Rectal examination in general practice.

OBJECTIVE--To investigate factors influencing a general practitioner''s decision to do a rectal examination in patients with anorectal or urinary symptoms. DESIGN--Postal questionnaire survey. SETTING--General practices in inner London and Devon. SUBJECTS--859 General practitioners, 609 (71%) of whom returned the questionnaire. MAIN OUTCOME MEASURES--Number of rectal examinations done each month; the indication score, derived from answers to a question asking whether the respondent would do a rectal examination for various symptoms; and the confidence score, which indicated the respondent''s confidence in the diagnosis made on rectal examination. RESULTS--279 General practitioners did five or fewer rectal examinations each month and 96 did more than 10 each month. Factors significantly associated with doing fewer rectal examinations were a small partnership and being a female general practitioner, and the expectation that the examination would be repeated. Lack of time in the surgery, and a waiting time of less than two weeks for an urgent outpatient appointment were also important. General practitioners were deterred from doing rectal examinations by reluctance of the patient (278), the expectation that the examination would be repeated (141), and lack of time (123) or a chaperone (39). Confidence in diagnosis was significantly associated with doing more rectal examinations, the perception of having been well taught to do a rectal examination at medical school, and being a male general practitioner. CONCLUSIONS--Factors other than clinical judgment influence the frequency of rectal examination in general practice. Rectal examination may become commoner with the trend towards larger group practices and if diagnostic confidence is increased and greater emphasis put on rectal examination in undergraduate and postgraduate teaching.     

Serologic evidence of Chlamydia trachomatis infection and risk of preterm birth.

OBJECTIVE: To determine whether serologic evidence of Chlamydia trachomatis during pregnancy is a risk factor for preterm delivery (before 37 weeks'' gestation). DESIGN: Chart review. SETTING: Antenatal clinics associated with a teaching hospital. PATIENTS: A group of 103 unselected consecutive patients presenting for routine prenatal care. OUTCOME MEASURES: Pregnancy outcome and C. trachomatis serologic status. RESULTS: A total of 21 women (20%) were found to be seropositive for IgG antibodies to C. trachomatis. They were similar to the seronegative women with respect to maternal age, parity, history of preterm birth, obstetric or medical problems, smoking status, history of drug abuse, educational status and psychosocial stressors. The seropositive women were significantly more likely than the seronegative women to have a preterm birth (24% [5/21] v. 7% [6/82]i p = 0.029, odds ratio 3.96, 95% confidence interval 1.08 to 14.57), an infant with a lower mean gestational age at birth (262 [standard deviation (SD) 19] days v. 273 [SD 15] days; p = 0.0052) and an infant with a lower mean birth weight (3125 [SD 692] g v. 3473 [SD 696] g; p = 0.0434). The positive predictive value of a seropositive result for preterm birth was 31% (5/16); the negative predictive value of a seronegative result for preterm birth was 8% (6/76). CONCLUSION: Women with serologic evidence of C. trachomatis may be at risk for preterm birth. Further study is required to determine whether serologic testing for C. trachomatis should be a routine part of prenatal care.     

GP trainees' views on hospital obstetric vocational training.

OBJECTIVES--To examine the content of hospital obstetric vocational training for general practice, the beliefs of general practitioner trainees about this training, and their perceived competence at practical obstetric procedures and the effect of training. DESIGN--Confidential postal questionnaire. SUBJECTS--A random one in four sample of all general practitioner trainees in the United Kingdom on vocational training schemes or in training practices in Autumn 1990. MAIN OUTCOME MEASURES--Trainees'' competence and beliefs on Likert scale, numbers of procedures witnessed and performed, type of maternity care trainees intended to provide. RESULTS--Of 1019 trainees sent questionnaires, 765 (75.1%) replied; 517 had done some hospital obstetric training. After six months as a senior house officer 232/367 (63%) believed they were competent to perform a normal delivery unaided, 228 (62%) to manage a severe postpartum haemorrhage, and 227 (62%) to resuscitate a newborn infant. 272 (35.6%) trainees intended to provide intrapartum care and 56 (7.5%) to book home deliveries in the future. Hospital training increased confidence in performing most obstetric procedures in all trainees. However, a greater proportion of trainees who intended to provide full care than shared care felt competent at performing a normal vaginal delivery (63% (170/272) full v 45% (215/473) shared), low forceps delivery (38% (103) v 17% (79)), manual removal of placenta (24% (65) v 17% (82)), and intubating a neonate (42% (114) v 34% (161)). Trainees who had done any obstetric training were less likely to think that training encouraged future provision of intrapartum care (113/509 (22%) training v 65/213 (31%) no training). CONCLUSION--Hospital vocational obstetric training increases the perceived competence of trainees but fails to encourage them to use obstetric skills.     

