General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey.

OBJECTIVES: To evaluate general practitioners'' knowledge of a range of psychosocial problems among their patients and to explore whether doctors'' recognition of psychosocial problems depends on previous general knowledge about the patient or the type of problem or on certain characteristics of the doctor or the patient. DESIGN: Multipractice survey of consecutive adult patients consulting general practitioners. Doctors and patients answered written questions. SETTING: Buskerud county, Norway. SUBJECTS: 1401 adults attending 89 general practitioners during one regular working day in March 1995. MAIN OUTCOME MEASURES: Doctors'' knowledge of nine predefined psychosocial problems in patients; these problems were assessed by the patients as affecting their health on the day of consultation; odds ratios for the doctor''s recognition of each problem, adjusted for characteristics of patients, doctors, and practices; and the doctor''s assessment of previous general knowledge about the patient. RESULTS: Doctors'' knowledge of the problems ranged from 53% (108/203) of "stressful working conditions" to 19% (12/63) of a history of "violence or threats." Good previous knowledge of the patient increased the odds for the doctor''s recognition of "sorrow," "violence or threats," "substance misuse in close friend or relative," and "difficult conflict with close friend or relative." Age and sex of doctor and patient, patient''s educational level and living situation, and location of practice influenced the doctor''s awareness. CONCLUSIONS: Variation in the patients'' communication abilities, the need for confidence in the doctor-patient relationship before revealing intimate problems, and a tendency for the doctors to be entrapped by their expectations may explain these findings.     

Screening for psychosocial problems among primary care patients: a pilot study.

The symptoms that a patient presents to the doctor are often not the underlying concern that prompted the consultation. The success of consultations involving a hidden diagnosis depends on how well the patient can express his or her concerns to the doctor and on how skilfully the doctor can encourage this. This study tested the feasibility and acceptability of having patients complete a brief health index questionnaire designed to help them describe their underlying concerns to the doctor. In two family medicine centres 996 patients were asked to complete a questionnaire while waiting to see the doctor; 724 (73%) did so. An evaluation of their responses showed the method to be acceptable to most. The doctors judged that it added valuable information in 41% of all consultations and in 73% of consultations in which the patient presented with psychologic complaints. There was, nevertheless, considerable variation among the physicians in their acceptance of the approach. This variability is discussed in the light of alternative models of how, in practical terms, to treat the psychosocial dimensions of a patient''s complaint.     

Self referral to accident and emergency department: patients' perceptions.

A study was conducted (a) to assess the number of patients registered with a south London general practice who over 11 weeks referred themselves to an accident and emergency department, (b) to identify the characteristics of those patients, and (c) to determine their perceptions of the services and resources available within their general practices and of the role of accident and emergency departments. Two hundred and thirty four patients referred themselves to a casualty department during the study period, of whom 217 (93%) were interviewed by means of a semistructured questionnaire. Of the 217 patients interviewed, only 15 had tried to contact their general practitioner before attending the casualty department. Eighty nine patients considered that their problem was urgent and required immediate attention and many that they would need an x ray examination. A substantial minority of patients thought that their doctor would not be available. It is concluded that patients'' perceptions of their problems and of access to their doctors are the main determinants of self referral to a casualty department. These findings have important implications for patient education.     

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.     

Continuity of care in general practice: effect on patient satisfaction.

OBJECTIVE--To evaluate the influence of continuity of care on patient satisfaction with consultations. DESIGN--Direct and episodic specific evaluation of patient satisfaction with recent consultation. SETTING AND SUBJECTS--A representative sample of 3918 Norwegian primary care patients were asked to evaluate their consultations by filling in a questionnaire. The response rate was 78%. MAIN OUTCOME MEASURES--The patient''s overall satisfaction with the consultation was rated on a six point scale. Continuity of care was recorded as the duration and intensity of the present patient-doctor relationship and as patients'' perception of the present doctor being their personal doctor or not. RESULTS--The multivariate analysis indicated that an overall personal patient-doctor relationship increased the odds of the patient being satisfied with the consultation sevenfold (95% confidence interval 4.9 to 9.9) as compared with consultations where no such relationships existed. The duration of the patient-doctor relationship had a weak but significant association with patient satisfaction, while the intensity of contacts showed no such association. CONCLUSION--Personal, continuous care is linked with patient satisfaction. If patient satisfaction is accepted as an integral part of quality health care, reinforcing personal care may be one way of increasing this quality.     

How much personal care in four group practices?

