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Objective To describe the attitudes and behaviours regarding placebo treatments, defined as a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself. Design Cross sectional mailed survey. Setting Physicians' clinical practices. Participants 1200 practising internists and rheumatologists in the United States. Main outcome measures Investigators measured physicians' self reported behaviours and attitudes concerning the use of placebo treatments, including measures of whether they would use or had recommended a "placebo treatment," their ethical judgments about the practice, what they recommended as placebo treatments, and how they typically communicate with patients about the practice. Results 679 physicians (57%) responded to the survey. About half of the surveyed internists and rheumatologists reported prescribing placebo treatments on a regular basis (46-58%, depending on how the question was phrased). Most physicians (399, 62%) believed the practice to be ethically permissible. Few reported using saline (18, 3%) or sugar pills (12, 2%) as placebo treatments, while large proportions reported using over the counter analgesics (267, 41%) and vitamins (243, 38%) as placebo treatments within the past year. A small but notable proportion of physicians reported using antibiotics (86,13%) and sedatives (86,13%) as placebo treatments during the same period. Furthermore, physicians who use placebo treatments most commonly describe them to patients as a potentially beneficial medicine or treatment not typically used for their condition (241, 68%); only rarely do they explicitly describe them as placebos (18, 5%). Conclusions Prescribing placebo treatments seems to be common and is viewed as ethically permissible among the surveyed US internists and rheumatologists. Vitamins and over the counter analgesics are the most commonly used treatments. Physicians might not be fully transparent with their patients about the use of placebos and might have mixed motivations for recommending such treatments. [ABSTRACT FROM AUTHOR]

Objective To determine the impact of a simple educational package for general practitioners on adherence to antihypertensive drugs. Design Cluster randomised controlled trial. Setting Six randomly selected communities in Karachi, Pakistan. Participants 200 patients with hypertension taking antihypertensive drugs; 78 general practitioners. Intervention Care by general practitioners specially trained in management of hypertension compared with usual care. Main outcome measure Correct dosing, defined as percentage of prescribed doses taken, measured with electronic medication event monitoring system (MEMS) bottle. Results 200 patients were enrolled, and 178 (89%) successfully completed six weeks of follow-up. Adherence was significantly greater in the special care group than in the usual care group (unadjusted mean percentage days with correct dose 48.1%, 95% confidence interval 35.8% to 60.4%, versus 32.4%, 22.6% to 42.3%; P=0.048). Adherence was also higher among patients who had higher levels of education (P<0.001), were encouraged by family members (P<0.001), believed in the effect of drugs (P<0.001), and had the purpose of the drugs explained to them (P<0.001). Conclusions Special training of general practitioners in management of hypertension, emphasising good communication between doctors and patients, is more effective than usual care provided in the communities in Karachi. Such simple interventions should be adopted by other developing countries that are now facing an increasing burden of hypertension. [ABSTRACT FROM AUTHOR]

ABSTRACT Objectives To describe progress and perceived challenges in implementing the NHS information and technology (IT) programme in England. Design Case studies and in-depth interviews, with themes identified using a framework developed from grounded theory. We interviewed personnel who had been interviewed 18 months earlier, or new personnel in the same posts. Setting Four NHS acute hospital trusts in England. Participants Senior trust managers and clinicians, including chief executives, directors of IT, medical directors, and directors of nursing. Results Interviewees unreservedly supported the goals of the programme but had several serious concerns. As before, implementation is hampered by local financial deficits, delays in implementing patient administration systems that are compliant with the programme, and poor communication between Connecting for Health (the agency responsible for the programme) and local managers. New issues were raised. Local managers cannot prioritise implementing the programme because of competing financial priorities and uncertainties about the programme. They perceive a growing risk to patients' safety associated with delays and a toss of integration of components of the programme, and are discontented with Choose and Book (electronic booking for referrals from primary care). Conclusions We recommend that the programme sets realistic timetables for individual trusts and advises managers about interim IT systems they have to purchase because of delays outside their control. Advice needs to be mindful of the need for trusts to ensure longer term compatibility with the programme and value for money. Trusts need assistance in prioritising modernisation of IT-for example, including implementation of the programme in the performance management framework. Even with Connecting for Health adopting a different approach of setting central standards with local implementation, these issues will still need to be addressed. Lessons learnt in [ABSTRACT FROM AUTHOR]

Difficulty in defecation, with or without soiling, is often encountered in children. It presents a management problem for general practitioners, and parental concern is often high. Constipation accounts for about 25% of a paediatric gastroenterologist's work and is one of the 10 most common problems seen by general paediatricians. We outline the epidemiology of chronic constipation in children, review the evidence base for the therapeutic interventions, and suggest strategies for management. We do not deal with the management of childhood constipation that results from an organic cause. This review is intended for general practitioners and hospital doctors who are not specialists in the management of constipation. [ABSTRACT FROM AUTHOR]

