of the information on the card. DESIGN--Consecutive patients discharged from the care of three consultant physicians over 16 weeks. SETTING--One general medical ward in a large teaching hospital. PATIENTS--A total of 275 consecutive discharges of 258 patients were studied. The mean age of patients was 60 years and mean duration of admission five days. INTERVENTION--At discharge from the ward all study patients received an information card and a copy of the card in the form of an interim discharge letter to be delivered to their general practitioner. Patients and general practitioners were asked to complete a questionnaire giving their views on the legibility, helpfulness, quality, and quantity of the information they received. Copies of all the information cards were scrutinised for completeness. MAIN RESULTS--The results were based on 208 (76%) forms returned by patients and 214 (78%) forms returned by general practitioners. Information was considered very helpful or quite helpful according to 170 (83%) forms from patients and 197 (92%) forms from general practitioners; sufficient information was provided according to 160 and 182 forms. Most patients and nearly all general practitioners thought it was a good idea to provide this information for patients at discharge. According to 125 forms from patients and 188 from general practitioners the information card was very easy or quite easy to read; 155 patients had read it at least twice and 149 were likely to refer to it again. OTHER RESULTS--The written information about the patient, the diagnosis, and what the patient had been told was generally well completed, although the date of discharge was omitted from 42 (15%) cards. Details of drugs prescribed at discharge were generally thorough. CONCLUSIONS--Giving an information card to all patients at discharge was feasible and favoured by most patients and their general practitioners. Having made minor changes in design, we think that we have produced an information card that is a convenient size and will improve communication between patients, their general practitioners, and hospital doctors. We now issue this card routinely to all patients discharged from our ward and hope that it might be widely adopted.     

General practitioners and management of infection with HIV

General practitioners will have an increasingly important role in the management of patients with the acquired immune deficiency syndrome (AIDS) and infections with human immunodeficiency virus (HIV) as the numbers of cases increase. Altogether 280 general practitioners working in Oxfordshire were sent a postal questionnaire inquiring about their education, knowledge, current practice, and attitudes in relation to managing infections with HIV. Of the 235 (84%) general practitioners who replied, nine out of 10 were giving advice about infection with HIV to their patients. One in two were testing patients for such infection, and one in four were caring for infected patients. Nevertheless, uncertainty remained about the risks of transmission of infection with HIV and general practitioners'' knowledge of educational activities for their patients could be improved.The introduction of a facilitator to work with general practitioners in managing patients with AIDS or infection with HIV is planned, especially to help general practitioners develop the skills needed for prevention.     

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland

Objectives To explore how general practitioners operate the sickness certification system, their views on the system, and suggestions for change.Design Qualitative focus group study consisting of 11 focus groups with 67 participants.Setting General practitioners in practices in Glasgow, Tayside, and Highland regions, Scotland.Sample Purposive sample of general practitioners, with further theoretical sampling of key informant general practitioners to examine emerging themes.Results General practitioners believed that the sickness certification system failed to address complex, chronic, or doubtful cases. They seemed to develop various operational strategies for its implementation. There appeared to be important deliberate misuse of the system by general practitioners, possibly related to conflicts about roles and incongruities in the system. The doctor-patient relationship was perceived to conflict with the current role of general practitioners in sickness certification. When making decisions about certification, the general practitioners considered a wide variety of factors. They experienced contradictory demands from other system stakeholders and felt blamed for failing to make impossible reconciliations. They clearly identified the difficulties of operating the system when there was no continuity of patient care. Many wished either to relinquish their gatekeeper role or to continue only with major changes.Conclusions Policy makers need to recognise and accommodate the range and complexity of factors that influence the behaviour of general practitioners operating as gatekeepers to the sickness certification system, before making changes. Such changes are otherwise unlikely to result in improvement. Models other than the primary care gatekeeper model should be considered.     

Overprescription of cholera vaccine to travellers by general practitioners.