OBJECTIVE--To establish the degree of continuity of care in general practice. DESIGN--Retrospective study of the records of all eligible patients attending the surgery at randomly selected sessions. SETTING--Four large group practices in the Southampton Health District, one of which operated a strict system of personal lists. PATIENTS--776 Patients who had been registered for at least two years and had consulted at least 12 times over six years or less. MAIN OUTCOME MEASURES--Continuity score for each patient calculated from the number of consultations (out of the past 12) with his or her usual doctor. Number of the times the patients had consulted the doctor with whom they were registered. RESULTS--In the practice with personal lists a mean of 10 of the 12 consultations had been with the same doctor (83% of consultations), but in the three practices with combined lists the means were 5.9 (49%), 6.2 (52%), and 6.9 (58%). Continuity was associated with increased age and with the recording of a major problem. In the practices with combined lists 63 of 72 children consulted at least five different doctors. Only 140 of 489 patients currently in the practice who were identified as being registered with a doctor had most usually consulted that doctor in the practices with combined lists. CONCLUSIONS--Personal continuity of care may be fairly low in group practice, especially for younger and healthier patients registered at practices with combined lists. These findings support the Department of Health''s recent decision to make "target payments" (for cervical smears and childhood immunisations) to groups rather than to individual principals but pose a question for the future of individual clinical responsibility.     

Value of the history in the office diagnosis of breast cancer.

A review of the histories of 1059 patients with breast problems seen consecutively in office consultation revealed an incidence of breast cancer of 13%. Patients over 50 years of age or whose mother or sister had had breast cancer had a substantially greater likelihood of having breast cancer. The finding of the problem on routine examination, a family history of breast cancer in a relative other than the mother or a sister, or prominent breast pain or nipple discharge made the diagnosis of cancer less likely. Menstrual status, a history of previous benign disease, nulliparity, current hormone therapy and duration of symptoms did not help identify the patient likely to have breast cancer. Much time could be saved for both doctor and patient in taking the history from patients with breast disorders. Only the patient''s age and the history of the mother and sisters with regard to breast cancer will help identify the "high-risk" patient. Other historical findings are either valueless or should be used to reassure these usually anxious women.     

Postal survey of patients' satisfaction with a general practice out of hours cooperative.

OBJECTIVE: To assess patients'' satisfaction with out of hours care by a general practice cooperative compared with that by a deputising service. DESIGN: Postal questionnaire survey. SETTING: A general practice cooperative in London and a deputising service operating in an overlapping area. SUBJECTS: Weighted samples of patients receiving telephone advice, a home visit, or attending a primary care centre after contacting either service in an eight week period. MAIN OUTCOME MEASURES: Patients'' overall satisfaction and scores for specific aspects of satisfaction. Satisfaction with telephone advice or attendance at centre compared with home visit. Relation between satisfaction and patient''s age, sex, ethnic group, car ownership, preference for consulting own doctor, and expectation of a visit. RESULTS: The overall response rate was 67% (1555/2312). There was little difference in overall satisfaction between patients contacting the cooperative or the deputising service, but patients contacting the latter were less satisfied with the explanation and advice received and the wait for a visit. There were significant differences between patients in different age and ethnic groups, with white patients and those aged over 60 years being more satisfied. Lower scores for overall satisfaction were reported by patients who received telephone advice, those who would have preferred to see their own doctor or who originally wanted a home visit, and those who waited longer for their consultation. Overall levels of patients'' satisfaction seemed to be lower than previously reported. CONCLUSIONS: There were larger differences in satisfaction between different groups of patients than between different models of organisation for out of hours care. A shift to a service based predominantly on telephone advice may lead to increased patient dissatisfaction.     

Patient satisfaction with general practitioner deputising services.

Proposed increases in the average hours of surgery sessions of general practitioners as part of the government programme for improving primary health care may result in more use of deputising services to provide off duty cover. The satisfaction of patients with such a service was studied during one week of October 1987 at nine of the 29 branches of Air Call Medical Services in urban areas in Britain by means of a postal questionnaire. Of a sample of 4626 callers to the service, 3887 (84%) responded. An estimated 32% of the patients expected that a doctor from their own practice would have attended them, 19% expected that they would be admitted to hospital and 8% were admitted. Over 90% of patients were satisfied with the telephonist''s handling of the call; 79% of those visited were satisfied with the waiting time; and over 80% were satisfied with various aspects of the doctor''s handling of the visit (bedside manner, communication, taking of history, physical examination, and explanation of findings), the lowest figure being for explanation of findings (81%). Satisfaction was generally higher during the daytime; among the elderly, especially men; and among patients who did not anticipate that a doctor from their doctor''s practice would call. The results suggest that a high proportion of patients were satisfied with the deputising service they received.     