Results of the peer assessment program of the College of Physicians and Surgeons of Ontario.

This paper describes the experience of the College of Physicians and Surgeons of Ontario in developing and conducting a program for the peer assessment of physicians'' office practices that would allow the standards of medical practice to be reviewed and assessed. Following two pilot projects in 1978 and 1979 that demonstrated the need, the feasibility and the acceptance of a peer assessment program the office practices of 391 randomly selected physicians were reviewed in 1981 and 1982. Included in the sample were 255 general/family practitioners and 136 specialists in seven fields. Serious deficiencies were found in the medical records of or in the care provided by 30 of the general/family practitioners and 3 of the specialists, accounting for 8% of the practices studied. The difference between the two groups of physicians was statistically significant (p less than 0.01). No predictors of significance were demonstrated in the general/family practitioner group. When follow-up assessments were done most of the physicians were found to have made the improvements that had been recommended.     

Response to Vogelstein: How the 2012 AAP Task Force on circumcision went wrong

Vogelstein cautions medical organizations against jumping into the fray of controversial issues, yet proffers the 2012 American Academy of Pediatrics' Task Force policy position on infant male circumcision as ‘an appropriate use of position‐statements.’ Only a scratch below the surface of this policy statement uncovers the Task Force's failure to consider Vogelstein's many caveats. The Task Force supported the cultural practice by putting undeserved emphasis on questionable scientific data, while ignoring or underplaying the importance of valid contrary scientific data. Without any effort to quantitatively assess the risk/benefit balance, the Task Force concluded the benefits of circumcision outweighed the risks, while acknowledging that the incidence of risks was unknown. This Task Force differed from other Academy policy‐forming panels by ignoring the Academy's standard quality measures and by not appointing members with extensive research experience, extensive publications, or recognized expertise directly related to this topic. Despite nearly 100 publications available at the time addressing the substantial ethical issues associated with infant male circumcision, the Task Force chose to ignore the ethical controversy. They merely stated, with minimal justification, the opinion of one of the Task Force members that the practice of infant male circumcision is morally permissible. The release of the report has fostered an explosion of academic discussion on the ethics of infant male circumcision with a number of national medical organizations now decrying the practice as a human rights violation.     

Poverty,prenatal care,and infant health in Puerto Rico

Using data from a survey administered to a representative sample of mothers who gave birth in Puerto Rico in 1994-95, we investigate whether prenatal care and infant health outcomes are associated with family poverty and neighborhood poverty. The results show that infant health outcomes are unrelated to both family poverty and neighborhood poverty, despite the association of family poverty with the adequacy of prenatal care and the content of prenatal care. However, the poverty paradigm does receive some support using measures of participation in government programs that serve the low-income population. Women who rely on the government to fund their medical care are more likely than women who rely on private health insurance to have an infant death. They are also less likely to receive the highest levels of prenatal care. Nonetheless, targeted government programs can have an ameliorative impact. The analysis shows that participants in the Women, Infants, and Children (WIC) program are more likely than non-participants to receive superior levels of prenatal care and are less likely to have negative infant health outcomes.     

Differences in intrapartum obstetric care provided to women at low risk by family physicians and obstetricians.

