List sizes and use of time in general practice.

The claim that list sizes in general practice should continue to fall towards a national average of 1700 patients rests heavily on the assumption that the extra time available to doctors would be used mainly for longer consultations, resulting in better standards of care. Evidence suggests, however, that the time is more likely to be used to increase rates of consultation in surgeries and home visits and to reduce the length of the working week. A national, random sample of 2104 principals in general practice in England and Wales were questioned about their allocation and use of time. The response rate was 67%, and no large biases in response were detected. The smaller their personal list size the less time general practitioners spent on all aspects of their work and the higher their rates of consultation and home visiting. The effects of further reductions in list sizes would be haphazard, being differentially distributed across the range of list sizes. Longer consultations would probably result, but most of the extra time would probably be used in higher rates of consultation in surgeries and home visits and some would be taken as free time.     

How can good general practitioner care be achieved?

It has been shown that to provide a high standard of care general practitioners probably need to book consultations at intervals of at least 10 minutes. In this study the maximum list size for which a general practitioner might be expected to provide a high standard of care was determined from calculations of the time spent consulting, based on various consultation rates and list sizes and assuming that consultations were 10 minutes long. If good quality care is to be provided and is to include the range of services suggested in the government''s recent green paper average list sizes should probably be no more than 1750, and lower in areas of high demand and high need. In addition to this, minimum standards could be determined for such measures as facilities available in surgeries, practice records, and accessibility of doctors to ensure that basic services were offered by all general practitioners.     

Workload of general practitioners before and after the new contract.

OBJECTIVE--To assess changes in general practitioners'' workload associated with the new contract introduced in April 1990. DESIGN--Weekly workload diary completed during four weeks in February-March 1990 and during the same period in 1991. SETTING--Sheffield, United Kingdom. SUBJECTS--All 300 general practitioners on Sheffield Family Health Services Authority list as principals in 1990 and 1991. MAIN OUTCOME MEASURES--Mean number of hours worked per week, number of patients seen each week, and mean time spent per patient. RESULTS--181 (60%) general practitioners responded in 1990 and 163 (54%) in 1991. Of these, 18 (10%) were not working in 1990 and 14 (7%) in 1991. General medical service work increased during a "normal working week" from a mean of 38.6 hours a week in 1990 to 40.6 hours in 1991, and non-general medical service work decreased from 5.4 hours a week to 4.5 hours. Hours spent on call were similar before and after the contract. For the 99 general practitioners who responded in both years, time spent on general medical service duties increased significantly (40.5 h in 1990 v 42.5 h [corrected] in 1991; p = 0.033), mainly due to more time being spent in clinics. Significantly more patients were being seen in clinics (9 v 14; p = 0.001); the average time spent per patient remained at about 8 1/2 minutes during surgeries and 16 minutes for a home visit, and rose from 13 to 14 minutes for patients seen in clinics. The time spent on practice administration fell but not significantly. CONCLUSION--Since the new contract there has been a significant increase in general medical services work, mainly due to more patients being seen in clinics, with no reduction in the time spent per patient.     

Does resource availability affect offspring begging and parental provisioning in a partially begging species?

In species where parents repeatedly provide their offspring with food, the offspring often communicate their need to the parents. Burying beetles, which breed on a wide size range of carcasses of small vertebrates, are interesting model systems to test theories on begging, because the larvae show partial begging, that is, they obtain food through both signalling to their parents (begging) and feeding directly from the carcass. We manipulated resource availability inNicrophorus vespilloides by providing parents with mouse carcasses spanning a wide size range, and allowing them to rear the larvae that hatched, so that both the amount of resources and the number of siblings varied. Time spent begging by each larva was strongly influenced by the time parents spent near the larvae. Brood size had a nonlinear effect on larval begging, with begging increasing with brood size for relatively smaller broods and decreasing again for larger broods. Carcass size and number of parents present had no effect on begging. Time spent provisioning the larvae by the parents was strongly associated with the time spent begging by each larva. Parents spent more time provisioning under biparental care than under uniparental care, while brood size and carcass size had no significant effect. These findings suggest that the larvae adjust their begging to the behaviour of their parents and the number of siblings, but not to the amount of resources. Furthermore, parents adjust the time spent provisioning to the average amount of begging by each larva in the brood, and not to the availability of resources.     

