[Clinical skills of Chilean general practitioners for the management of depressive disorders]

BACKGROUND

Diverse and sustained efforts have been developed to improve the management of depression by general practitioners (GPs), but they have not improved treatment coverage and quality of services.

AIM

To explore the level of knowledge and clinical skills to diagnose and treat depression by GPs in Primary Health Care (PHC) in the Metropolitan Area of Santiago de Chile (RM).

MATERIAL AND METHODS

Theoretical knowledge (TK), diagnostic skills (DS) and treatment skills (TS) were evaluated in 56 GPs of the RM with a battery of specially designed instruments.

RESULTS

In TK there were significant differences between GPs aged 31 years or less and their older counterparts and between Chilean and foreign doctors. Five percent of observed differences in TK were explained by age and nationality, respectively. Chilean GPs achieved higher scores in recognition of symptoms (RS), one of the dimensions of DS. No significant differences by age or nationality were observed for DS and TS.

CONCLUSIONS

Achievement of GPs on tests measuring TK, DS, and TS was generally below 50%. This deficiency should be improved.

Prevention of ischemic stroke in clinical practice: a role of internists and general practitioners

Stroke constitutes a substantial clinical and socio-economic burden. It is currently the third cause of death worldwide and results in mortality or disability in every third patient at the end of the first year following an acute cerebrovascular event. Although in-hospital mortality rates in stroke patients have decreased, prevention and cardiovascular risk control remain critical for improving the prognosis and reducing stroke burden worldwide. The definitions of stroke and transient ischemic attack (TIA) have been recently modified following the findings from neuroimaging and thrombolysis research. Both stroke and TIA are recurrent and preventable disorders. Both patients with stroke and those with TIA require prompt clinical workup, risk assessment, and appropriate management because the risk of recurrence, stroke, and coronary events is significant. The 5 most common cardiovascular risk factors (high blood pressure, smoking, abdominal obesity, diet, and lack of physical activity) are responsible for 80% of the cases. Stroke prevention involves lifestyle modification and specific treatment. Secondary prevention of ischemic stroke involves early treatment (antiplatelets and carotid interventions) and long-term management including lifestyle changes, antihypertensive therapy, antiplatelets, antithrombotic drugs in patients with atrial fibrillation, and the use of statins and other lipid-lowering drugs. Stroke patients are at risk of depression, dementia, epilepsy, and other complications that also require targeted treatment.

A Systematic Review of Training to Improve Melanoma Diagnostic Skills in General Practitioners

Australia has the highest incidence of melanoma in the world. General practitioners encounter melanoma in 9.9 per 10,000 clinical encounters and play a key role in diagnosis. A systematic review was conducted to study the efficacy of training methods to improve general practitioners' diagnostic skills in melanoma. Article abstracts (1307) were screened, from a Medline search. Four trials met our criteria and were highly variable in their intervention methods and outcome measures. The Cochrane risk of bias tool was used to assess study quality with only one good, one poor, and two of questionable quality. Our results showed limited evidence via one study that training of general practitioners in surface microscopy improved melanoma diagnosis, from a clinical (naked eye) pre-intervention score of 54.6 % to a post-intervention surface microscopy score of 75.9 % in 74 general practitioners. Future work should explore the barriers to implementing this strategy in clinical practice.

Resuscitation update for general practitioners

BACKGROUND

The latest changes to resuscitation guidelines in Australia were released in 2016. Few of the changes will have an impact on general practitioners (GPs) but there are some additional issues that they, as health professionals and leaders in the community, should be informed about.

OBJECTIVE

The objective of this article is to provide an update for GPs on the current resuscitation guidelines.

DISCUSSION

This article describes the latest changes in resuscitation recommendations in the fields of first aid, basic life support, advanced life support and paediatric resuscitation, with an emphasis on issues of particular relevance to GPs.

Outcomes of intrauterine device insertion training for doctors working in primary care

BACKGROUND

Intrauterine devices (IUDs) are underused in Australia despite being one of the most effective, reversible methods of contraception.

OBJECTIVE

The objective of this article is to report on the outcomes of a competency-based IUD training program by Family Planning NSW for general practitioners (GPs).

METHODS

Pre-training and post-training questionnaires were used for a 12-month cohort study of GPs who undertook IUD insertion training.

RESULTS

Twenty-two GPs (92%) completed the follow-up questionnaire; 19 participants reported attempting a total of 238 IUD insertions, 212 (89%) of which were successful. Few complications were reported. Most participants cited inadequate remuneration, time constraints and lack of appropriate patients as barriers to performing IUD insertion. Nearly all (96%) were confident with IUD insertion in multiparous women, but only 46% felt confident inserting in nulliparous women. There was evidence of a reduction in referrals to external IUD inserters following training.

