Survey of general practice audit in Leeds.

OBJECTIVE--To determine general practitioners'' attitudes to medical audit and to establish what initiatives are already being undertaken; to define future ideas for audit and perceived difficulties in implementing audit in primary care. DESIGN--Analysis of responses to a self administered postal questionnaire. SETTING--Urban conurbation with a population of about 750,000. PARTICIPANTS--386 general practitioners on the general medical list of Leeds Family Practitioner Committee. MAIN OUTCOME MEASURES--Extent of recording of practice activity data and outcome measures and clinical data, use of data, and audit performed; ideas for audit and perceived difficulties. RESULTS--317 doctors responded to the questionnaire (individual response rate 82%) from 121 practices (practice response rate 88%). In all, 206 doctors thought that audit could improve the quality of care; 292 collected practice activity data, though 143 of them did not use it. A total of 111 doctors recorded some outcome measures, though half of them did not use them. Varying proportions of doctors had registers, for various diseases (136 had at least one register), disease management policies (60 doctors), and prescribing policies. In all, 184 doctors met monthly with other members of the primary health care team. CONCLUSIONS--Much poorly focused data collection is taking place. Some doctors have experience in setting up basic information systems and practice policies, and some audit is being performed. The family health services authorities need to take seriously the perceived difficulties of time, organisation, and resources concerned with audit.     

Survey of general practitioners' attitudes to AIDS in the North West Thames and East Anglian regions

As the numbers of people suffering from human immunodeficiency virus infection and the acquired immune deficiency syndrome (AIDS) increase, so will the contribution to care required from general practice. A postal questionnaire survey was therefore carried out among general practitioners in the North West Thames and East Anglian regions to determine their attitudes to AIDS and the issues it raises for them. One hundred and thirty seven questionnaires were returned (response rate 57%) and four factors underlying the doctors'' attitudes identified; these concerned disease control, general practitioner care, patient support, and perception of seriousness. There were wide divergencies of attitude among the general practitioners, younger doctors being more in line with specialist thinking on AIDS than older colleagues, and evidence of important gaps between policies advocated by AIDS specialists and bodies of opinion in general practice.Attitudes to AIDS in general practice may partly be a function of personal experience; further study is required.     

General practitioners' attitudes towards AIDS and their perceived information needs.

A short questionnaire on general practitioners'' self perceived and actual knowledge of AIDS and their attitudes to the illness was sent to 1824 general practitioners throughout the United Kingdom. The rate of response was 70%. Women doctors, those who trained overseas, and those who were married tended to have less positive attitudes towards patients with HIV and AIDS, whereas younger doctors, trainers, and members of the Royal College of General Practitioners were more understanding, better informed, and had more positive attitudes. Doctors with the least knowledge about HIV and AIDS and the most negative attitudes towards the illness would benefit from further education, which would be most effectively delivered through the professional journals, the Department of Health and the charitable AIDS organisations.     

General practice orthopaedic outpatient referrals in North Staffordshire.

A study was made of 813 orthopaedic referrals by 134 general practitioners in North Staffordshire. The referral rates showed no relation to practice list size or the doctors'' previous orthopaedic experience. The published waiting times did not accurately reflect clinic vacancies, and no effective priority rating of letters by consultants was shown. Less than 1% of patients had an appointment within four weeks. One quarter of the patients failed to attend and, of those who did, 27% received physiotherapy or a "simple" appliance, or both, while 16% received treatment already available from their general practitioner. Patients from high referring doctors showed the same pattern of distribution in body area affected and treatment outcome as those from low referring doctors, but had a significantly longer time to wait for their appointment. A survey of non-attenders showed that 56% of the patients failed to attend because the condition had resolved.     

General practitioner's perceptions of the route to evidence based medicine: a questionnaire survey.