Excessive use of psychiatric services by suicidal patients.

The use of psychiatric services by patients with a suicidal history was examined to see if they placed a greater long-term burden on these services than other types of patient. Suicidal patients spent significantly more days in hospital and made more outpatient attendances; suicide attemptors in particular not only needed more emergency consultations but also spent more days in hospital. A more economical yet more effective treatment policy for the suicidal patient is needed.     

Twenty four hour care in inner cities: two years' out of hours workload in east London general practice.

Two inner city general practices in east London jointly provide care outside normal working hours without using deputising services for about 14,000 patients. The statistics on workload were reviewed for 1987 and 1988. An overall rate of face to face consultations of 4.1 per patient per year was recorded, there being 115,965 consultations over two years for a mean list size of 14,174 patients. Four per cent (4737) of such consultations were outside normal working hours. The annual rate of visiting outside normal hours was 128.1 per 1000 patients in 1987 (1793 visits) and 131.5 per 1000 in 1988 (1888 visits). The rates of night visiting were 18.8 (262 visits) and 18.9 (271 visits) per 1000 patients in 1987 and 1988 respectively. Only 24% of all the requests for medical help out of hours (1483/6220) were dealt with by advice given on the telephone. The high rates of consultation outside normal working hours with only a small proportion being dealt with on the telephone alone may be explained by indices of deprivation. Local rotas for out of hours work are a good compromise between meeting the needs of patients and doctors in deprived areas, but there are financial implications for inner cities.     

Waiting times: monitoring the total postreferral wait.

OBJECTIVES--To determine whether the period spent on the true inpatient waiting list is a valid indication of the total time that patients have to wait for an operation; and to assess the feasibility of monitoring the total "postreferral waiting time" by using existing computerised information systems. SETTING--Three randomly selected Scottish hospitals. SUBJECTS--Waiting list patients admitted to hospital for operations during June to August 1993 in six major specialties, separate attention being focused on cataract operations and hip and knee replacements. MAIN OUTCOME MEASURE--The total time that patients have to wait for an operation after the initial general practitioner referral--the postreferral waiting time--compared with that spent at the final stage of the process on the true inpatient waiting list. RESULTS--In the specialties investigated roughly half (58 days; 53%) of the average postreferral wait of 110 days was spent on the true inpatient waiting list, one third (35 days; 32%) being spent on the outpatient waiting list and one sixth (17 days; 15%) waiting between waiting lists. Only a quarter of cataract patients (73/292) were treated within three months of general practitioner referral compared with over three quarters (228/292) within three months of being placed on the inpatient waiting list. Nevertheless, within a year over 99% of patients (290) had been treated whichever date was taken as the starting point. CONCLUSIONS--Monitoring postreferral waiting times would provide a much more accurate picture for purchasers and patients of waiting times for treatment than is obtained by focusing exclusively on the true inpatient waiting list and facilitate fairer comparisons between NHS trusts in national league tables. Stringent national and local monitoring is essential to ensure (a) that future reductions in the time waiting on true inpatient waiting lists are not gained at the expense of longer periods waiting to be placed on the lists, and (b) that no increases occur in the number of patients placed instead on deferred waiting lists or exempted from the normal maximum waiting time guarantees.     

