The role of computers in preventive medicine in a rural family practice.

Five family physicians in a group practice in rural Quebec have introduced a computer system to improve the delivery of preventive medicine. In addition to billing, the computer is used mainly to recall specific groups of patients for preventive measures, to prompt the physicians to carry out certain procedures at the patient''s next visit, to indicate which procedures are required for the family members and to generate reminder letters. The physicians are conducting a randomized controlled trial to evaluate the impact of computer-generated reminder letters on patient compliance and disease prevention among families in their practice.     

A total audit of preventive procedures in 45 practices caring for 430,000 patients.

OBJECTIVE--To develop and report the results of a system of audit of computer records in general practice. DESIGN--A retrospective audit of records in practices using the same computer system. Information about recorded preventive procedures was collected by sending the same audit program to each practice on floppy disk. Other characteristics of the practices were determined by postal questionnaire. SETTING--Forty five general practices, widely distributed in England and Wales. SUBJECTS--All 430,901 patients registered with the practices. MAIN OUTCOME MEASURES--Within each practice the percentage of patients in specified age groups for whom certain preventive procedures were recorded as having been carried out. These measures were analysed in relation to practice characteristics. RESULTS--Practice characteristics and recording rates for preventive procedures varied over a wide range. Recording rates were higher in practices with computer terminals on every doctor''s desk. Only one practice achieved the new contract target of 90% coverage for recorded primary immunisations, and fewer than two thirds recorded 80% coverage for cervical cytology in the past five years. Practices holding clinics did no better than those without. Smaller partnerships and smaller doctors'' list sizes were associated with better performance. CONCLUSIONS--Centrally programmed audit of computerised records is a feasible method of providing data on a regular basis for epidemiological purposes and for performance review. The fact that practices with smaller list sizes had higher levels of recorded preventive care suggests that the trend towards larger lists promoted by the new contract might militate against the intended effect of better preventive care.     

What Is So Special About a Family Physician?

Around a core of common, acute and chronic, recurrent health problems, a family physician must marshall the traditional episodic management for both inpatient and outpatient illness. He must also be especially adept at recently emerging routines of prevention and early detection. He provides individual and familial psychologic support and counselling, for both its therapeutic and preventive values. In addition, he must relate the individual care of his patient and the patient''s family to the community as a whole. In doing this he will use not only his own skills but those of lay health volunteers, trained allied health care professionals and skilled subspecialists in the limited medical disciplines.The proper preparation of family physicians for this complicated role has far-reaching implications for change in both medical education and medical practice.     

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.     

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.     

Physician time-saving by employment of expanded-role nurses in family practice

Registered nurses working in five family practices in Kingston, Ontario, were given a period of in-service training and supplementary formal instruction at Queen''s University to expand their skills and enable them to undertake prescribed procedures in the physicians'' offices. Operational data collected from the five practices before and after training was analysed to assess the saving of physician time effected by the expansion of the nurses'' activities in providing primary medical care. Physician time was saved in all cases but the amount varied. The results are presented and discussed in relation to staff, physical premises and patterns of practice of the participating physicians. Under the most advantageous practice circumstances in this study, a 33.7% saving in original physician time was obtained. The mean time-saving for the five practices was 18.2%.     

Management of the rape victim.

A woman''s response to rape can be divided into three phases: an acute reaction, an intermediate stage and a period of resolution. Proper management of the physical and emotional problems of each phase, ideally by the woman''s family doctor or gynecologist, may prevent future problems. Treatment during the first phase includes responding to the emotional needs of the patient as well as doing a pelvic and general physical examination to detect any injuries; information for possible legal procedures may be obtained quickly and efficiently. Follow-up particularly psychological, is important in the second and third phases.     

The Role of a Medical Faculty in Reorganizing Family Practice to Meet Current Community Needs

There exists a crisis in the delivery of medical services, particularly by family doctors of whom there is an apparent shortage.A study of family practice in Kingston, Ontario, and in the nearby countryside indicates three critical needs in family practice: professional assistants for the family doctors, efficient office facilities and new methods of delivering family medical care in rural areas. The Faculty of Medicine at Queen''s University has involved itself in a study of these matters and is developing a program to help solve them, by research into the nature of the problems and into methods for alleviating them, by keeping practising physicians informed through research reports and the continuing education program of the Medical School, by the development of pilot projects, and by the evaluation of new services aimed at these problems, independently launched by physicians in the community. Pilot projects to date include two designed to study the use of registered nurses as doctor assistants and another which involves the organization and operation of a university-sponsored community health centre. Last, but by no mean least, the Provincial Government is continually briefed on all these activities.     