To determine differences in practice style and to examine maternal and neonatal outcomes, we reviewed the hospital charts of 1115 women admitted by family physicians and 1250 women admitted by obstetricians who gave birth at one of three teaching hospitals in Toronto between April 1985 and March 1986. All the women in the two groups were categorized retrospectively as being at low risk at the onset of labour on the basis of their prenatal records and their admission histories and physical examination results. There were higher proportions of younger women and women of lower socioeconomic status in the family physician group than in the obstetrician group (p less than 0.001). The rates of interventions, including artificial rupture of the membranes, induction, augmentation, low forceps plus vacuum extraction, episiotomy and epidural anesthesia, were all higher in the obstetrician group. The mean birth weight and the cesarean section rate were the same in the two groups. Differences in labour and delivery outcomes between the two groups, including a higher rate of spontaneous vaginal delivery for the family physicians, reflected a more "expectant" practice style by family doctors. However, there were no significant differences in the rates of maternal or neonatal complications. A practice style characterized by a higher rate of interventions was not associated with improved maternal or newborn outcome in this low-risk setting.     

Physicians' perception of personal risk of HIV infection and AIDS through occupational exposure.

Physicians'' response to acquired immune deficiency syndrome (AIDS) is poorly understood and often attributed to fear of human immunodeficiency virus (HIV) infection through occupational exposure. We surveyed 268 physicians from three geographic regions in North American with different specialties and responsibilities for HIV-positive patients. An important difference was found between the published risk and the physicians'' perceived risk of infection after a single occupational exposure. Almost half of the respondents stated that they feared contracting AIDS more than other diseases. The physicians who perceived themselves to be at high physical risk were more likely than the others to report that AIDS had changed the way they interact with their patients (r = 0.26, p less than 0.001). No relation was found between the perception of physical risk and the number of HIV-infected patients (r = -0.07, p = 0.15). However, the perception of social risk showed a small inverse correlation (r = -0.15, p less than 0.02), in which the physicians with more HIV-infected patients reported less concern about negative social consequences. The physicians who perceived themselves to be at high personal risk were more likely than the others to report that surgeons have the right to refuse patients who do not wish to undergo HIV antibody testing (r = -0.16, p less than 0.01 for physical risk; r = -0.29, p less than 0.001 for social risk). Multiple regression analyses indicated that physicians'' perception of physical risk was not related to age or sex but was modestly related to income source. The perception of social risk was related to sex and income source. Physicians'' perception of personal risk is a crucial, yet often unacknowledged, component of the fight against AIDS. Our findings suggest that lack of attention to this issue is seriously compromising initiatives designed to facilitate physician participation in AIDS care.     

Perinatal mortality rates in isolated general practitioner maternity units.

OBJECTIVE--To determine the perinatal mortality rate among normally formed, singleton babies with birth weights greater than or equal to 2500 g in Bath health district based on the intended place of delivery at the time of onset of labour or at the time of diagnosis of intrauterine death. DESIGN--The numbers of live births and stillbirths were collected monthly returns from the maternity units concerned. Deaths of infants aged less than or equal to 1 week were collected in the same returns. The intended place of delivery was confirmed at the monthly perinatal mortality meeting, during which maternal and fetal factors were discussed. SETTING--A rural health district of 400,000 population where one third of all deliveries occurred in seven isolated general practitioner maternity units, 8% in the integrated general practitioner unit, and the remainder in the consultant unit. SUBJECTS--All babies of women whose deliveries were booked in the district before the onset of labour or the diagnosis of intrauterine death, excluding twins, babies with lethal congenital malformations, and those less than 2500 g. MAIN OUTCOME MEASURES--Outcome of all deliveries and parity of mothers. RESULTS--14,415 Deliveries were analysed. The perinatal mortality rate was 2.8/1000 births in the consultant unit (7950 deliveries), 4.8 in the isolated general practitioner units (5237 deliveries), and zero in the integrated general practitioner unit (1228 deliveries). Perinatal deaths attributable to asphyxia were more common in the isolated general practitioner units (1.5 per 1000) than the consultant unit (0.6 per 1000). The perinatal mortality rate among babies born to nulliparous women was 3.2/1000 births in the consultant unit and 5.7 in the isolated general practitioner units; for those born to multigravid women it was 2.4 and 4.2 respectively. CONCLUSIONS--The outcome of delivery was not influenced by parity. Both antenatal and intrapartum care were responsible for the higher perinatal mortality rate in the isolated general practitioner units. The integrated unit, which shared midwifery staff with the consultant unit, seemed to work well. Analysis by intended place of delivery at the time of onset of labour or diagnosis of intrauterine death suggested that the care given in isolated units needs to be improved, perhaps by better training of general practitioners and consultant supervision of antenatal care.     