DISCUSSION

Training enabled GPs to insert IUDs in their practices, but more than two-thirds (68%) fitted fewer than 12 devices during follow-up. A number of barriers to IUD insertion in general practice can be addressed to improve community access.

Exploring the potential uses of value-added metrics in the context of postgraduate medical education

CONTEXT

Increasing pressure is being placed on external accountability and cost efficiency in medical education and training internationally. We present an illustrative data analysis of the value-added of postgraduate medical education.

METHOD

We analysed historical selection (entry) and licensure (exit) examination results for trainees sitting the UK Membership of the Royal College of General Practitioners (MRCGP) licensing examination (N = 2291). Selection data comprised: a clinical problem solving test (CPST); a situational judgement test (SJT); and a selection centre (SC). Exit data was an applied knowledge test (AKT) from MRCGP. Ordinary least squares (OLS) regression analyses were used to model differences in attainment in the AKT based on performance at selection (the value-added score). Results were aggregated to the regional level for comparisons.

RESULTS

We discovered significant differences in the value-added score between regional training providers. Whilst three training providers confer significant value-added, one training provider was significantly lower than would be predicted based on the attainment of trainees at selection.

CONCLUSIONS

Value-added analysis in postgraduate medical education potentially offers useful information, although the methodology is complex, controversial, and has significant limitations. Developing models further could offer important insights to support continuous improvement in medical education in future.

'If they're your doctor, they should care about you': Women on release from prison and general practitioners

BACKGROUND

Nearly half of the people leaving prison see a general practitioner (GP) within a month of release, which provides an opportunity to promote health for this vulnerable group.

OBJECTIVE

The objective of this article is to examine the expectations and experiences of GP care of women leaving prison.

METHODS

Semi-structured interviews pre-release and post-release from prison were analysed using inductive thematic analysis.

RESULTS

Sixty-nine interviews were conducted with 40 women while they were still in prison and 29 of these women after they were released. Women perceived GPs as lacking interest in their social support needs and believed GPs needed more skills in substance misuse management. Given the fear of stigma, women may not disclose recent incarceration, affecting the continuity of healthcare initiated in prison.

DISCUSSION

GPs' acknowledgement of, and assistance with, the broad issues that have an impact on the health and wellbeing of women after release is valued. Whole-person care also requires GP accessibility, management of substance misuse, continuity of care and understanding of the stigma associated with incarceration.

Membership in a diabetes-care network and adherence to clinical practice guidelines for treating type 2 diabetes among general practitioners: A four-year follow-up

OBJECTIVES

To assess whether private general practitioners (GPs) belonging to a diabetes-care network adhered more closely to clinical practice guidelines for diabetes care than GPs not in such a network, for all their patients with type 2 diabetes treated with medication (patients with diabetes), regardless of whether they received care through a network (that is, whether a halo effect occurred).

RESEARCH DESIGN AND MEASURES

The study, based on health insurance reimbursement databases in southeastern France, included 468 GPs in two networks and 468 non-network GPs in the same geographical area, matched one-to-one by propensity scores. We followed up their patients with diabetes (n=22,808) from 2008 through 2011, conducting multivariate time-to-event analyses (Cox models) that took the matching design into account to evaluate time from inclusion until performance of the given number of each of six recommended examinations/tests.

RESULTS

GPs belonging to a diabetes-care network adhered more closely to clinical practice guidelines but our result were slightly pronounced. Hazard ratios (HR) were significantly higher for patients of network GPs for the implementation of 3 HbA1C assays (HRa=1.13; [95%CI=1.10-1.16]), or 1 microalbuminuria assay (1.4 [1.35-1.45]); they were lower for LDL-cholesterol assays (1.04 [1.01-1.07]) and ophthalmological checkups (1.07 [1.04-1.10]), and not significant for creatinemia or cardiac monitoring.

CONCLUSIONS

Network GPs had better diabetes monitoring practices for all their patients with diabetes than the other GPs, especially for the most diabetes-specific tests. Further research is needed in other settings to confirm the existence of this halo effect.

Physician Associate and General Practitioner Consultations: A Comparative Observational Video Study

Background

Physician associates, known internationally as physician assistants, are a mid-level practitioner, well established in the United States of America but new to the United Kingdom. A small number work in primary care under the supervision of general practitioners, where they most commonly see patients requesting same day appointments for new problems. As an adjunct to larger study, we investigated the quality of the patient consultation of physician associates in comparison to that of general practitioners.