Abstract Objective To estimate the proportion of school age children with a persistent cough who have evidence of a recent Bordetella pertussis infection. Design Prospective cohort study (October 2001 to March 2005). Setting General practices in Oxfordshire, England. Participants 172 children aged 5-16 years who presented to their general practitioner with a cough lasting 14 days or more who consented to have a blood test. Main outcome measures Serological evidence of a recent Bordetella pertussis infection; symptoms at presentation; duration and severity of cough; sleep disturbance (parents and child). Results 64 (37.2%, 95% confidence interval 30.0% to 44.4%) children had serological evidence of a recent Bordetella pertussis infection; 55 (85.9%) of these children had been fully immunised. At presentation, children with whooping cough were more likely than others to have whooping (odds ratio 2.85, 95% confidence interval 1.39 to 5.82), vomiting (4.35, 2.04 to 9.25), and sputum production (2.39,1.14 to 5.02). Children with whooping cough were also more likely to still be coughing two months after the start of their illness (85% v 48%; P = 0.001), continue to have more than five coughing episodes a day (P = 0.049), and cause sleep disturbance for their parents (P = 0.003). Conclusions For school age children presenting to primary care with a cough lasting two weeks or more, a diagnosis of whooping cough should be considered even if the child has been immunised. Making a secure diagnosis of whooping cough may prevent inappropriate investigations and treatment. [ABSTRACT FROM AUTHOR]

The article discusses symptoms, diagnosis and treatment of irritable bowel syndrome (IBS). IBS is a difficult condition to diagnose and treat, and because of this, it is often dismissed as largely psychological and untreatable. As the disease can significantly lower the quality of a patient's life, it warrants future investigation and carefully constructed individualized care.

Objective To carry out an economic evaluation of a general practitioner with special interest service for non-urgent skin problems compared with hospital outpatient care. Design Cost effectiveness analysis and cost consequences analysis alongside a randomised controlled trial. Setting General practitioner with special interest dermatology service covering 29 general practices in Bristol. Participants Adults referred to a hospital dermatology clinic who were potentially suitable for management by a general practitioner with special interest. Interventions Participants were randomised 2:1 to receive either care by general practitioner with special interest service or usual hospital outpatient care. Main outcome measures Costs to NHS, patients, and companions, and costs of lost production. Cost effectiveness, using the two primary outcomes of dermatology life quality index scores and improved patient perceived access, was assessed by incremental cost effectiveness ratios and cost effectiveness acceptability curves. Cost consequences are presented in relation to all costs and both primary and secondary outcomes from the trial. Results Costs to the NHS for patients attending the general practitioner with special interest service were £208 ($361; euro 308) compared with £118 for hospital outpatient care. Based on analysis with imputation of missing data, costs to patients and companions were £48 and £51, respectively; costs of lost production were £27 and £34, respectively. The incremental cost effectiveness ratios for general practitioner with special interest care over outpatient care were £540 per one point gain in the dermatology life quality index and £66 per 10 point change in the access scale. Conclusions The general practitioner with special interest service for dermatology is more costly than hospital outpatient care, but this additional cost needs to be weighed against improved access and broadly similar health outcomes. [ABSTRACT FROM AUTHOR]

Objective To assess the effectiveness, accessibility, and acceptability of a general practitioner with special interest service for skin problems compared with a hospital dermatology clinic. Design Randomised controlled trial. Setting General practitioner with special interest dermatology service and hospital dermatology clinic. Participants Adults referred to a hospital dermatology clinic and assessed by a consultant or the general practitioner with special interest service. Suitable patients had non-urgent skin problems and had been identified from the referral letter as suitable for management by a general practitioner with special interest. Interventions Participants were randomised in 2:1 ratio to receive management by a general practitioner with special interest or usual hospital outpatient care. Main outcome measures Primary outcomes were disease related quality of life (dermatology life quality index) and improvement in patients' perception of access to services, assessed nine months after randomisation. Secondary outcomes were patient satisfaction, preference for site of care, proportion of failed appointments, and waiting times to first appointment. Results 49% of the participants were judged suitable for care by the general practitioner with special interest service. Of 768 patients eligible, 556 (72.4%) were randomised (354 to general practitioner with special interest, 202 to hospital outpatient care). After nine months, 422 (76%) were followed up. No noticeable differences were found between the groups in clinical outcome (median dermatology life quality index score = 1 both arms, ratio of geometric means 0.99, 95% confidence interval 0.85 to 1.15). The general practitioner with special interest service was more accessible (difference between means on access scale 14, 11 to 19) and waited a mean of 40 (35 to 46) days less. Patients expressed slightly greater satisfaction with consultations with a general practitioner with special interest (difference in mean satisfaction score 4, 1 to 7), and at baseline and after nine months 61% said they preferred care at the service. Conclusions The general practitioner with special interest service for dermatology was more accessible and preferred by patients than hospital outpatient care, achieving similar clinical outcomes. INSETS: What is already known on this topic;What this study adds. [ABSTRACT FROM AUTHOR]

Offers a look at Russia's attempts to establish a model of primary health care based on integrated general practice. Report that most central and eastern European countries are replacing the Soviet Union model of primary care with a system of integrated general practice; Report that reforms in Russia have been hampered by an adverse regulatory and working environment, poor professional recognition of general practitioners, inadequate health care infrastructure, and weak financing mechanisms; Claim that successful reform will require changes in the legislative and policy framework and better management of staff resources.

Studies the role of Quetiapine and rivastigmine and cognitive decline in Alzheimer's disease. Efforts to treat agitation in patients with Alzheimer's disease; Details of a placebo controlled trial.

