Search

Objective: To improve the quality of clinical care through better continuity of services between the public hospital and general practitioners (GPs), focusing on expediting discharge of patients from hospital through improved use of resources provided by GPs., Design: Stage 1: Participant observation during ward rounds and unstructured interviews to gain an understanding of the perceptions of hospital staff and GPs of the GP's role in the discharge process. Stage 2: Semi-structured interviews with registrars and GPs of 30 patients (who were admitted to a medical ward and discharged to the care of their GP) to get the participants' views of each other's roles in providing continuity of care., Results: There was a general lack of trust on both sides, and poor communication owing to several structural and perceptual problems. Registrars focused on specialist care and outpatient follow-up, being almost oblivious to GP functions, apart from monitoring the management plan developed in the hospital; they made no use of GPs' knowledge of the case or their experience in treating patients within their families and social milieu, and frequently wished to do everything within the hospital. GPs, on the other hand, often felt alienated from the hospital system, although they had much to offer by being able to contribute details of the patient's background and by using their special skills, which went well beyond passively monitoring progress., Recommendations: 1. Information about the patient's GP should be made available to hospital staff. 2. Interns should make telephone calls to GPs after admission and when the discharge date is known. 3. Early-discharge summaries should be forwarded and include: (i) reasons for giving or altering medications; (ii) specific plans after discharge; (iii) information conveyed to the patient and family about the illness; and (iv) a summary of the case by the consultant. 4. Registrars and interns should be educated about the appropriate involvement of GPs in the discharge process and throughout the patient's stay in hospital. 5. Direct involvement of the GP with the patient during hospital stay should be encouraged. 6. A pilot study should be set up to investigate the role of a liaison person in overcoming problems of the transition of care of hospitalised patients to the community.

Evaluation of a number of courses in clinical decision-making (CDM) indicates that there are well-defined problems in teaching this subject. This paper describes some of the difficulties and proposes appropriate remedies. Problems in teaching undergraduates are different from those in the postgraduate years. Three areas where the principles of CDM are particularly useful to undergraduates relate to the structuring of clinical problems, clarifying the place of value judgements and developing new concepts regarding test ordering, particularly the importance of false positive rates and the overwhelming power of prior probabilities. In postgraduate teaching the most important areas relate to the origin of probability and of utility estimates. The complexity of decision analysis also needs critical comment. Two remedies are suggested which will help course developers when faced with these problems. Firstly, the early introduction of concepts regarding sensitivity analysis, making it clear that with the aid of CDM we are able to deal with a wide range of probability estimates, precision rarely being required in clinical medicine. Secondly, the availability of educational support systems will help expert clinicians teach CDM concepts within their own field.

A condition commonly seen after motor vehicle accidents, the Late Whiplash Syndrome, which is defined as a collection of symptoms and disabilities seen more than six months after a neck injury occurring in a motor vehicle accident, is examined in a series of 300 cases. The author suggests that the development of the Late Whiplash Syndrome, some of whose characteristics are viewed as illness and some as illness behavior, depends on social variables. The differential distribution in Western countries and in Singapore is related to sanctions against entry into the sick role associated with this type of injury which are present in countries such as Singapore. Conversely, motor vehicle injury is legitimized in Western Countries such as Australia as an historical overview shows. The author's model of the Late Whiplash Syndrome lends itself to generalizations about the development of social illness in different cultures.

This paper describes the evaluation of an innovative course in clinical decision-making (CDM). A traditional course in neurology taught concurrently to the same group of students by the same teacher was used for comparison. The aim of the course was to introduce students to the basic concepts of CDM as an aid to rational decision-making. The end-point of the evaluation was their perception of the immediate clinical relevance of CDM. It was postulated that by seeing this relevance they would be more likely to change their decision-making behaviour than by simply learning factual content or principles. The evaluation used an ongoing formative approach, including ethnographic analysis, questionnaires, small group discussion and supportive feedback for the teacher. The ongoing evaluation of the course resulted in revisions with increasing relevance within the students' level of experience, changes in sequence of presentations and encouragement of active student participation. A pre-test showed that students had difficulty in the correct assessment of the validity of data and in the correct revision of opinion. Results of the evaluation indicated that the CDM course did not achieve its objective of making students aware of the immediate clinical relevance of CDM. Possible reasons for this include the lack of reinforcement from clinicians suitable for modelling and the context specific nature of the learning of thinking processes. For a CDM course to be successful, it may need to be taught within the context of specific clinical topics. It is suggested that the evaluation approach used here is a cost-effective method when considering innovations in the curriculum and useful for generating further questions for study.