The need for a more effective biological nomenclature for the 21st century

HAWKSWORTH, D. L., 1992. The need for a more effective biological nomenclature for the 21st century. The procedures of biological nomenclature are now under immense pressure to change. Users are frustrated by the instability of names and lack of consensus, and increasingly undertake work previously the province of taxonomists; data are presented to show they tend to ignore unwelcome changes. Taxonomists themselves are deflected from both systematic and phylogenetic investigations, and documenting the world's biodiversity, by nomenclatural matters. A survey of 60 U.K. botanical taxonomists revealed that about half spent 10–75% of their research time on nomenclatural matters; extrapolated to the U.K. as a whole, botanical nomenclature could occupy up to 52 full-time posts at a cost of £ 1.3 million. Further, an analysis of 15 monographs of fungal genera showed that overall 85% of the names investigated were not accepted. The major problems to confront relate to concepts of priority, effective and valid publication, illegitimacy, types, ambiregnal organisms and the decision-making bodies. While most of these issues have been overcome by bacteriologists, only now are those concerned with botanical and zoological nomenclature starting to tackle them in earnest. A more effective biological nomenclature could be produced by extending the concept of lists of nomenclaturally protected names. This would resolve questions of effective and valid publication, priority, and application. Such lists would primarily assist taxonomists by dealing with much of the nomenclatural ‘noise’ of the past. Registration procedures are needed to complement such lists for names introduced in the future. The need for standard names and classifications fixed for limited periods is increasingly being met by specialist user groups and also concerns some taxonomists, but is best handled outside formal systems by appropriate specialist bodies. Increased harmonization of the Codes is possible when facing common problems and essential to resolve the difficulties posed by ambiregnal organisms. The image of taxonomy is adversely affected by unsatisfactory nomenclatural systems. Taxonomists should be responsible and refrain from changing names only for nomenclatural reasons while these matters are in discussion. Users and taxonomists need to work with nomenclaturalists to improve the effectiveness of biological nomenclature, if they are to ensure that it will fulfil both their requirements in the 21st century. The prospects for systematics are bleak if it fails to consummate the dual responsibilities of scientific endeavour and user requirements     

Selection of Populations: An Overview and Some Recent Results

In practice the problem of comparing several treatments can often be formulated as which treatment can be considered best. Selection procedures have been designed specifically to answer questions like this one. In many situations selection procedures are more realistic than the usual testing procedures. In this paper an introduction and an overview of selection of populations will be given with special reference to Normal, Binomial, Poisson and Multinomial populations. In the field of agricultural applications these distributions play an important role. Bechhofer's and Gupta's approach are presented side by side for a number of problems. After that the relatively new procedures of Somerville are discussed. Finally, some recent results are presented.     

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.     

Medical students in community physicians' offices

Can the medical student benefit from spending time in the offices of community physicians? Eight consecutive final-year medical students visited the offices of 39 physicians, 31 family physicians and eight specialists, in the communities of Richmond and Delta, British Columbia. The students describe the value of their experience, common problems seen, continuity of care, practice variation, opportunities in specialist office practice and the standard of practice observed. We strongly suggest that some medical student instruction must take place in the community to ensure improved patient care from doctors with a reality-based training. All students, whatever their eventual area of work, would benefit from this experience and we recommend that other centres try similar experiments.     

Practice of preoperative assessment by anaesthetists.

The practice of preoperative assessment in 24 departments of anaesthesia in Great Britain and Ireland was surveyed. Most departments had no rigid policies governing assessment, and many served several hospitals. There was little evidence that admission procedures of patients scheduled for surgery or the organisation of operating lists took account of the problems encountered by anaesthetists undertaking preoperative assessment. From the participating departments 415 anaesthetists completed a questionnaire of their individual practice. Most (57%) visited at least 80% of their patients preoperatively, but 22% saw less than 50% of patients. The detection of potential anaesthetic problems and the establishment of rapport with patients were highly rated reasons for conducting such visits. Failure to visit was often related to organisational defects within the hospital service, and anaesthetists saw little prospect of improving these defects. The demands created by the needs of preoperative assessment on the one hand, and the need for a rapid turnover of surgical patients and financial stringency on the other, conflict, and this conflict is not easily reconciled.     

The Lumpy Breast

“Topics in Primary Care Medicine” presents articles on common diagnostic or therapeutic problems encountered in primary care practice. Physicians interested in contributing to the series are encouraged to contact the series'' editors.     

