General practitioners' attitudes towards the management of dental conditions and use of antibiotics in these consultations: a qualitative study

OBJECTIVES

This study aimed to produce an account of the attitudes of general practitioners (GPs) towards the management of dental conditions in general practice, and sought to explore how GPs use antibiotics in the treatment of dental problems.

DESIGN

Qualitative study employing semistructured telephone interviews and thematic analysis.

PARTICIPANTS

17 purposively sampled GPs working in Wales, of which 9 were male. The median number of years since graduation was 21. Maximum variation sampling techniques were used to ensure participants represented different Rural-Urban localities, worked in communities with varying levels of deprivation, and had differing lengths of practising career.

RESULTS

Most GPs reported regularly managing dental problems, with more socioeconomically deprived patients being particularly prone to consult. Participants recognised that dental problems are not optimally managed in general practice, but had sympathy with patients experiencing dental pain who reported difficulty obtaining an emergency dental consultation. Many GPs considered antibiotics an acceptable first-line treatment for acute dental problems and reported that patients often attended expecting to receive antibiotics. GPs who reported that their usual practice was to prescribe antibiotics were more likely to prioritise patients' immediate needs, whereas clinicians who reported rarely prescribing often did so to encourage patients to consult a dental professional.

CONCLUSIONS

The presentation of patients with dental problems presents challenges to GPs who report concerns about their ability to manage such conditions. Despite this, many reported frequently prescribing antibiotics for patients with dental conditions. This may contribute to both patient morbidity and the emergence of antimicrobial resistance. This research has identified the need for quantitative data on general practice consultations for dental problems and qualitative research exploring patient perspectives on reasons for consulting. The findings of these studies will inform the design of an intervention to support patients in accessing appropriate care when experiencing dental problems.

The Usefulness and Feasibility of Mobile Interface in Tuberculosis Notification (MITUN) Voice Based System for Notification of Tuberculosis by Private Medical Practitioners--A Pilot Project

INTRODUCTION

Tuberculosis (TB) is a notifiable disease and health care providers are required to notify every TB case to local authorities. We conducted a pilot study to determine the usefulness and feasibility of mobile interface in TB notification (MITUN) voice based system for notification of TB cases by private medical practitioners.

METHODOLOGY

The study was conducted during September 2013 to October 2014 in three zones of Chennai, an urban setting in South India. Private clinics wherein services are provided by single private medical practitioners were approached. The steps involved in MITUN included: Registration of the practitioners and notification of TB cases by them through voice interactions. Pre and post-intervention questionnaires were administered to collect information on TB notification practices and feasibility of MITUN after an implementation period of 6 months.

RESULTS

A total of 266 private medical practitioners were approached for the study. Of them, 184 (69%) participated in the study; of whom 11 (6%) practitioners used MITUN for TB notification. Reasons for not using MITUN include lack of time, referral of patients to government facility, issues related to patient confidentiality and technical problems. Suggestions for making mobile phone based TB notification process user-friendly included reducing call duration, including only crucial questions and using missed call or SMS options.

CONCLUSION

The performance (feasibility and usefulness) of MITUN voice based system for TB notification in the present format was sub-optimal. Perceived problems, logistical and practical issues preclude scale-up of notification of TB by private practitioners.

Old boys' network in general practitioners' referral behavior?

We analyzed the impact of social networks on general practitioners' (GPs) referral behavior based on administrative panel data from 2,684,273 referrals to specialists made between 1998 and 2007. For the definition of social networks, we used information on the doctors' place and time of study and their hospital work history. We found that GPs referred more patients to specialists within their personal networks and that patients referred within a social network had fewer follow-up consultations and less inpatient days thereafter. The effects on patient outcomes (e.g. waiting periods, days in hospital) of referrals within personal networks and affinity-based networks differed. Specifically, whereas empirical evidence showed a concentration on high-quality specialists for referrals within the personal network, suggesting that referrals within personal networks overcome information asymmetry with respect to specialists' abilities, the empirical evidence for affinity-based networks was different and less clear. Same-gender networks tended to refer patients to low-quality specialists.