Presents a study to design and validate a new competency-based selection system for recruiting general practice registrars, with a competency-based application form, referees' reports, and an assessment center. The longitudinal predictive validity study setting with three deaneries in Great Britain; Main outcome measures and results; Conclusion that the new competency based selection process improves the validity of selection compared with traditional methods.

Objective To identify a credible explanation for the excessively high mortality associated with general practitioners who were flagged up by the Shipman inquiry. Design Retrospective analysis of routine data. Setting Primary care. Participants Two general practitioners in the West Midlands who were associated with an unacceptably high mortality of patients during 1993-2000. Main outcome measures Observed and expected number of deaths and deaths in nursing homes. Results Preliminary discussions with the general practitioners highlighted deaths in nursing homes as a possible explanatory factor. No relation was found between the expected number of deaths and deaths in nursing homes in each year during 1993-2000 for either general practitioner. In contrast, the magnitude and shape of the curves of a cumulative sum plot for excess number of deaths (observed minus expected) in each year were closely mirrored by the magnitude and shape of the curves of the number of patients dying in nursing homes; and this was reflected in the high correlations (R 2 =0.87 and 0.89) between excess mortality and the number of deaths in nursing homes in each year for the general practitioners. These findings were supported by administrative data. Conclusions The excessively high mortality associated with two general practitioners was credibly explained by a nursing home effect. General practitioners associated with high patient mortality, albeit after sophisticated statistical analysis, should not be labeled as having poor performance but instead should be considered as a signal meriting scientific investigation. [ABSTRACT FROM AUTHOR]

Presents a clinical review on managing nocturia. Definition of nocturia; Sources of information for this review; Causes of frequent urination at night which generally affects older people; Suggested contributors to the disease; How the disorder caused sleep deprivation which has its own set of problems; Reasons to recognize and treat the disorder; Treatment options including implantation of a temporary device with a neuromodulation unit; One patient's story. INSETS: A Patient's success story;Additional Educational Resources.

Objective To examine the impact on general practitioners' workload of adding nurse practitioners to the general practice team. Design Randomised controlled trial with measurements before and after the introduction of nurse practitioners. Setting 34 general practices in a southern region of the Netherlands. Participants 48 general practitioners. Intervention Five nurses were randomly allocated to general practitioners to undertake specific elements of care according to agreed guidelines.The control group received no nurse. Main outcome measures Objective workload,derived from 28 day diaries,included the number of contacts per day for each of three conditions (chronic obstructive pulmonary disease or asthma,dementia, cancer),by type of consultation (in practice, telephone,home visit),and by time of day (surgery hours,out of hours).Subjective workload was measured by using a validated questionnaire. Outcomes were measured six months before and 18 months after the intervention. Results The number of contacts during surgery hours increased in the intervention group compared with the control group (P <0.06),particularly for patients with chronic obstructive pulmonary disease or asthma (P <0.01).The number of consultations out of hours declined slightly in the intervention group compared with the control group,but this difference did not reach significance.No significant changes became apparent in subjective workload. Conclusion Adding nurse practitioners to general practice teams did not reduce the workload of general practitioners,at least in the short term.This implies that nurse practitioners are used as supplements, rather than substitutes,for care given by general practitioners. [ABSTRACT FROM AUTHOR]

Abstract Objective To compare two models of revalidation for general practitioners. Design Randomised comparison of two revalidation models. Setting Primary care in Tayside, Scotland. Participants 66 Tayside general practitioners (principals and non-principals), 53 of whom completed the revalidation folders. Interventions Two revalidation models: a minimum criterion based model with revalidation as the primary purpose, and an educational outcome model with emphasis on combining revalidation with continuing professional development. Main outcome measures Feasibility and acceptability of each approach and effect on the doctor's continuing professional development. The ability to make a summative judgment on completed models and whether either model would allow patient groups to have confidence in the revalidation process. Results The criterion model was preferred by general practitioners. For both models doctors reported making changes to their practice and felt a positive effect on their continuing professional development. Summative assessment of the folders showed reasonable inter-rater reliability. Conclusions The criterion model provides a practical and acceptable model for general practitioners to use when preparing for revalidation. [ABSTRACT FROM AUTHOR]

Abstract Objective To explore management by general practitioners of victimised female patients, male partners who abuse, and children in the family. Design Triangulated qualitative study comparing doctors' reported management with current recommendations in the literature. Participants 28 general practitioners attending continuing medical education about management of domestic violence. Results Doctors perceived partner abuse in diverse ways. Their gender, perceptions, and attitudes could all affect identification and management of this difficult problem. A few doctors practised in recommended ways, but many showed stress and aversion, difficulties in resolving the tensions involved in managing all family members, and neglect of the risks to children. Some doctors used contraindicated practices, such as breaking confidentiality and undertaking or referring for couple counselling. Doctors who were not familiar with community based agencies were reluctant to use them. A lack of expertise and support could have a negative impact on doctors themselves. Conclusions General practitioners managing partner abuse need to be more familiar with and apply the central principles of confidentiality and safety of women and children. Recommended guidelines for managing the whole family should be developed. Doctors should consider referring one partner elsewhere and avoid couple counselling; always ask about and act on the children's welfare; refer to specialist family violence agencies; and seek training, supervision, and support for the inherent stress. Medical education and administration should ensure comprehensive training and support for doctors undertaking this difficult work.. [ABSTRACT FROM AUTHOR]

