The specialist of the discipline of general practice. Semantics and politics mustn't impede the progress of general practice

Diagnostic and Therapeutic Management of Helicobacter pylori Infection in Primary Care: Perspective of Application in France and Narrative Review of the Literature

BACKGROUND

Helicobacter pylori (Hp) infection affects 30% to 40% of people in industrialized countries.

AIM

This study aimed to synthesize knowledge on the diagnostic and therapeutic management of Hp infection in general practice in people under 40 years of age.

METHOD

A narrative review of the literature with an inductive content analysis of the articles was performed.

RESULTS

The extracted data (22 articles out of 106 included after screening of 965 articles) determined three areas of analysis: indications for screening, methods of screening and diagnosis by non-invasive tests, and treatment modalities.

DISCUSSION

Targeted, easily performed screening with noninvasive tests is recommended for patients younger than 45 years of age with no family history of gastric cancer and symptoms of dyspepsia without warning signs. Given their proximity to the general population and their coverage of the territory, general practitioners are ideally positioned. Treatment modalities are well-codified and feasible in primary care. Simplifying the recommendations available to them would optimize the identification of patients at risk and the management of Hp infection. Informing, educating, involving, supporting, and promoting the control of Hp infection in primary care will be future goals. Further research is needed in primary care to evaluate the impact of new procedures on Hp control.

General practitioners' willingness to participate in research: A survey in central Switzerland

It is difficult to enlist the participation of medical general practitioners (GPs) in research studies. We aimed to determine the willingness of GPs in central Switzerland to participate in research, and to identify factors that facilitate or hinder research participation by GPs. To that end, we conducted a postal questionnaire survey of all 268 active GPs in the canton of Lucerne. The survey explored their interest in participating in research projects (yes/no) and factors that potentially influence their participation (5-point Likert scale from “very important” to “not at all important”). We contacted all non-responders by phone. Background information of the GPs was retrieved from the database of the cantonal association of physicians. Associations between willingness to participate in research and GP’s age, gender, type and location of practice, and the perceived relevance of facilitators were investigated via multiple logistic regression. Out of 268 GPs, 115 (43%) agreed to be contacted for future research projects. Willingness was associated with age (willing: 55% ≤ 40 y vs. 33% > 60 y) and gender (44% male vs. 38% female), and to some degree with the type of practice (50% group vs. 31% single), and location (46% urban vs. 38% rural), independently from each other. Scientists should develop methods to motivate and support GPs in single and rural practices to participate so research is representative of primary care as a whole.

A doctor close at hand: How GPs view their role in cancer care

OBJECTIVE

To explore GPs' own views on their role in cancer care.

DESIGN

Qualitative study based on semi-structured interviews.

SETTING

Norwegian primary care.

METHODS

The stories of 14 GPs concerning 18 patients were analyzed for core content and abstracted into general ideas, to create a broader sense of the experienced professional role.

RESULTS

The GPs claimed to have an important role in cancer care. In our analysis, three main aspects of GPs' work emerged: first, as a flexible mediator, e.g. between the patient and the clinic, interpreting and translating; second, as an efficient "handyman", solving practical problems locally; and third, as a personal companion for the patient throughout the illness.

CONCLUSION

The interviewed GPs see their place in cancer care as being close to their patients. In their many tasks we found three main aspects: the mediating, the practical, and the personal.

Family history in primary care: understanding GPs' resistance to clinical genetics--qualitative study

BACKGROUND

National and local evaluations of clinical genetics service pilots have experienced difficulty in engaging with GPs.

AIM

To understand GPs' reluctance to engage with clinical genetics service developments, via an examination of the role of family history in general practice.

DESIGN OF STUDY

Qualitative study using semi-structured one-to-one interviews.

SETTING

The West Midlands, UK.

METHOD

Interviews with 21 GPs working in 15 practices, based on a stratified random sample from the Midlands Research Practices Consortium database. Thematic analysis proceeded alongside data generation. Framework grids were constructed for comparative analytical questioning. Interpretation was framed by two explanatory models: a knowledge deficit model, and practice and professional identity model.

RESULTS

There is a clear distinction between the routine use and function of family history in GPs' clinical decision making, and contrasting conceptualisations of genetics and 'genetic conditions'. Although genetics is clearly a part of current GP practice, with acknowledgement of genetic components to multifactorial disease, this is distinguished from 'genetic conditions' which are seen as rare, complex single-gene disorders. Importantly, family history takes its place within a broader notion of the 'family doctor' that interviewees identified as a key aspect of their role. In contrast, clinical genetics was not identified as a core component of generalist practice.

CONCLUSION

The likely effectiveness of educational policy interventions aimed at GPs that focus solely on knowledge deficit models, is questionable. There is a need to acknowledge how appropriate practice is constructed by GPs, within the context of accepted generalist roles and related identities.