Cost of prey capture, growth rate and ration size in pike, Esox lucius L., as functions of prey wheight

Prey intake, amount of time feeding, pursuit and manipulation times and growth rate were studied in the pike, Esox lucius , in relation to prey weight. Predator and prey were observed in tanks at 15°C and with a 14:10 h LD photoperiod. A total of 444 captures were recorded from five 1 g prey weight groups varying from 0 to 4.9 g. Ten pike were used weighing between 50 and 149 g.
As prey weight increased, the number and weight of prey consumed decreased as did the time spent feeding, which became concentrated into the first trial of the day. Pursuit time did not vary with prey weight, but manipulation time and the weight of prey gained per unit pursuit plus manipulation time increased with prey weight.
The growth rate of pike was a positive function of ration size and a negative function of the amount of time spent capturing each gramme of prey (capture cost). Growth rate was also correlated with the mean length and weight of prey eaten.
The most profitable prey, as estimated from optimal foraging theory, need only be available once every 84 min for pike to maximize their net energy gain. The data show that feeding behaviour can have a direct influence on the reproductive success of pike through its effect on growth rate.     

Female Choice for Male Morphological Traits in House Sparrows,Passer domesticus

Female mate choice for male morphological traits was examined in captive house sparrows in New Mexico, USA. A study of house sparrows in Denmark indicated that male bib size is important in female choice (Moller 1988, 1989). To examine this issue further, and to compare the selective pressures on male morphological traits between the two populations, bibs of males were manipulated to one of four standard sizes and females were allowed to choose from four males, one of each bib size. The amount of time the female spent with each male was recorded for 40 trials. Males were then ranked in each trial, with a rank of 4 given to the male the female spent the most time with. The ranks a male obtained were then averaged to provide an indication of a male's attractiveness to females. Data from 23 different males indicated that bib size was not correlated with a male's average rank, even when the effects of other traits were controlled statistically. In addition, the size of the original (unaltered) bib was not correlated with male average rank. Bill depth was the only trait significantly correlated with a male's average rank. Differences in the populations studied or the methodologies used may have led to differences between the results obtained in this study and that of Moller (1988).     

Timer: a new objective measure of consultation content and its application to computer assisted consultations.

As part of the research into the effect in the consultation of the use of a computer to prompt opportunistic preventive care a valid, objective, and practical measure of the consultation process was required. After a review of the alternative methods the Time Interval Medical Event Recorder (Timer) was developed, its reliability tested, and applied to 93 control consultations and 49 computer assisted consultations. Timer records, every five seconds, four consultation events: the problems being dealt with, the physical activity, the verbal activity, and the secondary tasks being attempted. Timer showed that control consultations lasted an average of 6 minutes 58 seconds. The doctors spent 35% of their time on administration, and patients and doctors were both conversational for just 33% of the consultation. Giving information was the most common verbal activity (48% of the duration of the consultation) with silence accounting for 21% of the time. When the computer was used the average consultation was longer, at 7 minutes and 46 seconds. The doctor''s contribution to the consultation appeared to have increased. Patient centred speech fell from 36% in controls to 28% of the duration of the consultation when the computer was used, while doctor centred speech rose from 30% to 34.5%. Secondary tasks (exploring patient concepts, education, management sharing, and prevention) were attempted during 28% of the control consultations and 40% of the computer consultations. This was accounted for by the increase in prevention (p less than 0.001). Timer is a reliable and practical tool for researching the consultation, and though it has shown validity in detecting differences between consultations that use a computer and those that do not, further applications are required to establish its full value.     

Waiting list management in general practice: a review of orthopaedic patients.