A Survey of GPs Awareness and Use of Risk Assessment Tools and Cardiovascular Disease Prevention Guidelines

Cardiovascular disease (CVD) is the leading cause of death worldwide. This study aimed to benchmark awareness and use of CVD risk assessment (RA) tools and prevention guidelines in Irish general practice. 493 (18%) Irish general practitioners (GPs) were invited to participate in a cross-sectional study in 2011. 213 (43%) GPs responded with most being male (n = 128, 58.2%) and aged ≥ 45 years (n = 124, 56.8%). While 197 (92.5%) GPs were aware of at least one RA tool, only 69 (32.4%) GPs reported frequent use. 187 (87.8%) GPs were aware of one or more CVD prevention guidelines with 115 (54.0%) GPs reporting frequent use of at least one guideline. No age or gender difference observed. Barriers to implementation of CVD prevention guidelines were lack of remuneration, too many CVD guidelines and time constraints. Most Irish GPs were aware of RA tools and CVD prevention guidelines with half reporting frequent use of guidelines.

Review of patient satisfaction with services provided by general practitioners in an antenatal shared care program

BACKGROUND

Antenatal shared care (ANSC) is a model of care in Australia whereby pregnant women are managed by their general practitioner (GP) and an obstetrician at a public antenatal clinic throughout the pregnancy. The aim of this study was to assess pregnant women's satisfaction with the ANSC program and the adequacy of advice provided to pregnant women.

METHODS

Women participating in ANSC in the Illawarra region of NSW were invited to complete a satisfaction survey, which included questions on relevant topics discussed with their GP.

RESULTS

Most women reported being highly satisfied with the ANSC service. Over half of the women had not received any information about breastfeeding and nutritional supplementation of iodine.

Characteristics of service users and provider organisations associated with experience of out of hours general practitioner care in England: population based cross sectional postal questionnaire survey

OBJECTIVE

To investigate the experience of users of out of hours general practitioner services in England, UK.

DESIGN

Population based cross sectional postal questionnaire survey.

SETTING

General Practice Patient Survey 2012-13.

MAIN OUTCOME MEASURES

Potential associations between sociodemographic factors (including ethnicity and ability to take time away from work during working hours to attend a healthcare consultation) and provider organisation type (not for profit, NHS, or commercial) and service users' experience of out of hours care (timeliness, confidence and trust in the out of hours clinician, and overall experience of the service), rated on a scale of 0-100. Which sociodemographic/provider characteristics were associated with service users' experience, the extent to which any observed differences could be because of clustering of service users of a particular sociodemographic group within poorer scoring providers, and the extent to which observed differences in experience varied across types of provider.

RESULTS

The overall response rate was 35%; 971,232/2,750,000 patients returned surveys. Data from 902,170 individual service users were mapped through their registered practice to one of 86 providers of out of hours GP care with known organisation type. Commercial providers of out of hours GP care were associated with poorer reports of overall experience of care, with a mean difference of -3.13 (95% confidence interval -4.96 to -1.30) compared with not for profit providers. Asian service users reported lower scores for all three experience outcomes than white service users (mean difference for overall experience of care -3.62, -4.36 to -2.89), as did service users who were unable to take time away from work compared with service users who did not work (mean difference for overall experience of care -4.73, -5.29 to -4.17).

CONCLUSIONS

Commercial providers of out of hours GP care were associated with poorer experience of care. Targeted interventions aimed at improving experience for patients from ethnic minorities and patients who are unable to take time away from work might be warranted.

Understanding, benefits and difficulties of home medicines review - patients' perspectives

BACKGROUND

The home medicines review (HMR) is an important tool for promoting a model of patient-centred care. This article seeks pa-tients' perspectives on understanding, and perceived benefits and difficulties of HMRs.

METHODS

A qualitative study based on semi-structured interviews of adult participants who completed an HMR was undertaken in Black-town, a growing, multicultural suburb in Western Sydney. The medical centre is a large general practice offering comprehensive, integrated care. Fifteen participants consented to be interviewed. There was even representation of men and women, and the majority had completed high school.

RESULTS

Three major areas were explored: understanding and expectation of an HMR, perceived patient benefits and difficulties.