Family practice: professional identity in transition. A case study of family medicine in Canada

With increasingly fewer family physicians in many countries and students less interested in primary care careers, generalists are becoming an endangered species. This situation is a major health care resource management challenge. In a rapidly changing health care environment, family medicine is struggling for a clear identity -- a matter which is crucial to health system restructuring because it affects the roles and functioning of other professions in the system. The objective of our study was to explore representations of roles and responsibilities of family physicians held by future family and specialist physicians and their clinical teachers in four Canadian medical school faculties of medicine, using both focus groups and individual interviews. In addition to family medicine, we targeted residency programs in general psychiatry, radiology and internal medicine -- three areas that interface significantly between primary care and specialized medicine. In each faculty, respondents included the vice-dean of postgraduate studies; the director of each relevant program; educators in the program; residents in each specialty in their last year of training. Findings are centred around three major themes: (1) the definition of family medicine; (2) family medicine as an endangered species, and (3) the generation gap between young family physicians and their educators. The sustained physician-patient relationship is considered a core characteristic of family medicine that is much valued by patients and physicians -- both generalists and specialists -- as something to be preserved in any model of collaboration to be developed. Overall, two divergent directions emerge: preserving all the professions' traditional functions while adapting to changing contexts, or concentrating on areas of expertise and moving towards creating "specialist" general practitioners, in response to a rapidly expanding scope of practice, and to the high value attributed to specialization by society and the professional system.

GPs with special interests: unanswered questions

The NHS Plan signalled the creation of GPs with special interests (GPwSIs) in the UK. The role of a GPwSI involves the acquisition of knowledge and skills that enable GPs to dedicate a portion of their time to performing the role of consultants to their colleagues within the ambit of general practice, and with respect to specific health problems encountered. The objectives behind the introduction of GPwSIs are to improve the patient's access to specialist care, to cut waiting-list times, and to save on referral costs, (and as a consequence to increase the prestige of the GPs involved). However, the reality may not meet these expectations. Before accepting the proposition for universal implementation of GPwSIs empirical evidence is required to demonstrate that overall health is improved (of patients as well as the population); patients, especially patients of doctors working alone or in small groups (specifically in rural areas) are not disadvantaged; referral is improved and made more appropriate to the requirements of patients and their health problems; real prestige is generated, not only among GPs and students, but also among patients; biological views typical of the specialist are not promoted; and a brake is not applied to other alternatives in, or the reorganisation of, primary care.

'Medicine's next goldmine?' The implications of new genetic health technologies for the health service

There is considerable uncertainty about the implications of the new genetics for health services. These are the enthusiasts who argue that molecular genetics will transform health care and others argue that the scope for genetic interventions is limited. The aim of this paper is to examine some of the questions, tensions and difficulties which face health care providers particularly in developed countries as they try to come to terms with the dilemmas raised by new genetic health care technologies (NGHTs). It identifies questions for research which may help the development of robust and flexible strategies for implementation.

The research domain of family medicine

This article characterizes the large research domain of family medicine. It is a domain that can be productively explored from different perspectives, including: (1) the ecology of medical care and its focus on the environments of health care and interactions among them; (2) the realm of causation and important opportunities to discover how people lose and regain their health; (3) knowing medicine in different ways, focusing on what things mean in the inner and outer realities of individuals and groups of individuals; (4) the nature of the work of family physicians, such as first-contact care for any type of problem, sticking with patients regardless of their diagnoses, incorporating context into decision making, development of relevant technologies, articulating useful theory, and measuring what happens in family medicine; (5) the standard research categories of basic, clinical, health services, health policy, and educational research; and (6) thinking of family medicine research as both a linear process of translation and a wheel of knowledge with iterative loops of discovery that come from within family medicine. The domain of family medicine research is important and ripe for fuller discovery, and it invites the thinking and imagination of the best investigators. It seems unlikely that medical research can ever be complete without a robust family medicine research enterprise. As the domain of family medicine research is explored, not a few, but billions of people will benefit.

A preliminary taxonomy of medical errors in family practice

OBJECTIVE

To develop a preliminary taxonomy of primary care medical errors.

DESIGN

Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods.

SETTING

The National Network for Family Practice and Primary Care Research.

PARTICIPANTS

Family physicians.

MAIN OUTCOME MEASURES

Medical error category, context, and consequence.

RESULTS

Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died.

CONCLUSIONS

This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

Informal carers and the primary care team

The number of carers in the community is rising, and the importance of general practice in providing supportfor them has been highlighted. Caring for a disabled friend or relative has been shown to be harmful to the health of the caregiver and changes in social and family structure have led carers to become isolated and more reliant on the formal support services. However, many carersfeel that GPs do not understand their needs, and in turn many GPs and nursesfeel that they lack the relevant resources and training to take a more proactive role. The shift from hospital to community-based care and the blurring of social roles of responsibility puts additional pressure on the carers and community services. However general practice is in the best position to help and there are many things that can be done by primary care teams, such as providing information about available support, benefits and local services, which would be appreciated by informal carers.