A questionnaire describing five hypothetical patients intending to travel to different countries was sent to 113 general practitioners, who were asked to state which patients they would recommend cholera vaccination to. The response rate was 80%. The general practitioners'' recommendations were compared with those of the Liverpool School of Tropical Medicine. Sixty three of 86 respondents recommended cholera vaccination when it would probably have been unnecessary. A review of common sources of information on cholera vaccination showed that general practitioners are given confusing or inappropriate advice. General practitioners should be educated about when cholera vaccination is necessary; alternatively, the vaccine should be available only through special centres.     

AIDS and the general practitioner: views of patients with HIV infection and AIDS.

An unselected series of outpatients infected with the human immunodeficiency virus (HIV) who attended two London hospitals were interviewed to assess their relationship with their general practitioner. Although most of the 192 patients were registered with a general practitioner, the doctors of only one half knew of the diagnosis. Patients feared a negative reaction from their general practitioner or were concerned about confidentiality. Although those who had told their doctor had received favourable reactions, few general practitioners attempted to counsel or educate their patients. The patients who previously had been open about their homosexuality were not more likely to have told their general practitioner of their HIV infection. Although most did not think that general practitioners were well informed about AIDS, half of the patients wished that general practitioners could take a bigger part in their care.     

General practitioner response to elderly patients discharged from hospital.

OBJECTIVE--To determine the effect of discharge information given to general practitioners on their management of newly discharged elderly patients. DESIGN--A random sample of 133 elderly patients who had unplanned readmission to a district general hospital within 28 days of discharge was compared with a matched control sample of patients who were not readmitted. Information was gathered from the hospital, the patients, the carers, and the general practitioners about the information that the hospital had sent the general practitioner and the general practitioners'' response to this information. SETTING--All specialties in a district general hospital. PATIENTS--266 Patients aged over 65 representative in the main demographic indices of the population of elderly patients admitted to hospital. RESULTS--Ten weeks after discharge the doctors had received notice of discharge about 169 of the patients, but fewer than half the discharge notices were received within the first week. General practitioners were dissatisfied with the information in 60 cases. A general practitioner visited 174 of the patients after their discharge from hospital and three quarters of the visits took place within two weeks of the discharge. These visits were more likely to have been initiated by patients or families than by the doctor, and this was not influenced by the doctor receiving notice of the patient''s discharge. Older patients and those who had carers were the most likely to be visited. Nearly half of the carers were dissatisfied with some aspect of general practitioner care, problems with home visiting being the commonest source of complaint. CONCLUSIONS--Hospital communications to general practitioners about the discharge of elderly patients still cause concern, particularly in the time they take to arrive. Written instruction to vulnerable elderly patients asking them to inform their general practitioner of the discharge might be helpful. Carers complained of lack of support, and it is clearly important for someone (either the general practitioner or another health worker) to visit elderly people shortly after their discharge.     

Simulated patients in general practice: a different look at the consultation.

To develop a better empirical basis for developing quality assessment in general practice three simulated patients made appointments with 48 general practitioners during actual surgery hours and collected facts about their performance. The simulated patients were indistinguishable from real patients and presented a standardised story of a symptomatic urinary tract infection. Two months later the same general practitioners received a written simulation about a patient who had the same urinary tract infection and were asked how they would handle this in real practice. Both results were scored against an existing consensus standard. The overall score for both methods did not show any substantial differences. A more differentiated analysis, however, showed that general practitioners performed significantly better with simulated patients. It also showed that general practitioners answering the written simulation performed significantly more unnecessary and superfluous actions. The results of this study show that the use of simulated patients seems to show the efficient performance of general practitioners in practice.     

Evaluation of the needs of male carriers of mutations in BRCA1 or BRCA2 who have undergone genetic counseling