DISCUSSION

The HMR has the potential to be a useful tool in patients' management of their medications. There are clear benefits when per-formed well. However, we have identified areas of limitations in effectiveness, which present opportunities for strengthening the HMR process. Training of doctors and pharmacists may be needed to ensure better patient outcomes.

Are GP supervisors confident they can assess registrar competence and safety, and what methods do they use?

BACKGROUND

The new Royal Australian College of General Practitioners' vocational training standards emphasise patient safety and matching the level of supervision to registrar competence.

METHODS

All supervisors attending a regional training provider's annual education workshop were surveyed about their overall confidence in assessing the safety of their registrars' patients, their registrars' competence across the five RACGP domains of general practice and supervision methods used.

RESULTS

Of 84 supervisors, 92.8% expressed overall confidence in their ability to assess their registrars' competence and 10.7% were totally confident. Consultation observation and audit techniques were infrequently used in their assessments.

DISCUSSION

Supervisors reported confidence in their ability to assess their registrars' competence, suggesting readiness for outcomes-based standards. The low frequency of using supervision methods considered more effective in targeting registrars' 'unknown unknowns' and the reduction in confidence with greater experiences as a supervisor raises concerns about the accuracy of this self-assessment.

Models of general practitioner services in residential aged care facilities

BACKGROUND

Provision of timely and high-quality general practitioner (GP) services to patients in residential aged care facilities (RACFs) is essential for this group of patients as they have high medical needs.

OBJECTIVE

The aim of this article is to describe different models for general practice care for patients in RACFs.

DISCUSSION

Models for general practice services include the Continuity Model, where GPs follow long-term patients; the RACF Panel model, where GPs provide care to several patients in nearby RACFs; the GPs with Special Interest in Residential Aged Care (GPwSI RAC) model, where GPs provide regularly scheduled services to larger groups of patients; the Longitudinal General Practice Team (LGPT) model, where GPs provide team-based care; and RACF-based models of care, where GPs partner with RACFs. Hospital-based models of care have also been developed to provide in-reach services to patients in RACFs during episodes of acute illness. There is limited evidence for which of these models is most effective. Developing and testing different models of general practice care should be a priority.

How general practitioners manage mental illness in culturally and linguistically diverse patients: an exploratory study

BACKGROUND

General practitioners (GPs) see a range of mental illnesses and a diversity of patients, including patients from culturally and linguistically diverse (CALD) backgrounds. The aim of this study was to understand the barriers and facilitators GPs encounter when managing mental illness in CALD patients.

METHODS

Semi-structured interviews with 10 Melbourne GPs were undertaken between May and July 2013. Data were analysed thematically.

RESULTS

GP barriers included difficulties in recognising initial symptoms, communicating the diagnosis and using interpreter services. Facilitators included cultural concordance between the GP and patient, practice-based initiatives targeting CALD patients, and areas of further education for GPs and CALD patients.

DISCUSSION

Cultural concordance between GPs and CALD patients is likely to be effective in facilitating management of mental illness. Further research is needed on interpreter use and scaling up practice-based initiatives to improve service delivery. At a population level, GPs thought it necessary to improve mental health literacy in CALD communities.

A training course for experts in diabetology in primary care

In the Netherlands so-called Diabetes Care Groups organize the primary diabetes care centrally with delegation to different health care providers. A training course for general practitioners who would like to become experts in diabetology in the primary care setting meets the need to guide the quality management processes in these care groups.

[Summary of the Dutch College of General Practitioners' (NHG) practice guideline 'ADHD in children']

The diagnosis of ADHD may be considered if a child is hyperactive, impulsive or inattentive, and if this behaviour results in evidently impaired functioning in multiple settings. Children with behavioural problems and slightly impaired functioning may benefit from patient information, education and parenting advice. From the age of 6 years, children can be offered diagnostic testing and professional support within the primary care setting, provided sufficient knowledge and expertise is available and there is collaboration with other health care providers. Management of a child with ADHD but no comorbid psychiatric disorder, consists of a step-by-step plan including education, parent and teacher guidance and, optionally, behavioural therapy for the child. In consultation with parents, child and other therapists, methylphenidate can be prescribed if behavioural interventions are not sufficiently effective. Children taking medication for ADHD should be monitored periodically, including assessment of the effectiveness and side effects.