OBJECTIVE: To review all patients on a current general practice orthopaedic waiting list for outpatient appointments with regard to accuracy of the list, clinical priority, and need for further radiological investigation before hospital attendance. DESIGN: Record review by one general practitioner and a radiologist, and discussion with patients of management alternatives. SETTING: Six partner city centre urban fund-holding general practice, list size 8651 (29% low deprivation payment status). SUBJECTS: 116 adults on an orthopaedic waiting list. MAIN OUTCOME MEASURES: List accuracy (patient details and status on waiting list); clinical priority (severity of condition); further investigations (results of tests after radiological review). RESULTS: 32 patients (28%) were removed from the waiting list because of inaccuracies. 14 patients were considered to be high priority and referred to other hospitals by utilising waiting list initiative funds. Of these patients, five agreed to referral to another hospital (treatment completed on average within three months of rereferral), six did not wish to be rereferred, and two did not attend to discuss the offer and remained on the original waiting list. One prioritised patient had further radiological investigations, was reassured, and was taken off the waiting list. 10 patients had further investigations. These resulted in six patients being referred to other hospitals, three being taken off the waiting list, and one seeking private care. CONCLUSIONS: Systematic review of patients on an orthopaedic waiting list of one general practice, though time consuming, led to the identification of inaccuracies in the list and changes in management. Costs need further evaluation, but if the findings occur widely substantial benefits could be achieved for patients.     

Flower choice by honey bees (Apis mellifera L.): sex-phase of flowers and preferences among nectar and pollen foragers

Bees foraging for nectar should choose different inflorescences from those foraging for both pollen and nectar, if inflorescences consist of differing proportions of male and female flowers, particularly if the sex phases of the flowers differ in nectar content as well as the occurrence of pollen. This study tested this prediction using worker honey bees (Apis mellifera L.) foraging on inflorescences of Lavandula stoechas. Female flowers contained about twice the volume of nectar of male flowers. As one would predict, bees foraging for nectar only chose inflorescences with disproportionately more female flowers: time spent on the inflorescence was correlated with the number of female flowers, but not with the number of male flowers. Inflorescence size was inversely correlated with the number of female flowers, and could be used as a morphological cue by these bees. Also as predicted, workers foraging for both pollen and nectar chose inflorescences with relatively greater numbers of both male and female flowers: time spent on these inflorescences was correlated with the number of male flowers, but not with the number of females flowers. A morphological cue inversely associated with such inflorescences is the size of the bract display. Choice of flowers within inflorescences was also influenced predictably, but preferences appeared to be based upon corolla size rather than directly on sex phase.     

Sleep in mammals

Quiet sleep (QS) was correlated with a different set of constitutional variables from those associated with active sleep (AS), in a sample of 69 species of mammals. The time spent in quiet sleep was negatively correlated with body size and basal metabolic rate. The latter relationship remained even after controlling for the effects of body weight. Neither the total time spent in active sleep, nor active sleep as a percentage of total sleep time was significantly correlated with body weight or metabolic rate. Altricial species spend more time in active sleep than do precocial species. The time between the onset of successive episodes of active sleep, the AS-QS cycle length, was positively correlated with body weight. For their body sizes, species that live in temperate regions have shorter AS-QS cycles than those living in tropical or sub-tropical regions. Correlations between patterns of sleep and adult brain weight probably result from the confounding effects of body weight. These findings were used to evaluate several explanations for interspecific differences in patterns of sleep among mammals.     

Psychological Traces of China's Socio-Economic Reforms in the Ultimatum and Dictator Games

Can traces of rapid socio-economic changes within a society be reflected in experimental games? The post-Mao reforms in China provide a unique natural quasi-experiment to study people from the same society who were raised with radically different values about distribution of wealth and altruistic behavior. We tested whether the size of offers in the ultimatum and dictator games are an increasing function of the number of years Chinese citizens experienced of the Mao era (“planned economy”). For the cohort that lived throughout the entire Mao era, we found that mean offers in the two games were substantially higher than what is typically offered in laboratory studies. These offers were also higher than those of two younger Chinese cohorts. In general, the amount offered decreased with less time spent under Mao, while in the oldest group in which every member spent the same amount of time under Mao, the younger members tended to offer more, suggesting an additional effect of early education under Mao and contradicting the alternative hypothesis that generosity increases with age. These results suggest that some of the observed individual differences in the offers made in experimental games can be traced back to the values of the socio-economic era in which individuals grew up.     