To date, the concerns of men at risk of inheriting a BRCA1 mutation or a BRCA2 mutation have received little attention. It had been anticipated that few men would be interested in predictive testing when a BRCA mutation was identified in their family. However, these men are often affected emotionally by diagnoses of breast cancer in their relatives and may themselves harbor fears that cancer will develop. Male carriers of BRCA1/2 mutations are at increased risk of development of cancers of several types, including those of the breast and prostate. We conducted an evaluation of the needs and experiences of 59 male carriers of BRCA1/2 mutations followed at either the University of Toronto or Creighton University. We assessed their motivations for seeking genetic counseling and testing, involvement in family discussions of breast and ovarian cancer, risk perception, changes in cancer-screening practices, and overall satisfaction with the genetic-counseling process. The principal motivation for seeking genetic counseling was concern for their daughters. The majority (88%) of men participated in family conversations about breast and ovarian cancer, and 47% participated in conversations about prophylactic surgery. Most men believed that they were at increased risk of development of cancer (prostate, breast, colorectal, and skin cancers). However, fewer than one-half (43%) of the men with no previous diagnosis of cancer stated that their prostate cancer-surveillance practices had changed after they had received genetic test results. More than one-half (55%) had intrusive thoughts about their cancer risk. Although levels of satisfaction were high, practitioners should be aware of (a) potential pressures influencing men to request predictive testing, (b) the difficulties that men encounter in establishing surveillance regimens for breast and prostate cancer, and (c) the general lack of information about men's particular experiences in the medical community.     

Diabetes,driving, and the general practitioner.

The medical fitness of drivers who have diabetes is assessed primarily by general practitioners. A survey was made of the knowledge of driving and diabetes of 105 general practitioners in Glasgow. Ninety four (90%) knew that people who were insulin dependent were required by law to declare their condition to the Driver and Vehicle Licensing Centre in Swansea, but most were unaware that people with diabetes should not hold a "till 70" driving licence. Seventy one doctors (69%) claimed that patients were recalled individually for fitness to drive. The minimum visual acuity for driving was stated correctly by 37 (35%). Only eight respondents knew that a hypoglycaemic diabetic driver can be charged with driving under the influence of a drug (Road Traffic Act 1972), and the practical advice that was given to patients about hypoglycaemia and driving was unsatisfactory. As a group the general practitioners showed deficiencies in knowledge regarding diabetes and driving, suggesting a need for further postgraduate education.     

Usefulness of letters from hospitals to general practitioners.

In an investigation of the communication between specialist hospital departments and general practitioners 97 general practitioners were asked to say how important selected items of information that the hospital could pass on would be for management of a patient receiving chemotherapy. In addition, the records of 68 patients were examined for coverage of these topics. General practitioners considered technical topics to be more important than social ones. Hospital letters covered technical topics well, apart from details of possible side effects, but did not do the same even for the two social topics that most doctors considered to be essential--namely, what patients have been told about their diagnosis and prognosis. Letters from hospitals to general practitioners cover technical topics well but should include more information relating to the social aspects of the patient''s disease.     

Attitudes of general practitioners to prehospital thrombolysis.

OBJECTIVE--To investigate reasons for general practitioners not giving thrombolytic treatment to eligible patients with acute myocardial infarction. DESIGN--Postal questionnaires were sent to 424 general practitioners. SUBJECTS--97 general practitioners who had taken part in the Grampian region early anistreplase trial, 185 whose practices in Scotland were at least 24 km from a district general hospital, and 142 who had attended postgraduate conferences at which thrombolysis had been discussed; 87, 158, and 125 respectively responded. MAIN OUTCOME MEASURES--Answers to questions about readiness to use thrombolytic treatment. RESULTS--Response rate was 87% (370/424). Almost all respondents (350) were convinced of benefits of thrombolysis for acute myocardial infarction, and 277 were convinced that there were additional benefits from its administration in the community at first opportunity. Most doctors working 16 km or more from hospital thought that giving treatment at home would appreciably save time (200/274). Most doctors agreed that they could make time to give thrombolytic treatment (278), and would be willing to record an electrocardiogram (284), and would be able to interpret it (280). Sixty four respondents (17%) reported using thrombolytic treatment in previous year. Among non-users, 150 (49%) were unwilling to use thrombolytic treatment without further training. While many non-users (210 (69%)) were willing to use thrombolytic treatment without encouragement from Department of Health, 184 (60%) were unwilling to use it unless encouraged to do so by their local cardiologist. CONCLUSIONS--The need to become better informed about thrombolysis and lack of encouragement from local cardiologists were important factors preventing wider use of thrombolytic treatment in the community by general practitioners.