[The general practitioner is not in the lead on ADHD]

The diagnosis of and therapy for ADHD is complex and should be done by experts in this field. In the Netherlands, a new guideline on ADHD for general practitioners has recently been issued. Although there is some room for general practitioners to start medication for this disorder, the main message is to exercise caution in starting medication in general practice. Many children with ADHD have psychiatric comorbidity and proper diagnosis by a specialist is recommended. The main task of the general practitioner is making the right choice concerning when to refer for further diagnosis. Children sometimes show behaviour which, although it is not always what adults want, does not necessarily require psychiatric intervention and this is what a general practitioner can determine.

[Revision of the Dutch College of General Practitioners practice guideline 'Acute sore throat']

The aim of a diagnostic work-up in patients with acute sore throat is to exclude serious causes of tonsillitis and, in cases of a pharyngotonsillitis, to assess the degree of illness and the risk of complications. A diagnostic work-up aimed at the distinction between a viral or bacterial cause of pharyngotonsillitis does not determine initial treatment policy. Pharyngotonsillitis usually has a benign natural course; patient information and analgesia are usually sufficient treatment. Complications of an infection with group A streptococci are rare; diagnostic work-up for this bacterial cause is, therefore, not recommended. Antibiotics are only useful in cases of severe pharyngotonsillitis, increased risk of complications or a peritonsillar infiltration. The antibiotic of choice is a narrow spectrum penicillin; however, amoxicillin/clavulanate is indicated in patients with peritonsillar infiltration. If there is discrepancy in adults between the severity of symptoms and findings on physical examination, the possibility of epiglottitis should be considered.

Food insecurity in Australia: Implications for general practitioners

BACKGROUND

In Australia, it would appear that food is abundant. For a proportion of people, however, accessing enough food to eat can be a daily or weekly struggle.

OBJECTIVE

This article provides a summary about the prevalence, causes and consequences of food insecurity that affects vulnerable populations in Australia, and discusses the implications for general practitioners (GPs).

DISCUSSION

It is estimated that 4% of Australians cannot access sufficient, safe and nutritious food. Food insecurity can be both a precursor to, and a by-product of, chronic disease and poverty. Patients who are food insecure may skip meals, eat cheap food and experience stress. They may show incredible resilience and skills in managing and masking this issue. Identifying this vulnerable population is of high importance to GPs as it has an impact on the work-up and care of such individuals. Effective links between welfare and health services are required to address patients' material, financial and environmental barriers to food security.

Knowledge of the diagnostic algorithm for pulmonary embolism in primary care

BACKGROUND

Diagnostic algorithms for pulmonary embolism (PE) have been validated in patients attending hospital emergency departments. However, general practitioners (GPs) are often the professionals of first resort for the majority of non-critical cases of PE.

AIM

To evaluate the knowledge of the diagnostic algorithm for PE among GPs in France.

DESIGN AND SETTING

Questionnaire-based survey of GPs with a private practice.

METHOD

All GPs in the study area were sent a questionnaire including several questions on the diagnosis of PE and two clinical cases scenario with suspected PE. Factors associated with knowledge of the diagnostic algorithm were analysed by univariate and multivariate analyses.

RESULTS

Five-hundred and eight questionnaires were distributed and 155 (30.5%) were available for analysis. Only 55% of the GPs did know about clinical scores for the assessment of clinical probability of PE and 42% of the GPs were aware that clinical probability is needed to interpret the result of D-dimer testing. Forty GPs (26%) gave valid responses to both clinical cases, 54 GPs (35%) had one valid case out of the two and 61 (39%) gave invalid responses to both clinical cases. Participation in specific training on PE was significantly associated with valid responses to the two clinical cases in multivariate analysis (p<0.017).

CONCLUSION

The majority of GPs were unaware of the diagnostic algorithm for PE. Clinical probability was rarely assessed and knowledge about D-dimers was poor. Specific training on PE and greater awareness of clinical probability scores may promote knowledge of PE algorithm diagnosis.

