Medicina de Família no Brasil e excelência acadêmica

Um colégio de especialistas incrivelmente jovem e vibrante. Quem não conseguiria ficar impressionado com tanta energia, entusiasmo e dedicação dos colegas médicos de família e comunidade no Brasil – muitos jovens médicos, muito comprometidos com Medicina de Família. A conferência da Sociedade Brasileira de Medicina de Família e Comunidade –SBMFC (11º Congresso Brasileiro de Medicina de Família e  Comunidade) foi uma experiência única e inspiradora em sua escala, com sua juventude e energia. Com 4.000 representantes, foi a maior conferência de médicos de família que já participei e, com poucos representantes com mais de 40 anos de idade, foi a mais jovem. Até 18 sessões paralelas foram realizadas facilmente juntas, e não houve participação farmacêutica. Foi surpreendente o diálogo horizontal entre os palestrantes e o público – foi uma conversa entre pessoas iguais. Nunca tinha visto algo parecido com aquilo. Os médicos de família brasileiros têm potencial para serem futuros líderes em Atenção Primária, mas não acho que têm apreciado isso.Como podem desenvolver tal potencial? Ao estabelecer uma agenda para o desenvolvimento da Medicina de Família como uma disciplina acadêmica, McWhinney ressaltou quatro princípios: um campo de ação único; um corpo de conhecimento definido; uma área de pesquisa ativa e um treinamento intelectual rigoroso1,2. A partir disso, a Medicina de Família têm se identificado como um campo de práticas único, e há consenso geral sobre o seu corpo de conhecimento, hoje bem definida – conforme é mostrado em alguns livros de autores brasileiros, tais como Bruce Duncan. O Brasil tem alguns excelentes cursos de pós-graduação para treinamento da Medicina de Família, principalmente os programas de residência médica. Nem todos os clínicos gerais brasileiros realizaram este treinamento, e é importante integrar aqueles que ainda não participaram de um treinamento formal. Os três pontos fundamentais da disciplina acadêmica já estão sendo realizados. Entretanto, como muitas disciplinas acadêmicas, a dificuldade está no fato de estimular o componente final: a pesquisa.A pesquisa é realmente necessária? Nós, na grande maioria, tornamo-nos médicos de família, pois estamos interessados nas pessoas e em suas doenças e condições. Ficar em bibliotecas e em laboratórios, e escrever artigos não eram nossas prioridades. Mas, pergunte a qualquer médico de família se está interessado em descobrir como a doença afeta seus pacientes, qual é a melhor forma de tratá-los na comunidade, e como fornecer a melhor assistência à saúde; indiscutivelmente tais médicos iriam concordar. A pesquisa faz essas perguntas. Se a disciplina Medicina de Família deve prosperar, a pesquisa não é uma opção, mas sim uma necessidade. Perguntar e pesquisar como podemos melhorar a assistência à saúde de nossos pacientes faz parte da disciplina.Quem deveria se envolver em pesquisas? Outros pesquisadores já estão investigando sobre assistência à saúde na comunidade no Brasil. Uma rápida busca na literatura mostra que muito disso está sendo feito por especialistas hospitalares. Portanto, é importante que médicos de família façam parte deste grupo de pesquisadores. Não basta deixar outras pessoas mostrarem o caminho. Isso perpetua o pensamento de que a Medicina de Família é uma disciplina acadêmica de segunda classe, o que irá atrasar nossa aceitação como iguais entre as especialidades médicas. Se a Medicina de Família deve ser valorizada entre os companheiros em outros ramos da medicina, devemos competir nas áreas em que eles valorizam. Embora, talvez, não gostamos disso, os principais critérios sob os quais toda disciplina acadêmica é medida são: o esforço acadêmico, publicações de pesquisas e diplomas superiores. Para termos nosso lugar como uma disciplina acadêmica, deve-se ter uma cultura de pesquisa vibrante, ou seja, os Médicos de Família precisarão ter os diplomas universitários de Mestrado e Doutorado e publicar pesquisas. Significa que isso precisa ser feito por vocês próprios, e não por outras pessoas.Será difícil criar uma cultura de pesquisa em Medicina de Família? Sim, mas vocês têm grandes vantagens. Vocês já possuem alguns departamentos acadêmicos de Medicina de Família ou Atenção Primária nas universidades. A maioria dos outros países que possui pesquisa em Medicina de Família  teve que vencer esta batalha antes de vocês. Vocês têm uma grande infraestrutura de Medicina de Família, alguns lugares com informatização em tempo real da consulta e um grande poder nos números e indicadores. Acelerar esse processo para alcançar o nível atual de pesquisa internacional é possível. Mas, a pesquisa e a publicação acadêmicas em revistas revisadas por pares possuem suas próprias regras e estrutura. Aqueles que estão interessados em pesquisa devem se encorajar em se juntarem a departamentos acadêmicos, e a SBMFC deveria fundar sociedades e fornecer bolsas de estudo para ajudar médicos a aprenderem suas habilidades em pesquisa. É importante construir parcerias internacionais por meio de intercâmbios de dois modos: médicos de família brasileiros poderiam passar um tempo em outras universidades e estudantes internacionais poderiam ser convidados a visitarem o Brasil para trabalharem com instituições locais.Há algo que deve ser evitado, alguns cuidados que devem ser tomados? Tente não separar a prática acadêmica da Medicina de Família da prática clínica dos médicos de família com seus pacientes. Todos devem ganhar, estar envolvidos, mas nem todos precisam ser líderes de pesquisa ou estarem diretamente envolvidos. Tente garantir que cada médico de família sinta que faça parte da agenda de pesquisa e que tenha orgulho disso. Mas, acima de tudo, garanta que os pesquisadores acadêmicos façam perguntas que realmente importem aos pacientes.Enfim, não se foquem nos problemas, mas observem seu potencial. O Brasil pode ser um líder mundial em Medicina de Família.