Infant Male Circumcision: Healthcare Provider Knowledge and Associated Factors

Background and Objectives

The emerging science demonstrates various health benefits associated with infant male circumcision and adult male circumcision; yet rates are declining in the United States. The American Academy of Pediatrics and the Centers for Disease Control and Prevention recommend that healthcare providers present evidence-based risk and benefit information for infant male circumcision to parent(s) and guardian(s). The purpose of this study was to assess providers’ level of infant male circumcision knowledge and to identify the associated characteristics.

Methods

An online survey was administered to healthcare providers in the family medicine, obstetrics, and pediatrics medical specialties at an urban academic health center. To assess infant male circumcision knowledge, a 17 point summary score was constructed to identify level of provider knowledge within the survey.

Results

Ninety-two providers completed the survey. Providers scored high for the following knowledge items: adverse event rates, protects against phimosis and urinary tract infections, and does not prevent hypospadias. Providers scored lower for items related to more recent research: protection against cervical cancer, genital ulcer disease, bacterial vaginosis, and reduction in HIV acquisition. Two models were constructed looking at (1) overall knowledge about male circumcision, and (2) knowledge about male circumcision reduction in HIV acquisition. Pediatricians demonstrated greater overall infant male circumcision knowledge, while obstetricians exhibited significantly greater knowledge for the HIV acquisition item.

Conclusion

Providers’ knowledge levels regarding the risks and benefits of infant male circumcision are highly variable, indicating the need for system-based educational interventions.     

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.     

Socioeconomic development,medical care,and nutrition as determinants of infant mortality in less‐developed countries

Abstract

Using data for sixty less‐developed countries, we constructed a causal model in which medical care, nutrition, status of women, and socioeconomic development are examined as determinants of infant mortality. Social and economic development are treated as exogenous variables; medical care, nutrition, and status of women are viewed as variables endogenous to the model. The model is tested by maximum likelihood methods. Results indicate that good nutrition and the presence of informally trained health care personnel, i.e., midwives, are more significantly related to low rates of infant mortality than are the employment status of women and the presence of formally trained health care personnel such as physicians and nurses. The general level of social and economic development conditions these relationships.     

What factors influence primary care physicians' charges for their services? An exploratory study using standardized patients

OBJECTIVE: To determine the extent of variation in physicians'' charges for health care encounters with unannounced standardized patients and factors associated with the variation. DESIGN: Cross-sectional study. SETTING: Family practices open to new patients within 1 hour''s drive of Hamilton, Ont. PARTICIPANTS: A stratified random sample of 125 physicians who had responded to an earlier survey regarding preventive care were invited to participate. Of the 125, 44 (35.2%) declined to participate, and an additional 19 (15.2%) initially consented but later withdrew because they closed their practices to new patients. Sixty-two physicians thus participated in the study. INTERVENTION: Unannounced standardized patients posing as new patients to the practice visited study physicians'' practices between September 1994 and August 1995, portraying 4 scenarios: 28-year-old woman, 52-year-old woman, 48-year-old man and 70-year-old man. OUTCOME MEASURES: Physician characteristics, encounter characteristics and charges made for services. RESULTS: The 62 physicians had 246 encounters with the standardized patients. Charges were made to the health insurance plan for services by 59 physicians for up to 4 encounters (215 encounters in all). Charges varied considerably both within and across patient scenarios. Time spent with the patient was an important factor predicting charges made (p < 0.01), although the effect of time spent on charges varied across scenarios (p < 0.01). Fee-for-service physicians charged more for their services than physicians who usually had alternative billing arrangements (p < 0.01). Female physicians charged more for their services than their male colleagues (p = 0.03). No relation was found between quality of preventive care and charges made (p = 0.15). CONCLUSIONS: Physician-related factors are better able to account for the variability in charges for their services than patient-related factors. Physicians seeing comparable patients may earn much more or less than their colleagues because of differences in the services they provide and the way they apply the fee schedule. Quality-assurance techniques are likely needed to reduce the variability in charges seen and increase value for money spent in health care.     