Abstract Objectives: To explore how general practitioners operate the sickness certification system, their views on the system, and suggestions for change. Design: Qualitative focus group study consisting of 11 focus groups with 67 participants. Setting: General practitioners in practices in Glasgow, Tayside, and Highland regions, Scotland. Sample: Purposive sample of general practitioners, with further theoretical sampling of key informant general practitioners to examine emerging themes. Results: General practitioners believed that the sickness certification system failed to address complex, chronic, or doubtful cases. They appeared to develop various operational strategies for its implementation. There seemed to be important deliberate misuse of the system by general practitioners, possibly related to conflicts about roles and incongruities in the system. The doctor-patient relationship was perceived to conflict with the current role of general practitioners in sickness certification. When making decisions about certification, the general practitioners considered a wide variety of factors. They experienced contradictory demands from other system stakeholders and felt blamed for failing to make impossible reconciliations. They clearly identified the difficulties of operating the system when there was no continuity of patient care. Many wished either to relinquish their gatekeeper role or to continue only with major changes. Conclusions: Policy makers need to recognise and accommodate the range and complexity of factors that influence the behaviour of general practitioners operating as gatekeepers to the sickness certification system before making changes. Such changes are otherwise unlikely to result in improvement. Models other than the primary care gatekeeper model should be considered. [ABSTRACT FROM AUTHOR]

Presents letters to the editor of "The British Medical Journal" as of July 2003. Effectiveness of lipid lowering drugs in general practice; Outcomes of screening to prevent cancer; Assisted suicide and euthanasia in Switzerland.

Abstract Objectives: To determine whether paperless medical records contained less information than paper based medical records and whether that information was harder to retrieve. Design: Cross sectional study with review of medical records and interviews with general practitioners. Setting: 25 general practices in Trent region. Participants: 53 British general practitioners (25 using paperless records and 28 using paper based records) who each provided records of 10 consultations. Main outcome measures: Content of a sample of records and doctor recall of consultations for which paperless or paper based records had been made. Results: Compared with paper based records, more paperless records were fully understandable (89.2% v 69.9%, P=0.0001) and fully legible (100% v 64.3%, P < 0.0001). Paperless records were significantly more likely to have at least one diagnosis recorded (48.2% v 33.2%, P=0.05), to record that advice had been given (23.7% vs 10.7%, P=0.017), and, when a referral had been made, were more likely to contain details of the specialty (77.4% v 59.5%, P=0.03). When a prescription had been issued, paperless records were more likely to specify the drug dose (86.6% v 66.2%, P=0.005). Paperless records contained significantly more words, abbreviations, and symbols (P < 0.01 for all). At doctor interview, there was no difference between the groups for the proportion of patients or consultations that could be recalled. Doctors using paperless records were able to recall more advice given to patients (38.6% v 26.8%, P=0.03). Conclusion: We found no evidence to support our hypotheses that paperless records would be truncated and contain more local abbreviations; and that the absence of writing would decrease subsequent recall. Conversely we found that the paperless records compared favourably with manual records. [ABSTRACT FROM AUTHOR]

Abstract Objective To determine whether Clinical Terms Version 3 provides greater accuracy and consistency in coding electronic patient records than the Read Codes 5 byte set. Design Randomised crossover trial. Clinicians coded patient records using both schemes after being randomised in pairs to use one scheme before the other. Setting 10 general practices in urban, suburban, and rural environments in Norfolk. Participants 10 general practitioners. Source of data Concepts were collected from records of 100 patient encounters. Main outcome measures Percentage of coded choices ranked as being exact representations of the original terms; percentage of cases where coding choice of paired general practitioners was identical; length of time taken to find a code. Results A total of 995 unique concepts were collected. Exact matches were more common with Clinical Terms (70% (95% confidence interval 67% to 73%)) than with Read Codes (50% (47% to 53%)) (P < 0.001), and this difference was significant for each of the 10 participants individually. The pooled proportion with exact and identical matches by paired participants was greater for Clinical Terms (0.58 (0.55 to 0.61)) than Read Codes (0.36 (0.33 to 0.39)) (P < 0.001). The time taken to code with Clinical Terms (30 seconds per term) was not significantly longer than that for Read Codes. Conclusions Clinical Terms Version 3 performed significantly better than Read Codes 5 byte set in capturing the meaning of concepts. These findings suggest that improved coding accuracy in primary care electronic patient records can be achieved with the use of such a clinical terminology. [ABSTRACT FROM AUTHOR]

Objectives: To examine the strengths and weaknesses of the national and local schemes for preregistration house officers to spend four months in general practice, to identify any added value from such placements, and to examine the impact on career choices. Design: Review of all studies that reported on placements of preregistration house officers in general practice. Setting: 19 accounts of preregistration house officers' experience in general practice, ranging from single case reports to a national evaluation study, in a variety of locations in Scotland and England. Participants: Views of 180 preregistration house officers, 45 general practitioner trainers, and 105 consultant trainers. Main outcome measures: Main findings or themes weighted according to number of studies reporting them and weighted for sample size. Results: The studies were unanimous about the educational benefits of the placements. The additional learning included communication skills, social and psychological factors in illness, patient centred consultations, broadening of knowledge base, and dealing with uncertainty about diagnosis and referral. Conclusions: Despite the reported benefits and recommendations of the scheme, it is not expanding. General practitioner trainers reported additional supervision that was unremunerated. The reforms of the senior house officer grade may resolve this problem by offering the placements to senior house officers, who require less supervision. INSETS: Box 1: Experiences gained by preregistration house officers in...;Box 2: Main themes emerging as new areas of learning in...;What is already known on this topic;What this study adds [ABSTRACT FROM AUTHOR]

Presents letters between medical practitioners as of April 26, 2003. Consideration of the policies of boarding schools in the United Kingdom with regard to severe acute respiratory syndrome (SARS); Effectiveness of hip protectors; Quality of impact factors of general medical journals; Benefits from the shift from selective narrative to systemic review within medicine.