OBJECTIVES: To determine the attitude of general practitioners towards evidence based medicine and their related educational needs. DESIGN: A questionnaire study of general practitioners. SETTING: General practice in the former Wessex region, England. SUBJECTS: Randomly selected sample of 25% of all general practitioners (452), of whom 302 replied. MAIN OUTCOME MEASURES: Respondents'' attitude towards evidence based medicine, ability to access and interpret evidence, perceived barriers to practising evidence based medicine, and best method of moving from opinion based to evidence based medicine. RESULTS: Respondents mainly welcomed evidence based medicine and agreed that its practice improves patient care. They had a low level of awareness of extracting journals, review publications, and databases (only 40% knew of the Cochrane Database of Systematic Reviews), and, even if aware, many did not use them. In their surgeries 20% had access to bibliographic databases and 17% to the world wide web. Most had some understanding of the technical terms used. The major perceived barrier to practising evidence based medicine was lack of personal time. Respondents thought the most appropriate way to move towards evidence based general practice was by using evidence based guidelines or proposals developed by colleagues. CONCLUSION: Promoting and improving access to summaries of evidence, rather than teaching all general practitioners literature searching and critical appraisal, would be the more appropriate method of encouraging evidence based general practice. General practitioners who are skilled in accessing and interpreting evidence should be encouraged to develop local evidence based guidelines and advice.     

General practitioners' continuing medical education within and outside their practice.

To study continuing medical education 96 out of 101 general practitioners chosen at random from the list held by a family practitioner committee were interviewed. The results provided little evidence of regular attendance at local postgraduate centre meetings, though practice based educational meetings were common. Thirty one of the general practitioners worked in practices that held one or more practice based educational meetings each month at which the doctors provided the main educational content. Performance review was undertaken in the practices of 51 of the general practitioners, and 80 of the doctors recognised its value. The general practitioners considered that the most valuable educational activities occurred within the practice, the most valued being contact with partners. They asked for increased contact with hospital doctors. The development of general practitioners'' continuing medical education should be based on the content of the individual general practitioner''s day to day work and entail contact with his or her professional colleagues.     

Should general practitioners call patients by their first names?

OBJECTIVE--To assess the acceptability to patients of the use of patients'' first names by doctors and doctors'' first names by patients in general practice. DESIGN--An administered questionnaire survey. SETTING--5 General practices in Lothian. PATIENTS--475 Patients consulting 30 general practitioners. MAIN OUTCOME MEASURE--Response by patients to questionnaire on attitude to use of first names. RESULTS--Most of the patients either liked (223) or did not mind (175) being called by their first names. Only 77 disliked it, most of whom were aged over 65. Most patients (324) did not, however, want to call the doctor by his or her first name. CONCLUSIONS--General practitioners should consider using patients'' first names more often, particularly with younger patients.     

B.M.A. Deputizing Service in Sheffield, 1970

Seventy-four per cent. of Sheffield general practitioners and 78% of those in Nottingham used a deputizing service in 1970. In each city the deputizing service was used by about 80% of single-handed general practitioners, 90% of doctors in two-doctor practices, and 60% of those in partnerships of three or more.The Sheffield deputizing service handled 15,988 new calls in the year, an average of 106 per subscribing doctor, and in addition made 339 revisits. The median number of calls handled for single-handed doctors was 98, for those in two-doctor practices 95, and for those in partnerships of three or more 75. The growth of group practice has not eliminated the demand for deputizing services.Sixty-six per cent. of consultations were with deputies who were primarily hospital doctors, 20% with a full-time deputy, 11% with deputies who were primarily general practitioners, and 3% with the switchboard staff, who were also trained nurses. The deputies had been qualified, on average, for eight years. Seventy-two per cent. of patients attended were seen within one hour of receipt of the call.Calls handled by the deputizing service represented approximately 1% of all the subscribers'' consultations, 5% of their home visits, and half their calls between midnight and 07.00 hours. At this level of activity the concept of “personal doctoring” was not threatened.     

General practitioners' attitudes to professional reaccreditation.

OBJECTIVE--To determine the views of general practitioners about professional reaccreditation. DESIGN--Postal questionnaire. SUBJECTS--All 278 general practitioner principals working in Cleveland. MAIN OUTCOME MEASURES--General practitioner characteristics; attitudes to reaccreditation; and views on the development, conduct, content, and format of reaccreditation. RESULTS--210 out of 278 (76%) general practitioners responded to the questionnaire. 128 (61%) agreed that general practitioners should undergo reaccreditation. 149 (72%) thought the General Medical Services Committee and local medical committees were appropriate bodies to lead its development. 120 respondents suggested that reaccreditation should be carried out by assessors appointed by the doctor''s own local medical committee. The most favoured interval between reaccreditation episodes was 10 or more years. 152 doctors thought that doctors who failed reaccreditation should be advised on education and reassessed soon afterwards. Clinical knowledge (82%), clinical skill (82%), prescribing practices (67%), standards of medical record keeping (60%), and consultation behaviour (58%) were the most popular subjects for scrutiny. 138 (67%) respondents felt that reaccreditation should be part of continuing medical education. CONCLUSION--Most general practitioners support professional reaccreditation. They believe the process should be led by the profession, be educational, and take account of a range of professional activities.     