Problematic character coding methods in morphology and their effects

The effects of different coding practices in morphological phylogenetic analysis are well documented. In many cases, we can determine that certain practices can be regarded as undesirable and should be avoided. Certain coding practices do not correctly translate the expected information to the cladistic algorithm. It may go unnoticed that expressions of character information in character lists, which may be entirely logical to any reader, do not necessarily reflect the mathematics employed by a phylogenetic algorithm. Despite a wealth of literature on coding procedures and documentation of these issues, problematic character coding practices are still common. A review is provided of different coding and character formulation practices, particularly relating to multistate character information that may either: (1) lead to a failure to capture grouping information implied in the character list; (2) cause problematic weighting or spuriously high certainty in particular optimizations; and (3) impose congruence artificially, by linking more than one variable character to a particular state. Each of these is reviewed and presented with a hypothetical example. Recommendations for avoiding these pitfalls are described in light of how parsimony algorithms work with character data. Character lists must be drawn up not only to present character variation logically, but also with consideration for how computer algorithms implement cladistic logic. The widespread use of problematic character coding procedures may account for some of the perceived problems with morphological data. Therefore, an exploration of the effects of these methods and standardization of methods should be a goal for the very near future. © 2011 The Linnean Society of London, Biological Journal of the Linnean Society, 2011, 104 , 489–498.     

Managing uncertainty in family practice.

Because patients present in the early stages of undifferentiated problems, the family physician often faces uncertainty, especially in diagnosis and management. The physician''s uncertainty may be unacceptable to the patient and may lead to inappropriate use of diagnostic procedures. The problem is intensified by the physician''s hospital training, which emphasizes mastery of available knowledge and decision-making based on certainty. Strategies by which a physician may manage uncertainty include (a) a more open doctor-patient relationship, (b) understanding the patient''s reason for attending the office, (c) a thorough assessment of the problem, (d) a commitment to reassessment and (e) appropriate consultation.     

Lifestyle assessment: applying microcomputers in family practice.

A randomised trial of assessment by computer was conducted with 180 patients in a family practice clinic. Histories of alcohol, tobacco, and drug use were obtained by computer (n = 60), interview (n = 60), or self completed questionnaire (n = 60). The results of previous research suggest that some patients may provide more accurate information about "sensitive" problems to a computer. No significant differences, however, in levels of consumption or problems were reported for the three methods of assessment. Patients gave differential ratings about the method of assessment, with the computer rated as more interesting but also more mechanical, cold, and impersonal. Although the interview was initially preferred by most, patients who completed the assessment by computer showed a significant increase (13% to 43%) in their preference for the computer after the assessment. The results of our study indicate that patients'' acceptance of computers in family practice may be favourably influenced by direct experience with a microcomputer.     

Why are clinical problems difficult? General practitioners' opinions concerning 24 clinical problems.

This study was conducted to describe the difficulties perceived by general practitioners concerning 24 common clinical problems and to compare their perceptions with those of faculty members in family medicine. A random sample of 467 general practitioners and all 182 faculty members in family medicine in Quebec were sent one of four open-ended questionnaires, each of which dealt with six clinical problems; 214 general practitioners and 114 faculty members participated. A total of 5111 difficulties were reported; the number reported by each subject varied from 0 to 13 (mean 2.6 [standard deviation 2.09]) per problem. The problems that generated the most difficulties were depression, confusion in the elderly, chronic back pain, loss of autonomy in the elderly and sexually transmitted disease. The most frequent difficulties were with the patient''s noncompliance with treatment, clinical diagnosis, failure of a specific treatment, inadequate health care resources and the physician''s own emotional reactions. The difficulties for each problem were the same in the two groups 70% of the time. Physician''s perceptions of their difficulties can be useful in the planning of initial training and continuing medical education.     

Prevention of psychosocial problems in children with chronic illness.

Children with chronic illness and disability are at considerably increased risk of psychosocial problems, such as neurosis, attention deficit and poor adjustment to school. Health care professionals, especially primary care physicians, can do a great deal to prevent such problems in these children and their families. The approach outlined here is based on an understanding of the transactional model of development, in which the child interacts with--and to some extent creates--the social environment, and on a "noncategorical" concept in which common elements in chronic illness are recognized and emphasized. The physician''s role is to inform the family of the child''s condition as soon as possible, to offer hope, encouragement and guidance, to watch the child''s development, to maintain a shared view of the child and family, and, if possible, to ensure continuity of care.