Objective: To assess the long term effectiveness of the "green prescription" programme, a clinician based initiative in general practice that provides counselling on physical activity. Design: Cluster randomised controlled trial. Practices were randomised before systematic screening and recruitment of patients. Setting: 42 rural and urban general practices in one region of New Zealand. Subjects: All sedentary 40-79 year old patients visiting their general practitioner during the study's recruitment period. Intervention: General practitioners were prompted by the patient to give oral and written advice on physical activity during usual consultations. Exercise specialists continued support by telephone and post. Control patients received usual care. Main outcome measures: Change in physical activity, quality of life (as measured by the "short form 36" (SF-36) questionnaire), cardiovascular risk (Framingham and D'Agostino equations), and blood pressure over a 12 month period. Results: 74% (117/159) of general practitioners and 66% (878/1322) of screened eligible patients participated in the study. The follow up rate was 85% (750/878). Mean total energy expenditure increased by 9.4 kcal/kg/week (P=0.001) and leisure exercise by 2.7 kcal/kg/week (P=0.02) or 34 minutes/week more in the intervention group than in the control group (P=0.04). The proportion of the intervention group undertaking 2.5 hours/week of leisure exercise increased by 9.7% (P=0.003) more than in the control group (number needed to treat= 10). SF-36 measures of serf rated "general health," "role physical," "vitality," and "bodily pain" improved significantly more in the intervention group (P < 0.05). A trend towards decreasing blood pressure became apparent but no significant difference in four year risk of coronary heart disease. Conclusion: Counselling patients in general practice on exercise is effective in increasing physical activity and improving quality of life over 12 months. [ABSTRACT FROM AUTHOR]

Abstract Objective: To assess whether transferring knowledge from specialists at centres of excellence to referring doctors through online consultations can improve the management of patients requiring specialised care. Design: Retrospective case review of the first year of internet based patient initiated consultations between referring doctors and consulting specialists. Setting: US teaching hospitals affiliated with an organisation providing internet based consultations. Participants: Doctors in various settings around the world engaging in internet based consultations with specialists. Main outcome measures: New recommendations for treatment, change in diagnosis, and turnaround time for consultation compared with time to see a specialist. Results: 79 consultations took place. 90% (n=71) of consultations were for services related to oncology. 90% of consultations involved new recommendations for treatment. The most common recommendation was a new chemotherapeutic regimen (68%, n=54). Diagnosis changed in 5% (n=4) of cases. The average turnaround time was 6.8 working days compared with an average of 19 working days to see a comparable specialist. Conclusions: Internet based consultations between specialists at centres of excellence and referring doctors contribute to patient care through recommendations for new treatment and timely access to specialist knowledge. Although change in diagnosis occurred in only a few cases, the prognostic and therapeutic implications for these patients may be profound. [ABSTRACT FROM AUTHOR]

The use of primary care physicians as gatekeepers to specialists and other medical resources--considered to be a managed care innovation in the United States--has proliferated during the past few decades. Some health maintenance organizations which use primary care physicians as gatekeepers to specialists are allowing patients to refer themselves if they are prepared to pay more out of pocket. Although gatekeeping is associated with a greater range of conditions managed by general practitioners at the point of first contact, it has not been linked to other changes in the diagnostic or management styles of general practitioners or primary care physicians, or their coordination of referral care. There is no compelling evidence that gatekeeping modifies physicians' style of decision making or that primary care physicians apply resources any differently to patients for whom they are a gatekeeper. Capitation payments may act at the margins of primary care physicians' scope of practice, increasing the likelihood that health problems which could be managed either in primary care or by a specialist are referred.

Objective: To ascertain the beliefs, current practices, and decision making of general practitioners in the diagnosis and management of suspected heart failure in primary care, with a view to identifying barriers to good care. Design: A qualitative approach using focus groups with 30 general practitioners from four primary care groups. The sampling strategy was stratified and purposive. The contents of interviews were transcribed and analysed according to the principles of "pragmatic variant" grounded theory. Setting: North east England. Results: Three categories of difficulties contribute to variations in medical practice and to the reasons why general practitioners experience difficulties in diagnosing and managing heart failure. The first is uncertainty about clinical practice, including lack of confidence in establishing an accurate diagnosis and worries about using angiotensin converting enzyme inhibitors, β blockers, and spironolactone in patients who are often elderly and frail, with comorbidity and polypharmacy. The second is a lack of awareness of relevant research evidence in what was perceived to be a complex and rapidly changing therapeutic field. Doubts about the applicability of research findings in primary care, and fear of information overload also emerged. The third category consists of influences of individual preference and local organisational factors. Medical training, negative clinical experiences, and outside agencies influenced the behaviour of general practitioners and professional culture. Local factors included the availability of diagnostic services, resources (such as accessible cardiologists), and interactions between professionals in primary or secondary care, and they seemed to shape the practice and decision making processes in primary care. Conclusions: The national service framework for coronary heart disease stresses that the substandard care of patients with heart failure is unacceptable. This study identified barriers... [ABSTRACT FROM AUTHOR]