Community Nurses' View of General Practice Attachment

An analysis of 98 health visitors and district nurses attached and non-attached to general practitioners in three local authority areas showed that most of them were aged over 40 and that many had entered domiciliary work because of the convenient hours or because of its intangible attractions. Adequate preparation for attachment was considered important, particularly a clear definition of the roles of the attached staff and their relationships to other workers in the practice.Attached staff were found to be much more satisfied with the information given by the general practitioner about their patients than were unattached staff, and the former usually had access to the patients'' medical records. The principal advantages of attachment were listed as access to family history; improved co-ordination within the practice and co-operation with the social services; favourable patient response; and increased mileage and work-load; the impossibility of crossing local authority boundaries; and having to deal with families registered with more than one doctor.     

Observational Study Assessing Demographic,Economic and Clinical Factors Associated with Access and Utilization of Health Care Services of Patients with Multiple Sclerosis under Treatment with Interferon Beta-1b (EXTAVIA)

Multiple sclerosis (MS) results in an extensive use of the health care system, even within the first years of diagnosis. The effectiveness and accessibility of the health care system may affect patients'' quality of life. The aim of the present study was to evaluate the health care resource use of MS patients under interferon beta-1b (EXTAVIA) treatment in Greece, the demographic or clinical factors that may affect this use and also patient satisfaction with the health care system. Structured interviews were conducted for data collection. In total, 204 patients (74.02% females, mean age (SD) 43.58 (11.42) years) were enrolled in the study. Analysis of the reported data revealed that during the previous year patients made extensive use of health services in particular neurologists (71.08% visited neurologists in public hospitals, 66.67% in private offices and 48.53% in insurance institutes) and physiotherapists. However, the majority of the patients (52.45%) chose as their treating doctor private practice neurologists, which may reflect accessibility barriers or low quality health services in the public health system. Patients seemed to be generally satisfied with the received health care, support and information on MS (84.81% were satisfied from the information provided to them). Patients'' health status (as denoted by disease duration, disability status and hospitalization needs) and insurance institute were found to influence their visits to neurologists. Good adherence (up to 70.1%) to the study medication was reported. Patients'' feedback on currently provided health services could direct these services towards the patients'' expectations.     

Determinants of non-compliance with short term antibiotic regimens.

The contribution of doctor, patient, and consultation interaction patterns to compliance with antibiotic treatment was examined in 233 adult patients seen in general practice. Twelve variables were shown to discriminate between compliers and non-compliers. Discriminating variables relating to patients included health state, employment state, knowledge of tablet, and perception of anxiety level, difficulty in complying, and their observed anger, distance, and assertiveness in the consultation. Discriminating variables relating to doctors included provision of advice on duration of treatment, complexity of dosage schedule, age of doctor, and number of years in practice. For the most part these results confirmed previous research. It is concluded that the doctor should consider both the dosage schedule and the patient''s daily routine when prescribing antibiotic tablets. Advice on how to take the tablets should be given in specific rather than in general terms. The significant effect of the age of the doctor and the years spent in practice has not been found in previous work. This finding may reflect differences in behavior between younger doctors and their patients. This difference was not detected in the observation of consultation events.     

Palliative care: views of patients and their families.

OBJECTIVE--To investigate the current problems and needs of terminally ill cancer patients and their family members, and to discover their views of hospital, community, and support team services. DESIGN--Prospective study of patients and families by questionnaire interviews in the patients'' homes. SETTING--Inner London and north Kent (London suburbs). SUBJECTS--65 Patients, each with a member of their family or a career. MAIN OUTCOME MEASURES--Ratings of eight current problems and ratings and comments on three services-hospital doctors and nurses, general practitioners and district nurses, and the support team staff-obtained after a minimum of two weeks'' care from palliative care support teams. RESULTS--Effect of anxiety on the patient''s nearest career. and symptom control were rated as the most severe current problems by both patients and families; a few patients and families identified other severe problems. Families'' ratings of pain control, symptom control, and effect of anxiety on the patient were significantly worse than the patients'' ratings (p less than 0.05). Support teams received the most praise, being rated by 58 (89%) patients and 59 (91%) of family members as good as excellent. General practitioners and district nurses were rated good or excellent by 46 (71%) patients and 46 (71%) family members, but six (9%) in each group rated the service as poor or very bad, and ratings in the inner London district were significantly worse than those in the outer London district. Hospital doctors and nurses were rated good or excellent by 22 (34%) patients and 35 (54%) of family members, and 14 (22%) patients and 15 (23%) family members rated this service as poor or very bad. Negative comments referred to communication (especially at diagnosis), coordination of services, the attitude of the doctor, delays in diagnosis, and difficulties in getting doctors to visit at home. Family members were more satisfied with the services than were patients. CONCLUSIONS--Palliative care needs to include both the patient and family because the needs of the family may exceed those of the patient. Support teams and some hospital and community doctors and nurses met the perceived needs of dying patients and families, but better education and organisation of services are needed.     