Interaction between bedding and sleeping position in the sudden infant death syndrome: a population based case-control study.

OBJECTIVE--To determine the relation between sleeping position and quantity of bedding and the risk of sudden unexpected infant death. DESIGN--A study of all infants dying suddenly and unexpectedly and of two controls matched for age and date with each index case. The parents of control infants were interviewed within 72 hours of the index infant''s death. Information was collected on bedding, sleeping position, heating, and recent signs of illness for index and control infants. SETTING--A defined geographical area comprising most of the county of Avon and part of Somerset. SUBJECTS--72 Infants who had died suddenly and unexpectedly (of whom 67 had died from the sudden infant death syndrome) and 144 control infants. RESULTS--Compared with the control infants the infants who had died from the sudden infant death syndrome were more likely to have been sleeping prone (relative risk 8.8; 95% confidence interval 7.0 to 11.0; p less than 0.001), to have been more heavily wrapped (relative risk 1.14 per tog above 8 tog; 1.03 to 1.28; p less than 0.05), and to have had the heating on all night (relative risk 2.7; 1.4 to 5.2; p less than 0.01). These differences were less pronounced in the younger infants (less than 70 days) than the older ones. The risk of sudden unexpected death among infants older than 70 days, nursed prone, and with clothing and bedding of total thermal resistance greater than 10 tog was increased by factors of 15.1 (2.6 to 89.6) and 25.2 (3.7 to 169.0) respectively compared with the risk in infants of the same age nursed supine or on their side and under less than 6 tog of bedding. CONCLUSIONS--Overheating and the prone position are independently associated with an increased risk of sudden unexpected infant death, particularly in infants aged more than 70 days. Educating parents about appropriate thermal care and sleeping position of infants may help to reduce the incidence of the sudden infant death syndrome.     

Outcome of pregnancies referred to a general practitioner maternity unit in a district hospital.

OBJECTIVE--To audit the outcome of pregnancies booked for confinement in a general practitioner maternity unit in a district general hospital. DESIGN--Retrospective review of case records. SETTING--General practitioner maternity unit in a district general hospital. PATIENTS--685 Women referred to a general practitioner unit in 1987. RESULTS--315 Nulliparous women and 330 multiparous women were booked for confinement; 202 women transferred to consultant care before delivery and a further 104 during labour or after delivery. Recognised risk factors, other than nulliparity, rarely predicted the need for transfer. Confinement in the general practitioner unit was associated with low intervention and good fetal outcomes. CONCLUSIONS--The general practitioner maternity unit provides a safe alternative for confinement in low risk pregnancies. High rates of transfer deny this facility to many women who desire confinement in a low technology environment.     

Prenatal care: a comparative evaluation of nurse-midwives and family physicians.

We evaluated the prenatal care provided to 44 low-risk women by nurse-midwives (NMs) at a special clinic of a large obstetric referral hospital and a sample of 88 low-risk women attended by family physicians (FPs) in their offices. The women were matched on the basis of date of delivery, age, parity, number of previous miscarriages, gravidity, socioeconomic status and delivery after 32 weeks'' gestation. The Burlington Randomized Controlled Trial criteria, which reflect community standards of care, were updated and used to assess the information, which was provided on standard provincial prenatal care forms. Scoring was carried out blindly, and interrater reliability was high. A highly significant difference was found in the proportions of NM and FP charts that were rated adequate, superior or inadequate: 77% v. 24%, 7% v. 16% and 16% v. 60% respectively. The rate at which procedures were omitted (leading to an inadequate score) in the categories of initial assessment, monitoring and management also varied between the two patient groups. These findings, even when considered in terms of several biases that may have resulted in the high proportion of NM charts rated at least adequate, suggest that NMs provide prenatal care to low-risk women that is comparable, if not superior, to the care provided by FPs.     