Method

We conducted a comparative observational study using video recordings of consultations by volunteer physician associates and general practitioners with consenting patients in single surgery sessions. Recordings were assessed by experienced general practitioners, blinded to the type of the consulting practitioner, using the Leicester Assessment Package. Assessors were asked to comment on the safety of the recorded consultations and to attempt to identify the type of practitioner. Ratings were compared across practitioner type, alongside the number of presenting complaints discussed in each consultation and the number of these which were acute, minor, or regarding a chronic condition.

Results

We assessed 62 consultations (41 general practitioner and 21 physician associates) from five general practitioners and four physician associates. All consultations were assessed as safe; but general practitioners were rated higher than PAs in all elements of consultation. The general practitioners were more likely than physician associates to see people with multiple presenting complaints (p<0.0001) and with chronic disease related complaints (p = 0.008). Assessors correctly identified general practitioner consultations but not physician associates. The Leicester Assessment Package had limited inter-rater and intra-rater reliability.

Conclusions

The physician associate consultations were with a less complex patient group. They were judged as competent and safe, although general practitioner consultations, unsurprisingly, were rated as more competent. Physician associates offer a complementary addition to the medical workforce in general practice.

Applicability of the theory of planned behavior in explaining the general practitioners eLearning use in continuing medical education

BACKGROUND

General practitioners (GP) update their knowledge and skills by participating in continuing medical education (CME) programs either in a traditional or an e-Learning format. GPs' beliefs about electronic format of CME have been studied but without an explicit theoretical framework which makes the findings difficult to interpret. In other health disciplines, researchers used theory of planned behavior (TPB) to predict user's behavior.

METHODS

In this study, an instrument was developed to investigate GPs' intention to use e-Learning in CME based on TPB. The goodness of fit of TPB was measured using confirmatory factor analysis and the relationship between latent variables was assessed using structural equation modeling.

RESULTS

A total of 148 GPs participated in the study. Most of the items in the questionnaire related well to the TPB theoretical constructs, and the model had good fitness. The perceived behavioral control and attitudinal constructs were included, and the subjective norms construct was excluded from the structural model. The developed questionnaire could explain 66 % of the GPs' intention variance.

CONCLUSIONS

The TPB could be used as a model to construct instruments that investigate GPs' intention to participate in e-Learning programs in CME. The findings from the study will encourage CME managers and researchers to explore the developed instrument as a mean to explain and improve the GPs' intentions to use eLearning in CME.

Clinical challenge

Questions for this month's clinical challenge are based on articles in this issue. The clinical challenge is endorsed by the RACGP Quality Improvement and Continuing Professional Development (QI&CPD) program and has been allocated 4 Category 2 points (Activity ID:47512).Answers to this clinical challenge are available immediately following successful completion online at http://gplearning.racgp.org.au. Clinical challenge quizzes may be completed at any time throughout the 2014-16 triennium; therefore, the previous months' answers are not published. Each of the questions or incomplete statements below is followed by four suggested answers or completions. Select the most appropriate statement as your answer.

High diagnostic value of general practitioners' presumptive diagnosis for pyelonephritis, meningitis and pancreatitis

INTRODUCTION

In Denmark, patients referred from the general practitioner (GP) to the emergency department (ED) can be referred with either specific symptoms or with a presumptive diagnosis. The aim of the present study was to evaluate the diagnostic accuracy for various presumptive diagnoses made by the GP in a population acutely referred to an ED.

METHODS

This was a retrospective cohort study of all registered acute referrals for admission to Kolding ED in 2010. Eight presumptive diagnoses were selected for further studies: meningitis, acute coronary syndrome (ACS), pulmonary embolism, pneumonia, pancreatitis, deep venous thrombosis (DVT), pyelonephritis and intestinal obstruction. The presumptive diagnoses were compared with the final diagnosis on discharge. Sensitivity, specificity, predictive values and likelihood ratios were calculated.

RESULTS

A total of 8,841 patients were enrolled. The highest and lowest sensitivities were seen for DVT (90%) and meningitis (36%), respectively; and the highest and lowest values for specificity were observed for meningitis (99%) and ACS (30%), respectively. The positive predictive value had a wide range with the lowest value for ACS (9%) and the highest for pneumonia (59%). For pyelonephritis, meningitis and pancreatitis, the likelihood ratio of a positive test was above 10. The likelihood ratio of a negative test was above 0.1 for all diagnoses.