Use of deputising services and night visit rates in general practice.

Examining all of the claim forms for night visits submitted to the Nottingham Family Practitioner Committee over a three month period allowed us to calculate the night visit rate for all 184 practices in Nottinghamshire. To take all of the practices together the mean night visit rate (covering all visits requested and made between 11 00 pm and 7 00 am) was 15.5 visits per 1000 patients a year, range 1.2 to 46.1. Whether or not a deputising service is used accounted for 12% of the total variance detected, while the other factors studied, such as area of practice, patient list size, and number of partners, accounted for approximately 1% each. The local deputising service responds to 97% of night calls with a visit to the patient, whereas the patient''s own doctor is more likely to provide advice over the telephone. The ability to provide telephone advice, however, will vary according to the breakdown of the practice by age and social class.     

Diagnosis and management of hypertension: the stated practices of family physicians.

Hypertension is an important and common problem in family practice, but there is no general agreement on the systolic and diastolic pressures at which it should be diagnosed and treated. Responses from 273 family physicians surveyed by mail in Metropolitan Toronto showed a wide variation in the pressures used as cut-off points. The probability that in a given patient hypertension would be diagnosed or treated at different systolic and diastolic pressures varied considerably among the physicians, the variation increasing with the age of the patient. There was also wide variation in opinion among the surveyed physicians about how often patients should be screened for hypertension; depending on the patient''s age, up to 35% of the physicians stated that the blood pressure should be measured at every visit. Only one third reported using any one or more methods to ensure that patients with hypertension were not lost to follow-up. The family physicians with an academic appointment used higher cut-off points for diagnosis and treatment, and they screened and scheduled follow-up visits less frequently than those without an academic appointment.     

Rocky mountain spotted Fever

We compare health maintenance organization enrollees'' evaluations of the care they received from family physicians and chiropractors for low back pain. Patients of chiropractors were three times as likely as patients of family physicians to report that they were very satisfied with the care they received for low back pain (66% versus 22%, respectively). Compared with patients of family physicians, patients of chiropractors were much more likely to have been satisfied with the amount of information they were given, to have perceived that their provider was concerned about them, and to have felt that their provider was comfortable and confident dealing with their problem. Although the more positive evaluations of chiropractors may be related to differences in the patient populations served by the two providers or to benefits of spinal manipulation, it is suggested that a potentially more potent force--the therapeutic effect of the patient and provider interaction itself--may explain the observed differences.     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Patients' accounts of calling the doctor out of hours: qualitative study in one general practice.

OBJECTIVE: To investigate patients'' accounts of calling the doctor out of hours. DESIGN: Qualitative analysis of semi-structured interviews with two groups of patients who called their doctors out of hours from one general practice. SUBJECTS: 23 people who had called the doctor on their behalf or on behalf of another adult and 23 people who had called on behalf of a child between 6 pm and 8 am on a week day (omitting the weekend from 6 pm on Friday to 8 am on Monday). RESULTS: although respondents described symptoms as the main reason for the call, they also described a range of other factors that led to the call, including their feelings, concerns about specific illnesses, their responsibility for others, and their previous attempts to manage the problem themselves. They also described past experiences with health services that were important in explaining the current out of hours call or explaining their general approach to using services. CONCLUSIONS: The pursuit of a model of out of hours care based on medical necessity that neglects the psychosocial context of illness may not be appropriate. The importance of previous experiences of health services and contacts with health professionals in explaining current service use requires wider acknowledgement by health professionals across sectors. Separate educational programmes to encourage patients to use out of hours services more appropriately that neglect these issues may be too simplistic.