Lithium treatment: prescribing and monitoring habits in hospital and general practice.

OBJECTIVES--To define current clinical practice of lithium prescribing and monitoring and to compare hospital based practice with general practice. DESIGN--Prospective study of doctors'' practice. SETTING--Psychiatric hospital day and outpatient facilities and general practices in Edinburgh and Midlothian district (population 600,000). SUBJECTS--458 patients taking lithium who had been stabilised and who remained as outpatients during the year of study. 219 were treated by their general practitioner and 190 by the hospital; 49 had shared care or care transferred during the study. MAIN OUTCOME MEASURES--Daily dose, duration of treatment, psychiatric diagnosis, mean annual serum lithium concentration, frequency of occurrence of and response to raised serum concentrations. RESULTS--Compared with hospital doctors general practitioners were more likely to prescribe lithium three or more times daily (43/219 (general practice) v 10/190 (hospital); chi 2 = 18.6, p = 0.001) and to estimate serum concentrations less frequently (4.5 v 5.3 measurements/year; t = 3.04, p = 0.003), and their patients were more likely to experience raised lithium concentrations (39/219 v 17/190; chi 2 = 6.8, p = 0.01). One third of doctors made no response to raised lithium concentrations in the next six weeks. CONCLUSIONS--General practitioners and hospital doctors care for similar types of patients and the stringency of lithium surveillance varies greatly among doctors. Certain aspects of practice give cause for concern and could be improved by following more uniform guidelines.     

Identifying the intergenerational effects of the 1959–1961 Chinese Great Leap Forward Famine on infant mortality

Using the 1959–1961 Chinese Great Leap Forward Famine as a natural experiment, this study examines the relationship between mothers’ prenatal exposure to acute malnutrition and their children's infant mortality risk. According to the results, the effect of mothers’ prenatal famine exposure status on children's infant mortality risk depends on the level of famine severity. In regions of low famine severity, mothers’ prenatal famine exposure significantly reduces children's infant mortality, whereas in regions of high famine severity, such prenatal exposure increases children's infant mortality although the effect is not statistically significant. Such a curvilinear relationship between mothers’ prenatal malnutrition status and their children's infant mortality risk is more complicated than the linear relationship predicted by the original fetal origins hypothesis but is consistent with the more recent developmental origins of health and disease theory.     

Effects of residency training in family medicine v. internship training on professional attitudes and practice patterns.

OBJECTIVES: To determine whether the professional attitudes and practice patterns of physicians with residency training in family medicine differ from those of generalists with internship training. DESIGN: Mail survey conducted in 1985-86. SETTING: Province of Quebec. PARTICIPANTS: A stratified random sample of French-speaking family and general practitioners who graduated after 1972 (325 physicians with residency training and 304 with internship training) (response rate 82%). MAIN RESULTS: Physicians with residency training were 3 years younger on average than those with internship training, were more likely to be female (38% v. 18%, p less than 0.001) and were more likely to work on a salaried basis in CLSCs (public community health centres) (36% v. 14%, p less than 0.001). Even after these confounding factors were controlled for, physicians with residency training seemed to be more sensitive to the psychosocial aspects of patient care and tended to attach more importance to informing patients about useful materials and resources concerning their health problems. They were not, however, more likely to value health counselling or integrate it in medical practice. CONCLUSION: Our findings provide some evidence that the new requirement that physicians complete a residency in family medicine to obtain medical licensure in general practice in Quebec may foster a more patient-centred approach to health care.