Abstract Objectives: To understand why general practitioners prescribe antibiotics for some cases of sore throat and to explore the factors that influence their prescribing. Design: Grounded theory interview study. Setting: General practice. Participants: 40 general practitioners: 25 in the maximum variety sample and 15 in the theoretical sample. Results: General practitioners are uncertain which patients will benefit from antibiotics but prescribe for sicker patients and for patients from socioeconomically deprived backgrounds because of concerns about complications. They are also more likely to prescribe in pressured clinical contexts. Doctors are mostly comfortable with their prescribing decisions and are not prescribing to maintain the doctor-patient relationship. Conclusions: General practitioners have reduced prescribing for sore throat in response to research and policy initiatives. Further interventions to reduce prescribing would need to improve identification of patients at risk of complications and be workable in busy clinical situations. [ABSTRACT FROM AUTHOR]

Presents correspondence between medical practitioners as of January 4, 2003. Consideration of how the attitudes of trainees to shift work depend on grade and shift; Possibility of delayed discharge and hospital congestion; Management of acute appendicitis; Prevention and treatment of eclamptic seizures; Others.

Abstract Objective: To compare the workloads of general practitioners and nurses and costs of patient care for nurse telephone triage and standard management of requests for same day appointments in routine primary care. Design: Multiple interrupted time series using sequential introduction of experimental triage system in different sites with repeated measures taken one week in every month for 12 months. Setting: Three primary care sites in York. Participants: 4685 patients: 1233 in standard management, 3452 in the triage system. All patients requesting same day appointments during study weeks were included in the trial. Main outcome measures: Type of consultation (telephone, appointment, or visit), time taken for consultation, presenting complaints, use of services during the month after same day contact, and costs of drugs and same day, follow up, and emergency care. Results: The triage system reduced appointments with general practitioner by 29-44%. Compared with standard management, the triage system had a relative risk (95% confidence interval) of 0.85 (0.72 to 1.00) for home visits, 2.41 (2.08 to 2.80) for telephone care, and 3.79 (3.21 to 4.48) for nurse care. Mean overall time in the triage system was 1.70 minutes longer, but mean general practitioner time was reduced by 2.45 minutes. Routine appointments and nursing time increased, as did out of hours and accident and emergency attendance. Costs did not differ significantly between standard management and triage: mean difference £1.48 more per patient for triage (95% confidence interval -0.19 to 3.15). Conclusions: Triage reduced the number of same day appointments with general practitioners but resulted in busier routine surgeries, increased nursing time, and a small but significant increase in out of hours and accident and emergency attendance. Consequently, triage does not reduce overall costs per patient for managing same day appointments. [ABSTRACT FROM AUTHOR]

Presents correspondence between medical practitioners as of October 26, 2002. How general practitioners are treating more cases of diabetes; Relationship between obesogenic environments and diabetes; Focus on mental health in developing countries; Risks of thioridazine as an antipsychotic drug; Others.

Abstract Objective To study the efficacy of case method learning, for general practitioners, on patients' lipid concentrations in the secondary prevention of coronary artery disease. Design Prospective controlled trial. Setting Sodertalje, Stockholm County, Sweden. Participants 255 consecutive patients with coronary artery disease. Intervention Guidelines were mailed to all general practitioners (n=54) and presented at a common lecture. General practitioners who were randomised to the intervention group participated in recurrent case method learning dialogues at their primary healthcare centres during a two year period. A locally well known cardiologist served as a facilitator. Main outcome measure Concentration of low density lipoprotein cholesterol at baseline and after two years. Analysis according to intention to treat (intervention and control groups (n=88)) was based on group affiliation at baseline. Results Low density lipoprotein cholesterol was reduced by 0.5 mmol/1 (95% confidence interval 0.2 to 0.8 mmol/1) (9.3% (2.9% to 15.8%)) from baseline in patients in the intervention group and by 0.5 (0.1 to 0.9) mmol/1 compared with controls (P < 0.05). No change occurred in the control group (0.0(-0.2 to 0.2) mmol/l). Low density lipoprotein cholesterol decreased by 0.6 (0.4 to 0.8) mmol/1 in a group of patients who received specialist care. Conclusion Case method learning resulted in a lowering of low density lipoprotein cholesterol in the primary care patients with coronary artery disease comparable to that achieved at a specialist clinic. Conventional presentation of practice guidelines had no effect. [ABSTRACT FROM AUTHOR]

Objective To assess the effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy. Design Parallel group, cluster randomised, controlled trial of an educational package on cognitive behaviour therapy. Setting General practices in north London. Participants 84 general practitioner principals and 272 patients attending their practices who scored above the threshold for psychological distress on the hospital anxiety and depression scale. Intervention A training package of four half days on brief cognitive behaviour therapy. Main outcome measures Scores on the depression attitude questionnaire (general practitioners) and the Beck depression inventory (patients). Results Doctors' knowledge of depression and attitudes towards its treatment showed no major difference between intervention and control groups after 6 months. The training had no discernible impact on patients' outcomes. Conclusion General practitioners may require more training and support than a basic educational package on brief cognitive behaviour therapy to acquire skills to help patients with depression. [ABSTRACT FROM AUTHOR]