The circadian intracranial pressure would be a prognostic factor in traumatic brain injury?

Traumatic brain injury (TBI) generally influences circadian rhythms and has been implicated changes in circadian rhythm. Whether TBI-induced changes in circadian rhythm may affect the prognosis or recovery from TBI remains to be investigated. Sixty-two patients with TBI were continuously monitored for intracranial pressure (ICP) during the first 24 hours after the implantation of ICP monitor. The data from each patient were analyzed using the least squares fit of a 24-h cosine function by single cosinor method. Parameters of circadian A (Amplitude)/M (MESOR) were used to evaluate the circadian rhythm of the patients. Student’s t-test and Pearson’s chi-squared test were utilized to analyze the differences between good prognosis group and poor prognosis. A linear regression analysis was then applied to calculate the correlation between circadian A/M of ICP and Glasgow Coma Scale (GCS) before discharge, the Extended Glasgow Outcome Scale (GOS-E), the dosage of mannitol, and time spent in the intensive care unit (ICU), respectively. The results demonstrated that circadian A/M of patients’ ICP exhibited a positive correlation with GCS scores taken before discharge, GOS-E scores, and was negatively correlated with the amount of mannitol, and time spent in the ICU. We conclude that changes in the ICP circadian rhythm in TBI patients could reflect an internal signal of brain damage and, therefore, may be useful to predict a patient’s prognosis and recovery from TBI.     

Facilitating Adolescents' Constructive Use of Time in One-Parent Families

Many adolescents in 1-parent families experience positive conditions for development. In this article, we use experience sampling data from 101 mother-only families to evaluate factors associated with adolescents' devotion of time to constructive activities, such as reading, sports, creative, and religious activities. Findings show that a set of family management variables, including firm discipline, family routines, and mothers' amount of time spent in child-supportive activities, were associated with adolescents' constructive use of free time. Adolescents' constructive time was also correlated with mothers' time spent reading, participating in religious activities, and watching TV; and with mothers' well-being and cooperation with the nonresident father. These results demonstrate how many families adjust positively to the situation of single parenthood.     

Aerobic metabolism during predation by a boid snake

We quantified the oxygen uptake rates (VO(2)) and time spent, during the constriction, inspection, and ingestion of prey of different relative sizes, by the prey-constricting boid snake Boa constrictor amarali. Time spent in prey constriction varied from 7.6 to 16.3 min, and VO(2) during prey constriction increased 6.8-fold above resting values. This was the most energy expensive predation phase but neither time spent nor metabolic rate during this phase were correlated with prey size. Similarly, prey size did not affect the VO(2) or duration of prey inspection. Prey ingestion time, on the other hand, increased linearly with prey size although VO(2) during this phase, which increased 4.9-fold above resting levels, was not affected by prey size. The increase in mechanical difficulty of ingesting larger prey, therefore, was associated with longer ingestion times rather than proportional increases in the level of metabolic effort. The data indicate that prey constriction and ingestion are largely sustained by glycolysis and the intervening phase of prey inspection may allow recovery between these two predatory phases with high metabolic demands. The total amount of energy spent by B. c. amarali to constrict, inspect, and ingest prey of sizes varying from 5 to 40% of snake body mass varied inversely from 0.21 to 0.11% of the energy assimilated from the prey, respectively. Thus, prey size was not limited by the energetic cost of predation. On the contrary, snakes feeding on larger prey were rewarded with larger energetic returns, in accordance with explanations of the evolution of snake feeding specializations.     

Estimating list inflation in a practice register.

The reason why patients were incorrectly registered in an age-sex register was studied. Whereas underregistration was caused by patient delay in registering with a doctor, the much greater number of overregistered patients were thought to be there largely because of administrative delays in removing their names from the register. It is suggested that it would be possible for the software of a computer system in general practice to correct the population size and structure for estimated list inflation.