Sexual knowledge and attitudes of general practitioners in Wessex.

A survey of the sexual attitudes and knowledge of general practitioners in Wessex found that GP trainees and those in practice for less than 10 years were less conservative and better informed than doctors in practice for 20 years or more, The results suggest that the attitudes of the doctors are determined by their early environmental influences rather than their clinical experience.     

General practitioners' management of acute myocardial infarction and cardiac arrest: relevance to thrombolytic treatment.

A questionnaire was sent to 61 general practitioners who had participated 18 months previously in a study of their experience of cardiopulmonary resuscitation and defibrillation in acute myocardial infarction. Fifty (82%) replies were received. Only 16 of the 50 respondents thought that every general practitioner should have a defibrillator, but 46 thought that every group practice should have one. Most practitioners felt the need for more tuition and practice in advanced life support, but 15 did not have the practice defibrillator with them when on call. Only nine doctors normally had an electrocardiograph with them when on call, most relying on clinical acumen to make an operational diagnosis; there appeared to be reluctance to use any drugs other than opiates and atropine in the management of acute myocardial infarction. This study highlights the difficulty of maintaining readiness to deal effectively with myocardial infarction in the community and the problems of relying on the electrocardiogram in deciding who should be given thrombolytic treatment.     

Do personal computers make doctors less personal?

Ten months after the installation of a computer in a general practice surgery a postal survey (piloted questionnaire) was sent to 390 patients. The patients'' views of their relationship with their doctor after the computer was introduced were compared with their view of their relationship before the installation of the computer. More than 96% of the patients (n=263) stated that contact with their doctor was as easy and as personal as before. Most stated that the computer did not influence the duration of the consultation. Eighty one patients (30%) stated, however, that they thought that their privacy was reduced.Unlike studies of patients'' attitudes performed before any actual experience of use of a computer in general practice, this study found that patients have little difficulty in accepting the presence of a computer in the consultation room. Nevertheless, doctors should inform their patients about any connections between their computer and other, external computers to allay fears about a decrease in privacy.     

Use of bacteriological investigations by general practitioners.

The numbers of vaginal swabs, faecal specimens, throat swabs, and urine specimens submitted by 104 city general practitioners to the bacteriology laboratory at Aberdeen differed widely. The doctors who made most use of the laboratory service rarely did so equally for all four investigations but usually for only one or two. Similarly, those who used the service least often made frequent use of one particular investigation. Further studies are needed to identify and evaluate the reasons for the apparently substantial disagreement among general practitioners concerning the value of these diffferent bacteriological investigations in general practice.     

Grampian Health Board's joint drug formulary.

OBJECTIVE--To develop a model for creating a joint general practice-hospital formulary, using the example of ulcer healing drugs. DESIGN--A joint formulary development group produced draft guidelines based on an earlier hospital formulary, which were sent to interested local general practitioners for consultation. Revised guidelines were then drawn up and forwarded to the health board''s medicines committee for approval and distribution. SETTING--Grampian Health Board. SUBJECTS--Nine members of joint formulary development group plus local general practitioners who were invited to comment on a list of 11 ulcer healing drugs. MAIN OUTCOME MEASURE--Degree of coincidence of drugs selected by hospital doctors and general practitioners. RESULTS--The ulcer healing drugs selected by the panel of general practitioners and by hospital doctors were highly coincident. The cost of one day''s treatment with drugs varied considerably between hospital and general practice--for example, one drug cost 46p in hospital and 1 pounds in general practice and another cost 1.26 pounds in hospital and 1.01 pounds in general practice. Overall, six drugs cost more in hospital and five cost more in general practice. CONCLUSIONS--A joint formulary for use in hospitals and general practice in a health board can be devised fairly simply by consultation as virtually the same drugs are used in both types of practice. It should influence the health board''s expenditure on drugs and affect the choice of drugs when a patient is discharged from hospital or is referred to any hospital in the region.     

Questioning behaviour in general practice: a pragmatic study.