Objectives: To measure the prevalence of domestic violence among women attending general practice; test the association between experience of domestic violence and demographic factors; evaluate the extent of recording of domestic violence in records held by general practices; and assess acceptability to women of screening for domestic violence by general practitioners or practice nurses. Design: Self administered questionnaire survey. Review of medical records. Setting: General practices in Hackney, London. Participants: 1207 women (> 15 years) attending selected practices. Main outcome measures: Prevalence of domestic violence against women. Association between demographic factors and domestic violence reported in questionnaire. Comparison of recording of domestic violence in medical records with that reported in questionnaire. Attitudes of women towards being questioned about domestic violence by general practitioners or practice nurses. Results 425/1035 women (41%, 95% confidence interval 38% to 44%) had ever experienced physical violence from a partner or former partner and 160/949 (17%, 14% to 19%) had experienced it within the past year. Pregnancy in the past year was associated with an increased risk of current violence (adjusted odds ratio 2.11, 1.39 to 3.19). Physical violence was recorded in the medical records of 15/90 (17%) women who reported it on the questionnaire. At least 202/1010 (20%) women objected to screening for domestic violence. Conclusions With the high prevalence of domestic violence, health professionals should maintain a high level of awareness of the possibility of domestic violence, especially affecting pregnant women, but the case for screening is not yet convincing. [ABSTRACT FROM AUTHOR]

Objectives: To determine exposure to violence by a partner or spouse among women attending general practice and its association with respondents' demographic and personal characteristics; frequency of inquiry about violence by general practitioners; and women's views on routine questioning about domestic violence by general practitioners. Design: Cross sectional, self administered, anonymous survey. Setting: 22 volunteer Irish general practices. Participants: 1871 women attending general practice. Main outcome measures: Proportion who had experienced domestic violence, severity of such violence, and context in which violence occurred. Results Of the 1692 women who had ever had a sexual relationship, 651 (39%, 95% confidence interval 36% to 41%) had experienced violent behaviour by a partner. 78/651 (12%) women reported that their doctor had asked about domestic violence. 298/651 (46%, 42% to 50%) women had been injured, 60 (20%) of whom reported that their doctor had asked about domestic violence. 1304/1692 (77%, 77% to 80%) were in favour of routine inquiry about domestic violence by their usual general practitioner. 1170 women (69%) reported controlling behaviour by their partner and 475 (28%) reported feeling afraid of their previous or current partner. Women who reported domestic violence were 32 times more likely to be afraid of their partner than women who did not report such violence. Conclusions: Almost two fifths of women had experienced domestic violence but few recalled being asked about it. Most women favoured routine questioning by their practitioner about such violence. Asking women about fear of their partner and controlling behaviour may be a useful way of identifying those who have experienced domestic violence. [ABSTRACT FROM AUTHOR]

Objectives: To examine the interaction between general practitioners and pharmaceutical company representatives. Design: Qualitative study of 13 consecutive meetings between general practitioner and pharmaceutical representatives. A dramaturgical model was used to inform analysis of the transcribed verbal interactions. Setting: Practice in south west England. Participants: 13 pharmaceutical company representatives and one general practitioner. Results: The encounters were acted out in six scenes. Scene ! was initiated by the pharmaceutical representative, who acknowledged the relative status of the two players. Scene 2 provided the opportunity for the representative to check the general practitioner's knowledge about the product. Scene 3 was used to propose clinical and cost benefits associated with the product. During scene 4, the general practitioner took centre stage and challenged aspects of this information. Scene 5 involved a recovery strategy as the representative fought to regain equilibrium. In the final scene, the representative tried to ensure future contacts. Conclusion: Encounters between general practitioners and pharmaceutical representatives follow a consistent format that is implicitly understood by each player. It is naive to suppose that pharmaceutical representatives are passive resources for drug information. General practitioners might benefit from someone who can provide unbiased information about prescribing in a manner that is supportive and sympathetic to the demands of practice. [ABSTRACT FROM AUTHOR]