[The Dutch College of General Practitioners' practice guideline 'Problem drinking']

The Dutch College of General Practitioners' practice guideline "Problem drinking" contains recommendations for the (early) recognition, diagnosis and treatment of problem drinking and includes recommendations for young people and the management of acute alcohol intoxication. In daily practice problems with alcohol manifest themselves mainly as indirect signals and aspecific symptoms. The practice guideline recommends asking about alcohol use in every case where symptoms cannot be directly explained. General practitioners are usually able treat patients with a drinking problem themselves. Short-term interventions by the general practitioner and practice nurse are effective in the reduction of alcohol use. 'E-mental health' is an aid that can be used in the diagnosis and treatment of problem alcohol use.

[Dutch College of General Practitioners' practice guideline on 'Vaginal bleeding']

The revised Dutch College of General Practitioners' practice guideline on 'Vaginal bleeding' provides recommendations for abnormal bleeding in women in the reproduction phase of life and for post-menopausal bleeding. This guideline is closely attuned to the guideline on 'Heavy menstrual bleeding' of the Dutch Society of Obstetrics and Gynaecology. Transvaginal sonography is not reliable for excluding endometrial carcinoma in women with abnormal vaginal bleeding treated with tamoxifen. The choice of medical treatment is determined in consultation with the patient. The following factors are assessed: severity and bother, long-term need for contraception, preference for cycle control, desire to have a child, pain during menstruation, comorbidity and use of medication. Treatment options are nonhormonal (NSAIDs, or tranexamic acid) or hormonal (a levonorgestrel-releasing intrauterine system, or combined oral contraceptive). In women of reproductive age, referral is indicated if medical treatment is not effective. Other indications are intracavitary abnormalities diagnosed by transvaginal sonography, tamoxifen use, persistent contact bleeding, and suspicion of coagulation disorders. Indications for referral for post-menopausal bleeding include: sonographic endometrial thickness > 4 mm, abnormal cervical cytology, tamoxifen use, irregular bleeding during use of hormone therapy for vasomotor symptoms and persistent or recurrent bleeding, regardless of endometrial thickness.

Development and face validation of strategies for improving consultation skills

While formative workplace based assessment can improve learners' skills, it often does not because the procedures used do not facilitate feedback which is sufficiently specific to scaffold improvement. Provision of pre-formulated strategies to address predicted learning needs has potential to improve the quality and automate the provision of written feedback. To systematically develop, validate and maximise the utility of a comprehensive list of strategies for improvement of consultation skills through a process involving both medical students and their clinical primary and secondary care tutors. Modified Delphi study with tutors, modified nominal group study with students with moderation of outputs by consensus round table discussion by the authors. 35 hospital and 21 GP tutors participated in the Delphi study and contributed 153 new or modified strategies. After review of these and the 205 original strategies, 265 strategies entered the nominal group study to which 46 year four and five students contributed, resulting in the final list of 249 validated strategies. We have developed a valid and comprehensive set of strategies which are considered useful by medical students. This list can be immediately applied by any school which uses the Calgary Cambridge Framework to inform the content of formative feedback on consultation skills. We consider that the list could also be mapped to alternative skills frameworks and so be utilised by schools which do not use the Calgary Cambridge Framework.

GP supervisors assessing GP registrars – theory and practice

BACKGROUND

General practice supervisors are increasingly being expected to assess their registrars.

OBJECTIVE

In this article we explore the issues this raises for supervisors, and discuss the literature, which suggests that global assessments are the most accurate and feasible.

DISCUSSION

We suggest the following guidelines for supervisors: inform registrars at the beginning of the term about how and when they will be assessed; be clear that the aim is to decide if the registrars' practice is safe for patients and appropriate for their stage of training; ob-serve registrars at work; make an initial judgement of registrars' performance; test the initial judgement on performance applying qualitative research methods to improve trustworthiness and reduce potential biases; use the working diagnosis of registrar performance to guide the level of support and clinical oversight needed and flag registrars who require further assessment by educational organisations for remediation decisions.