Family communication, genetic testing and colonoscopy screening in hereditary non-polyposis colon cancer: a qualitative study

OBJECTIVE

Genetic testing and colonoscopy is recommended for people with a strong history of colorectal cancer (CRC). However, families must communicate so that all members are aware of the risk. The study aimed to explore the factors influencing family communication about genetic risk and colonoscopy among people with a strong family history of CRC who attended a genetic clinic with a view to having a genetic test for hereditary non-polyposis colon cancer (HNPCC).

METHODS

Interviews were held with 30 people with a high familial risk of colon cancer. The transcripts were transcribed verbatim and analysed using Interpretative Phenomenological Analysis.

RESULTS

The family context, family history and perceptions about family duties and responsibilities were important motivators for communication about risk, genetic testing and colonoscopy and influenced participation in genetic testing and screening programmes. Participants reported usually communicating openly with their relatives about genetic risk and colonoscopy. Individuals felt a duty towards affected relatives and to their own children. The influence of the spouse and other relatives, particularly those affected by CRC, was also important. Colonoscopy was perceived to be embarrassing, unpleasant and sometimes painful. While there was sometimes anxiety about the result of the colonoscopy the results were usually reassuring.

CONCLUSIONS

The family context and the experience of the family history can have an impact on communication, genetic testing and screening in HNPCC and this should be explored during counselling. Some individuals might benefit from support in communicating with relatives about genetic risk. Ways of improving the individual's experience of colonoscopy should also be examined.

General Practitioners involvement in enteral tube feeding at home: a qualitative study

Background

Complex medical treatment is moving from hospital to primary care and General Practitioners (GPs) are increasingly asked to undertake new roles. There are now an estimated 19,500 patients being fed in the UK in the community on enteral tube feeding using a variety of different feeding tubes (Percutaneous endoscopic gastrostomy (PEG), Jejunostomy, or nasogastric (NG). The majority of patients are over the age of 65 years when they had artificial feeding initiated and mainly because of dysphagia. The aim of this study was to explore GPs knowledge, attitudes and skills relating to enteral feeding in the community.