Objectives: To explore the reasons why general practitioners do not always implement best evidence. Design: Qualitative study using Balint-style groups. Setting: Primary care. Participants: 19 general practitioners. Main outcome measures: Identifiable themes that indicate barriers to implementation. Results: Six main themes were identified that affected the implementation process: the personal and professional experiences of the general practitioners; the patient-doctor relationship; a perceived tension between primary and secondary care; general practitioners' feelings about their patients and the evidence; and logistical problems. Doctors are aware that their choice of words with patients can affect patients' decisions and whether evidence is implemented. Conclusions: General practitioner participants seem to act as a conduit within the consultation and regard clinical evidence as a square peg to fit in the round hole of the patient's life. The process of implementation is complex, fluid, and adaptive. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of a multifaceted intervention directed at general practitioners on six year mortality, morbidity, and risk factors of patients with newly diagnosed type 2[ ]diabetes. Design: Pragmatic, open, controlled trial with randomisation of practices to structured personal care or routine care; analysis after 6[ ]years. Setting: 311 Danish practices with 474 general practitioners (243 in intervention group and 231 in comparison group). Participants: 874 (90.1%) of 970 patients aged 40 years who had diabetes diagnosed in 1989-91 and survived until six year follow up. Intervention: Regular follow up and individualised goal setting supported by prompting of doctors, clinical guidelines, feedback, and continuing medical education. Main outcome measures: Predefined clinical non-fatal outcomes, overall mortality, risk factors, and weight. Results: Predefined non-fatal outcomes and mortality were the same in both groups. The following risk factor levels were lower for intervention patients than for comparison patients (median values): fasting plasma glucose concentration (7.9 v 8.7[ ]mmol/l, P=0.0007), glycated haemoglobin (8.5% v 9.0%, P<0.0001; reference range 5.4-7.4%), systolic blood pressure (145 v 150[ ]mm Hg, P=0.0004), and cholesterol concentration (6.0 v 6.1 mmol/l, P=0.029, adjusted for baseline concentration). Both groups had lost weight since diagnosis (2.6 v 2.0 kg). Metformin was the only drug used more frequently in the intervention group (24% (110/459) v 15% (61/415)).Intervention doctors arranged more follow up consultations, referred fewer patients to diabetes clinics, and set more optimistic goals. Conclusions: In primary care, individualised goals with educational and surveillance support may for at least six years bring risk factors of patients with type 2 diabetes to a level that has been shown to reduce diabetic complications but without weight gain. [ABSTRACT FROM AUTHOR]

Conclusions: General practitioners perceive that their professional position and training adversely influence their attitudes to illness in themselves and their colleagues. Organisational changes within general practice, including revalidation, must take account of barriers experienced by general practitioners in accessing health care. Medical education and culture should strive to promote appropriate self care among doctors. [ABSTRACT FROM AUTHOR]

Conclusions: General practitioners and practice nurses were negative about a new health promotion payment, despite agreeing to pilot it. Health promotion payments do not automatically generate effective health promotion activity, and policymakers should consider careful piloting and evaluation of future changes in health promotion payments. [ABSTRACT FROM AUTHOR]

Conclusions: The factors influencing the introduction of new drugs, particularly in primary care, are more multiple and complex than suggested by early theories of drug innovation. Early experience of using a new drug seems to strongly influence future use. [ABSTRACT FROM AUTHOR]

Conclusions: This study provides no evidence that singlehanded general practitioners are underperforming clinically. Our results offer insight into the structural difference between the two types of practice and underline the importance of the effect of other practice characteristics on process and outcome measures. [ABSTRACT FROM AUTHOR]

Compares the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. Determination whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference; Methods; Results; Conclusion.

Conclusion: Patients in primary care strongly want a patient centred approach, with communication, partnership, and health promotion. Doctors should be sensitive to patients who have a strong preference for patient centrednessthose vulnerable either psychosocially or because they are feeling unwell. [ABSTRACT FROM AUTHOR]

Objective: To compare the cost effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients.Design: Prospective, controlled trial with randomised and patient preference allocation arms.Setting: General practices in London and greater Manchester.Participants: 464 of 627 patients presenting with depression or mixed anxiety and depression were suitable for inclusion.Interventions: Usual general practitioner care or up to 12sessions of non-directive counselling or cognitive-behaviour therapy provided by therapists.Main outcome measures: Beck depression inventory scores, EuroQol measure of health related quality of life, direct treatment and non-treatment costs, and cost of lost production.Results: 197 patients were randomly assigned to treatment, 137 chose their treatment, and 130 were randomised only between the two psychological therapies. At four months, both non-directive counselling and cognitive-behaviour therapy reduced depressive symptoms to a significantly greater extent than usual general practitioner care. There was no significant difference in outcome between treatments at 12 months. There were no significant differences in direct costs, production losses, or societal costs between the three treatments at either four or 12 months. Sensitivity analyses did not suggest that the results depended on particular assumptions in the statistical analysis.Conclusions: Within the constraints of available power, the data suggest that both brief psychological therapies may be significantly more cost effective than usual care in the short term, as benefit was gained with no significant difference in cost. There are no significant differences between treatments in either outcomes or costs at 12months. [ABSTRACT FROM AUTHOR]

Presents information on a study which compared the cost effectiveness of general practitioners and nurse practitioners in primary care. Main outcome measures; Methodology of the study; Results and discussion; Conclusions.

Presents information on a study which evaluated whether nurse telephone consultation in out of hours primary care may reduce costs compared to general practice care. Concept of nurse telephone consultation; Methodology of the study; Results and discussion; Conclusions.

Presents information on a study which investigated whether nurse practitioner care differs from general practitioner care for patients requesting same day consultations. Consultation satisfaction of patients; Ratio of consultation times between general and nurse practitioners; Methodology of the study; Results and discussion; Conclusions.

Presents information on a study which reviewed published literature concerning the effects of on-site mental health professionals on physicians' management of mental health. Methods; Results; Discussion. INSETS: What is already known on this topic;What this study adds;Why 19th century institutions are governed by..., by G.M. Young.

Deals with several stories pertaining to failures of good medical practice. Lessons about internal self regulation by the medical profession in New Zealand; Description of internal morality and external morality.

Focuses on the fairness of oral examinations in the Royal College of General Practitioners in Britain. Difficulties experienced by candidates from ethnic minorities and those trained abroad in oral examination; Methodology of the study; Results and discussion; Types of discourse.