OBJECTIVE: To study the extent to which general practitioners'' questioning behaviour in routine practice is likely to encourage the adoption of evidence based medicine. DESIGN: Self recording of questions by doctors during consultations immediately followed by semistructured interview. SETTING: Urban Australian general practice. SUBJECTS: Random sample of 27 general practitioners followed over a half day of consultations. MAIN OUTCOME MEASURES: Rate of recording of clinical questions about patients'' care which doctors would like answered; frequency with which doctors found answers to their questions. RESULTS: Doctors asked a total of 85 clinical questions, at a rate of 2.4 for every 10 patients seen. They found satisfactory answers to 67 (79%) of these questions. Doctors who worked in small practices (of one or two doctors) had a significantly lower rate of questioning than did those in larger practices (1.6 questions per 10 patients v 3.0 patients, P = 0.049). No other factors were significantly related to rate of questioning. CONCLUSIONS: These results do not support the view that doctors routinely generate a large number of unanswered clinical questions. It may be necessary to promote questioning behaviour in routine practice if evidence based medicine and other forms of self directed learning are to be successfully introduced.     

Psychological and social problems in HIV infection: interviews with general practitioners in London.

OBJECTIVE--To assess current practice and opinions of general practitioners in London about managing psychological and social problems relating to HIV infection. DESIGN--A stratified random sample of general practitioners, including those with a range of experience of people with HIV infection, were interviewed by medically trained interviewers. SETTING--Doctor''s surgeries. PARTICIPANTS--270 General practitioners working within the area covered by London postcodes. RESULTS--Two thirds of doctors had treated at least one patient with HIV infection and described their work with these patients. General practitioners were counselling and educating many of their patients about AIDS and associated risk behaviours and were aware of the need for careful attention to confidentiality. Doctors with no experience of patients with HIV infection were often older, in singlehanded practice, less inclined to deal with drug abusers or to counsel their patients on risk behaviours, and more in favour of insurance companies'' policies towards people with HIV infection. CONCLUSIONS--General practitioners in London are quickly becoming involved in the care of patients with HIV infection and their relatives and friends. Many are counselling patients and testing for antibodies themselves and regard this as an integral part of their work. A considerable workload in primary care comprised patients who obsessively fear contracting HIV infection.     

Responses by general practitioners in Avon to proposals for general practice in the white paper Working for Patients.

OBJECTIVE--To determine the views of Avon''s general practitioners about the general practice proposals within the government''s white paper Working for Patients. DESIGN--Postal questionnaire survey. SETTING--A county in south west England. SUBJECTS--All general practitioner principals (n = 537) under contract with Avon Family Practitioner Committee. MEASUREMENTS AND MAIN RESULTS--492 doctors (92%) responded to the survey. More than three quarters of the respondents were opposed to the government''s proposals on budgets for specific surgical procedures, prescribing, and diagnostic tests; and between 63% and 93% felt negative about advantages that might accrue from the proposals. Over three quarters of general practitioners were in favour of family practitioner committees monitoring work load, prescribing, and referrals. General practitioners in large, potentially budget holding practices held similar views to doctors in smaller practices. CONCLUSIONS--Avon''s general practitioners substantially reject most of the government''s proposals about general practice in the white paper Working for Patients.     

Doctors' experience with handheld computers in clinical practice: qualitative study

Objective To examine doctors'' perspectives about their experiences with handheld computers in clinical practice.Design Qualitative study of eight focus groups consisting of doctors with diverse training and practice patterns.Setting Six practice settings across the United States and two additional focus group sessions held at a national meeting of general internists.Participants 54 doctors who did or did not use handheld computers.Results Doctors who used handheld computers in clinical practice seemed generally satisfied with them and reported diverse patterns of use. Users perceived that the devices helped them increase productivity and improve patient care. Barriers to use concerned the device itself and personal and perceptual constraints, with perceptual factors such as comfort with technology, preference for paper, and the impression that the devices are not easy to use somewhat difficult to overcome. Participants suggested that organisations can help promote handheld computers by providing advice on purchase, usage, training, and user support. Participants expressed concern about reliability and security of the device but were particularly concerned about dependency on the device and over-reliance as a substitute for clinical thinking.Conclusions Doctors expect handheld computers to become more useful, and most seem interested in leveraging (getting the most value from) their use. Key opportunities with handheld computers included their use as a stepping stone to build doctors'' comfort with other information technology and ehealth initiatives and providing point of care support that helps improve patient care.