Methods

Semi-structured one-to-one interviews with a convenience sample of GPs in Northern Ireland.

Results

Twenty-three GPs in three health boards in Northern Ireland participated in the study. Most found dealing with enteral feeding to be a predominantly negative experience. They had little involvement in patient selection for the procedure and poor or no discharge information. GPs felt inadequately trained, there was poor communication between primary and secondary care and little support. There was anger and frustration among GPs about lack of resources (funding and training), and the perception that primary care was used as a dumping ground.

Conclusion

Moving complex medical treatment from secondary to primary care has major implications for GPs who should be included in the patient selection process, have adequate discharge information about their patients, be adequately resourced and have appropriate support and training.

Cancer genetics: consultants' perceptions of their roles, confidence and satisfaction with knowledge

RATIONALE, AIMS AND OBJECTIVES

Genetic testing for susceptibility for common cancers is widely available. Cancer specialists and specialists in other areas may have a role in identifying and referring patients who would benefit from a consultation with a specialist in genetics. This study aimed to find out which consultants believed that genetic testing was relevant to their practice. We also wanted to determine their views of their roles in relation to genetic testing, their confidence in these roles, and the value of different educational tools.

METHODS

This was a self-completed, cross-sectional, postal survey of all the consultants in Northern Ireland (n=520, response rate=59.3%) identified from the Central Services Agency list.

RESULTS

Three hundred and ninety questionnaires were returned (44%). A total of 28.6% did not complete the questionnaire stating that genetics was not relevant to their practice. Few consultants reported having consultations related to genetic disease, receiving training in genetics and referring to genetics services. There was some dissatisfaction with their current knowledge of genetics and they believed that guidelines and educational tools may be useful. The respondents lacked confidence in undertaking some of their roles. Through their responses to the cancer scenarios, these consultants showed that they would offer appropriate advice and referrals. Many consultants did not know if family history information should be provided to insurance companies.

CONCLUSIONS

Some consultants may require further training to enable them to fulfil their roles in relation to genetics. Tools or guidelines to assist with referral decisions may also be useful. Consultants may need clearer guidance regarding the provision of family history information to insurance companies.

Genetic consultations in primary care: GPs' responses to three scenarios

OBJECTIVE

This study investigated general practitioners' responses to three scenarios in which patients consulted regarding genetic conditions.

DESIGN

Self-completed postal study. Setting. Primary care in Northern Ireland.

SUBJECTS

Questionnaire were distributed to all the GPs in Northern Ireland (n = 1079). A total of 541 GPs participated (50%).

MAIN OUTCOME MEASURES

Responses to three scenarios in which patients consulted regarding their family history and risk of bowel cancer, breast cancer, and cystic fibrosis.

RESULTS

Most GPs correctly identified the patients' risk of bowel cancer, recommended regular colonoscopy, advised lifestyle changes, and did not refer to the genetic clinic. GPs who were qualified for longer were more likely to recommend colonoscopy and less likely to advise lifestyle changes. With the breast cancer patient GPs adopted a cautious approach; most would refer to the genetic and mammography clinics. With the cystic fibrosis example, most correctly identified the patient's risk of carrying the gene, would refer to the genetic clinic, and would encourage the patient to discuss the risk with his partner. In general, doctors were unsure, but would pass on genetic information to insurance companies if requested.

CONCLUSION

The study suggests that, in most cases, general practitioners correctly identify at-risk individuals but there may still be some uncertainty regarding referrals. The results suggest that ways of educating GPs should be explored. Educational interventions should be linked to a greater understanding of factors involved in referral (including the influence of gender and experience). The guidelines provided to GPs in relation to the provision of genetic information to insurance companies may need to be reviewed in some countries.