CONCLUSIONS

Patients referred with the presumptive diagnoses pyelonephritis, meningitis and pancreatitis had a high likelihood of having the disease in question. It is important not to discard any of the included presumptive diagnoses even if the GPs fail to suggest them on admission.

FUNDING

none.

TRIAL REGISTRATION

none.

[General practitioner and specialist elderly care medicine paramount: a strong pairing in the care of the vulnerable elderly]

The Dutch National Care for the Elderly Programme (NPO) was launched as a large-scale project, in which screening for vulnerability, followed by a comprehensive geriatric assessment, played an important role. An oft-cited explanation for the poor effects of the NPO projects is the high quality of Dutch primary care. However, the complexity of frail elderly care raises the question as to whether the competence of a nurse or practice nurse is sufficient to ensure proper care and treatment. Moreover, studies used vulnerability as a risk status, as if vulnerability were reversible. Medical care for the frail elderly needs instead to be patient-centred and encompass jointly established goals. This approach offers opportunities to reduce unwanted hospitalisations and referrals to secondary care. This view underlies the University Practice Elderly Care Medicine, where general practitioners and specialists in elderly care medicine collaborate in the care and treatment of vulnerable elderly patients, and satisfaction, continuity of care and concerns of compliance with life goals are the outcome measures.

[The Dutch College of General Practitioners practice guideline on 'Sexual problems']

The Dutch College of General Practitioners practice guideline on 'Sexual problems' describes the diagnostics and management of common sexual problems. An adequate sexual anamnesis is essential in order to obtain a good picture of the patient's symptoms and of any underlying causes. Additional physical or other medical examination is of limited value. The provision of information and advice are central to the treatment of sexual problems. Attention should be paid to the different aspects of sexual functioning: physical, psychological, relational and sociocultural, and to gender differences. In many cases, management is determined by the causal factor, for instance comorbidity, sexual trauma or relational problems. In other cases, a more specific problem is diagnosed, and management is based on this.

[The revised Dutch College of General Practitioners (NHG) practice guideline on 'Visual symptoms']

The 2001 NHG practice guideline on 'Refraction disorders' was revised for the second time in October 2015. The title has been changed to 'Visual symptoms', since besides refraction disorders other conditions such as glaucoma, macular degeneration, cataract and acute eye symptoms are also covered. The ophthalmologist is the specialist to whom GPs refer patients most often. Apart from the GP, ophthalmologist and youth health care physician, various other allied health professions are involved in eye healthcare. Orthoptist and optometrist are registered allied health professions; the title 'optician' is however not registered - on the so-called BIG-register - with the Dutch Ministry of Health, Welfare and Sport. The NHG practice guideline particularly focuses on ophthalmological diagnostics with limited equipment, and on specific referrals to ophthalmology and allied health professions.

Medical teleconsultation to general practitioners reduces the medical error vulnerability of internal medicine patients

BACKGROUND

e-Health strategies are supposed to improve the performance of national health systems. Medical teleconsultation (MT) is an important component of such e-Health strategies.

OBJECTIVES

The outcome of MT was evaluated with regard to the impact on the medical error vulnerability (MEV) of internal medicine patients.

METHODS

A team of internal medicine doctors plus a network of forty specialists was set-up in one health district belonging to a unified and universal national health system of a country of Western Europe, in order to provide free-of-charge MT to support general practitioners in solving internal medicine cases. In this observational study, the case series of 2013 is reviewed.

RESULTS

a) Only 21% of the MT fell short to the general practitioner's expectations about the case solving focus; b) throughout the medical care process of the patient, 49% of the cases met with one or more of the five MEVs, namely: 1) clinical test mishandling; 2) inaccurate differential diagnosis; 3) inadequate information flow between health providers at different levels of care (transition care); 4) poor coordination between health providers; and 5) poor reconciliation of medications or hazardous therapies. c) MT canceled or prevented MEVs in 56% and mitigate MEVs in 15% of the cases; d) MT canceled or prevented 85% of MEV caused by poor information exchange in transition care, therefore improving patient referral and counter-referral.

CONCLUSIONS

MT reduces MEV and therefore, whenever implemented to a large extent, may improve the quality of health care delivery and the performance of national health systems.

Challenges in the treatment of lactational mastitis for general practitioners

OBJECTIVES

To determine how GPs manage breastfeeding women with mastitis and how confident they are in treating women with breast conditions that occur during lactation.

DESIGN, PARTICIPANTS AND SETTING

A cross-sectional survey conducted among all Croatian GPs.

