Guidelines for medical practice: 1. The reasons why.

Various external special interest groups are promoting attempts to better measure and control the performance of the medical profession, primarily to restrain costs. We can neither afford to ignore the rising costs nor reject efforts by provincial licensing authorities to improve supervision of the quality of care. Furthermore, there is increasing public interest in the outcome of medical treatment and a suspicion that some care may be unnecessary or inappropriate. Much of what physicians do is not based on impeccable or complete scientific evidence, and we have not established a method whereby science can consistently be translated into practice. Optimal practice patterns must be defined to improve the quality of care and to maximize the efficiency with which scarce resources are used. Careful scientific evaluation of data is particularly necessary with the arrival of new drugs and technology. Sensible, flexible guidelines produced by appropriate panels will help promote improved practice. Rigid standards must be avoided to allow for individual consideration and scientific innovation. The recognized difficulties of influencing clinical practice by precept or education and the problems imposed by rapidly changing scientific knowledge are two hurdles to be overcome. Licensing bodies must identify and enforce minimal standards, but optimal practice patterns are better devised by a broader segment of the profession. Intervention by third-party payers, as is prevalent in the United States, intrudes upon physician autonomy and reduces access to care. Physicians must support the development of guidelines for optimal medical practice based on the best existing data and focused on improving the quality of care.     

Guidelines for medical audit: seven principles.

The government, general managers, and professional bodies all agree that medical audit should be implemented throughout the United Kingdom. Nevertheless, it is not yet decided either nationally or locally how audit should be defined and what its implications will be. In an analysis to find ways of measuring the design and effectiveness of hospital audit, therefore, seven main measures emerged that might serve as practical criteria. These were the definition of medical and managerial responsibilities; medical organisation; scope of audit; essential characteristics; resources needed; record keeping; and evaluation. Though generally consistent with the proposals of the government and the Department of Health, these seven principles offer some alternative approaches.     

Adhesion: A possible survival strategy for leptospires under starvation conditions

The saprophyticLeptospira biflexa serovarpatoc 1 did not undergo a major reduction in size upon starvation, but starvation did result in greater adhesiveness of the leptospires. Adhesion may provide a strategy for survival of leptospires in oligotrophic habitats because these bacteria can scavenge fatty acids adsorbed at surfaces. Provision of an energy substrate (fetal calf serum) to starved cells resulted in an increase in cell size and motility and a decrease in adhesion of the leptospires. Glucose was not utilized as an energy source.     

General practice observed. A do-it-yourself medical centre.

A group practice commissioned a local building company to build their own medical centre comprising 370 m2 (4000 ft2) of building with an adequate car park at a total cost of 60 000 pounds with design to completion in nine months. A bank loan for 10 years was assigned to the partnership and each partner made his own arrangements for repayment. The updated cost for June 1979 is 80 000-85 000 pounds. Building a centre in this way is professionally and financially rewarding.     

Family doctors: their choice of practice strategy.

The economic decisions taken by family doctors in one family practitioner area in the north of England were examined. There was evidence of a differential response to professional and economic incentives by a group of "high investing" practices. On five indicators of improvement in practice 32% of the practices accounted for 71% of the positive scores. Nearly all the high investing practices were in affluent areas; they were on average larger and had younger partners than the other practices. The high investing practices also faced more financial problems. There was evidence that older doctors with long lists of patients had a different strategy of income maximization. Innovation in primary care is not determined by attitude alone but also by objective factors such as age, location, and size of the practice.     

Anglo-French contrasts in medical practice.

Medical practice in a British and French town was compared. The British and French general practitioners (GPs) and specialists were observed for one session each, and questionnaires were presented to the doctors and to samples of the inhabitants. Style of practice may largely determined by fiscal factors.