Are sports medicine journals relevant and applicable to practitioners and athletes?

OBJECTIVE

To examine the evidence base of sports medicine research and assess how relevant and applicable it is to everyday practice.

METHODS

Original research articles, short reports, and case reports published in four major sport and exercise medicine journals were studied and classified according to the main topic of study and type of subjects used.

RESULTS

The most common topic was sports science, and very few studies related to the treatment of injuries and medical conditions. The majority of published articles used healthy subjects sampled from the sedentary population, and few studies have been carried out on injured participants.

CONCLUSIONS

There is a dearth of studies addressing diagnostic and treatment interventions in the sports medicine literature. The evidence base for sports medicine must continue to increase in terms of volume and quality.

Defining the sports medicine specialist in the United Kingdom: a Delphi study

OBJECTIVE

To define the role and responsibilities of the sports medicine specialist using a recognised research technique.

METHODS

A Delphi technique was employed using anonymous postal questionnaires sent to a random sample of 300 members of the British Association of Sport and Exercise Medicine. The questionnaire of 300 putative attributes was developed in a pilot study and the Delphi technique used allowed participants to modify their responses according to the responses of other participants.

RESULTS

There was a 53% response to both rounds of the study with 75.6% of the respondents being male, 39% having a higher qualification in sports medicine, and 45.6% being general practitioners. Some 86.3% strongly agreed that sport and exercise medicine should be a recognised speciality and 90% strongly agreed that it should be available on the National Health Service (NHS). The most important specialist attributes were orthopaedic and soft tissue medicine (83.6% strongly agreed) and emergency medical management (79.7% strongly agreed). More than 75% of respondents did not agree that either research or personal playing experience were relevant.

CONCLUSION

Sports and exercise medicine is an evolving speciality in the United Kingdom. We believe this is the first systematic attempt to define the role and responsibilities of the sports medicine specialist and the findings are of relevance to the future development of a career pathway.

No preventive effect of dietary fiber against colon cancer in the Japanese population: a cross-sectional analysis

The report of Fuchs et al. in 1999 on the protective effects of dietary fiber (DF) against colon carcinogenesis has led many researchers to question the benefits of DF. We analyzed the relationship between dietary intake and mortality from colon cancer in Japan cross-sectionally. Dietary data were taken from the National Nutrition Survey. The standardized mortality ratio (SMR) was calculated using data from "Vital Statistics" and "the Population Census in Japan." Multiple regression analysis (stepwise variable selection method) was performed with the SMR of colon cancer as the objective variable and intake of DF, nutrients, and food groups in 1966 as the explanatory variables. The beta regression coefficient was significantly positive for intakes of fat, protein, and vitamin C and significantly negative for intakes of calcium and vitamin A to the SMR of colon cancer. However, no significant correlation was observed for DF or for any of the various food groups analyzed. In conclusion, our data do not demonstrate any protective effect of DF on colon cancer in subjects with a low fat intake (Japanese subjects), which supports Fuchs' findings in subjects with high fat intake (U.S. subjects).

The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials

BACKGROUND

There are wide variations in the clinical use of cryotherapy, and guidelines continue to be made on an empirical basis.

STUDY DESIGN

Systematic review assessing the evidence base for cryotherapy in the treatment of acute soft-tissue injuries.

METHODS

A computerized literature search, citation tracking, and hand searching were carried out up to April 2002. Eligible studies were randomized-controlled trials describing human subjects recovering from acute soft-tissue injuries and employing a cryotherapy treatment in isolation or in combination with other therapies. Two reviewers independently assessed the validity of included trials using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Twenty-two trials met the inclusion criteria. There was a mean PEDro score of 3.4 out of of 10. There was marginal evidence that ice plus exercise is most effective, after ankle sprain and postsurgery. There was little evidence to suggest that the addition of ice to compression had any significant effect, but this was restricted to treatment of hospital inpatients. Few studies assessed the effectiveness of ice on closed soft-tissue injury, and there was no evidence of an optimal mode or duration of treatment.