KEY FINDINGS

Sixty-four per cent of the total number of respondents (171/268) had seen a patient with lactational mastitis (LM) in the previous 12 months. Among respondents who recommended medication for the treatment of LM, 93% prescribed an antibiotic (122/131). Fifteen per cent of respondents who gave advice on infant feeding advised alternative feeding methods. Approximately half (47%) felt completely confident when treating LM while more than half (57%) felt partially confident when treating other breast conditions that can occur during lactation.

CONCLUSION

The management of LM among Croatian GPs is not in full compliance with current recommendations. FUTURE IMPLICATIONS: There is a need for further training of Croatian GPs in the management of mastitis.

How GPs value guidelines applied to patients with multimorbidity: a qualitative study

OBJECTIVES

To explore and describe the value general practitioner (GPs) attribute to medical guidelines when they are applied to patients with multimorbidity, and to describe which benefits GPs experience from guideline adherence in these patients. Also, we aimed to identify limitations from guideline adherence in patients with multimorbidity, as perceived by GPs, and to describe their empirical solutions to manage these obstacles.

DESIGN

Focus group study with purposive sampling of participants. Focus groups were guided by an experienced moderator who used an interview guide. Interviews were transcribed verbatim. Data analysis was performed by two researchers using the constant comparison analysis technique and field notes were used in the analysis. Data collection proceeded until saturation was reached.

SETTING

Primary care, eastern part of The Netherlands.

PARTICIPANTS

Dutch GPs, heterogeneous in age, sex and academic involvement.

RESULTS

25 GPs participated in five focus groups. GPs valued the guidance that guidelines provide, but experienced shortcomings when they were applied to patients with multimorbidity. Taking these patients' personal circumstances into account was regarded as important, but it was impeded by a consistent focus on guideline adherence. Preventative measures were considered less appropriate in (elderly) patients with multimorbidity. Moreover, the applicability of guidelines in patients with multimorbidity was questioned. GPs' extensive practical experience with managing multimorbidity resulted in several empirical solutions, for example, using their 'common sense' to respond to the perceived shortcomings.

CONCLUSIONS

GPs applying guidelines for patients with multimorbidity integrate patient-specific factors in their medical decisions, aiming for patient-centred solutions. Such integration of clinical experience and best evidence is required to practise evidence-based medicine. More flexibility in pay-for-performance systems is needed to facilitate this integration. Several improvements in guideline reporting are necessary to enhance the applicability of guidelines in patients with multimorbidity.

General practitioners versus other physicians in the quality of primary care: a cross-sectional study in Guangdong Province, China

BACKGROUND

The primary care in China can be provided by general practitioners (GPs) and other physicians (non-GPs). However, China's general practice system has never been really established. Chinese patients tend to consider the quality of primary care provided by GPs much lower than that of non-GPs. Besides, many GPs presently prefer leaving their own positions and seeking better development in big hospitals, which has made the already weak GP system weaker. Yet, few studies have specially compared the quality of primary care provided by Chinese GPs and other physicians and no studies have explored the independent predictors of Chinese GPs' intentions to stay on their current job. In this study, we aimed to compare the quality of primary care offered by GPs with non-GPs and to explore the independent predictors of GPs' future work intentions.

METHODS

This cross-sectional study applied multi-stage random cluster sampling methodology. The data were collected from November 2013 to September 2014 in Guangdong Province. In total, 401 effective questionnaires were selected from the physicians. Quality of primary care was assessed using the Primary Care Assessment Tool (PCAT) Provider Part, representing six primary care domains: ongoing care, coordination (i.e., referrals and information systems), comprehensiveness (i.e., service available and service provided), family-centeredness, community orientation and cultural competence.

RESULTS

Of 401 participating physicians, 163 (40.6 %) were GPs. The total PCAT score was 26.32 ± 2.24 which was the sum score of the six domains and represent the quality of primary care. GPs achieved significantly different total scores and scores on three individual scales: comprehensiveness: service available, comprehensiveness: service provided and community orientation. Multiple linear regressions revealed GPs had a higher total score and scores for comprehensiveness: service provided and community orientation after adjusting for sociodemographic characteristics. In addition, GPs were more likely to intend to stay in their current job in the coming year, and this was associated with their educational level.

CONCLUSIONS

Our findings showed that GPs reported higher quality of primary care than other physicians, and were more inclined to stay in their current job. With more comprehensive care and community orientation provided by GPs, residents could reach basic medical cares and needn't to crowd into larger hospitals.