CONCLUSION

Many more high-quality trials are needed to provide evidence-based guidelines in the treatment of acute soft-tissue injuries.

Immediate care of school sport injury

School sport is a major cause of injury in the post-primary age group. The importance of primary prevention in sport has been identified; however secondary prevention of school related sport injury has not been described in Ireland. A random sample of 450 schools in Northern Ireland and the Republic of Ireland was studied using a postal questionnaire. Current management of sport injury, with particular interest in the expertise and training of teachers and coaches, was explored. Replies were received from 333 (74%) schools. There was no physical education teacher with up to date first aid training in 37% schools. Immediate care in terms of mechanisms and equipment to deal with injury was available in 35%-81% of schools responding. Correct response ranged from 65%-90% to four scenarios: commonly presenting yet potentially serious management problems. This study demonstrated deficiencies in sport injury care. In addition to concern about current training, a need for basic life support training is highlighted. These findings have implications for the prevention of school sports injuries.

Impact of school sports injury

BACKGROUND

Most injuries in school occur during sport.

OBJECTIVES

To explore the impact of sports injury in supervised school sport.

METHOD

A prospective study of sports injury in children of secondary school age presenting to the accident and emergency department. Each patient was identified on registration, matched with medical records after discharge, and contacted later by telephone to complete a structured interview. Patients were only included if their injury was sustained during supervised school sport.

RESULTS

During the study period, 194 patients aged 11-18 attended the accident and emergency department with an injury, 51% of which occurred during school sport. Injuries occurred most commonly in rugby (43%), followed by physical education and games together (17.5%). Most injuries were x rayed (72%). Just over 12% of pupils lost no time from sport, most (71%) were back to sport within three weeks, and 2.7% were injured for more than eight weeks. Almost a third of parents needed to take time off from work to deal with the injured child.

CONCLUSION

School sports injuries are important. They account for just over half of all injuries in secondary school children. They cause significant disruption to school and sport and have important implications for the wider family.

Life expectancies in the United Kingdom and Japan

BACKGROUND

Compared with other developed countries, the United Kingdom has exhibited less of an increase in life expectancy over the past 30 years.

METHODS

We compared the chronological changes in the age-adjusted mortality rates (AMRs) from all causes or major causes, and in life expectancy in the United Kingdom and Japan between 1970 and 1997.

RESULTS

In both 1970 and 1997 the AMRs for most major causes were higher in the United Kingdom than in Japan; the difference in the AMR between countries was smaller in 1970 than in 1997. The difference in the AMR from all causes between the United Kingdom and Japan in 1997 was mainly due to differences in the AMR for heart diseases. The trend for an increasing difference over time between the United Kingdom and Japan in the AMR from all causes was due to the decreased rate of AMR from heart diseases from 1970 to 1997 in the United Kingdom being lower than those from cerebrovascular diseases in same period in Japan.

CONCLUSIONS

These data suggest that mortality rates could be reduced by a change in focus of the National Health Service toward an emphasis on primary rather than secondary prevention and associated clinical interventions. The greatest priority should be placed on reducing the incidence of heart disease by aggressively improving primary prevention.

Comparison of etiology of right-sided diverticula in Japan with that of left-sided diverticula in the West

BACKGROUND AND AIMS

Colonic diverticula are located predominantly on the right-side in patients in Japan, in contrast to those in Europe and the United States. This study compared the etiology of right-sided diverticula in Japan with that of left-sided diverticula in the West.

METHODS

A literature review was conducted from 1950 to 2001 using Medline and Index Medicus.

RESULTS

Diverticula occur predominantly in the right-sided colon (over 70%) in Japanese patients, and even among Japanese who emigrate, in contrast with the diverticula in Western. Incidence (detection) rates of colon diverticula have rapidly increased in Japan since World War II with the increased dietary fiber intake. The increased detection rate over time is higher in urban areas than in rural areas, and it corresponds to the distribution of dietary fiber intake. Birth cohort analysis suggests that right-sided diverticula is affected more by environmental factors than other types. Furthermore, the significant relationship of right-sided diverticula with intraluminal pressure in Japan is similar to that of left-sided diverticula in the West, and the pathological feature of these diverticula are similar.

CONCLUSION

The etiology of right-sided diverticula in Japan (and perhaps also other Mongolian peoples) is very similar to that of left-sided diverticula in the West. The location may represent a difference in morphology of the large intestine between Mongolians (including Japanese), and Westerners, rather than environmental differences.

Trends in dietary fiber intake in Japan over the last century

BACKGROUND

Insufficient intake of dietary fiber (DF) is currently a major problem in the overall promotion of health in the general population in Japan.

AIM OF THE STUDY

To analyze the time trends in DF intake, including DF density (total DF intake/1,000 kcal), and the ratio of water-insoluble fiber to water-soluble fiber (IS ratio) in Japan.

METHODS

The time trend in DF intake in Japan was calculated from data compiled in the Japanese National Nutrition Survey.

RESULTS

The mean daily DF intake (total DF intake) in 1952 was 20.5 g/day, which rapidly declined to about 70 % of the 1952 level in 1970, after which there was little change to 1998. DF density in 1952 was 9.7 g/1000 kcal, which declined by about 30 % in 1970, and remained at about the same level to 1998. The IS ratio has remained stable over this period. Whereas total DF intake and DF density in Japan are similar to those in Western countries, the IS ratios are higher in Japan. Therefore, the higher incidence of, and mortality from, colon diverticulosis, coronary heart disease, hyperlipidemia, etc., which are all thought to be related to fiber deficiency, in Western countries compared to Japan might be due to the differences in the IS ratio.

CONCLUSIONS

A decline in total DF intake and DF density is predicted for Japan in the future, because these parameters were lower among the younger generation. This may be due to the marked changes in the dietary habits of the younger generation, and is a problematic trend for Japanese health.

Sports medicine and the accident and emergency medicine specialist

BACKGROUND

Sport and exercise related injuries are responsible for about 5% of the workload in the accident and emergency (A&E) department, yet training in sports medicine is not a compulsory part of the curriculum for Higher Specialist Training.

AIM

To determine how A&E medicine consultants and specialist trainees view their role and skill requirements in relation to sports medicine.

METHOD

A modified Delphi study, consisting of two rounds of a postal questionnaire. Participants were invited to rate the importance of statements relating to the role and training of the A&E specialist in relation to sports injuries (six statements) and the need for knowledge and understanding of defined skills of importance in sports medicine (16 statements). VALUE OF RESEARCH: This provides a consensus of opinion on issues in sport and exercise medicine that have educational implications for A&E specialists, and should be considered in the curriculum for Higher Specialist Training. There is also the potential for improving the health care provision of A&E departments, to the exercising and sporting population.

The quality of research in sports journals

OBJECTIVE

To examine the evidence base of sports medicine research.

METHODS

A sample of four major journals that present core research in sport and exercise medicine (British Journal of Sports Medicine, Medicine and Science in Sports and Exercise, Journal of Sports Medicine and Physical Fitness, and Physical Therapy) was examined using assessment criteria taken from the READER method.

RESULTS

Randomised controlled trials comprised 10% or less of all original research articles. Observational/descriptive studies were the most commonly published study design. There was a highly significant difference (p<0.0001) in the contents of the four journals but when they were compared by categorising the better quality methods together (randomised control trial, case-control, and cohort studies), the difference was not significant (p = 0.09).

CONCLUSIONS

The overall pattern of publication type seems remarkably stable over medical journals, indicating that the quality of sports medicine research is comparable to that in other specialities.

Sterilization and disinfection in general practice within university health services

A postal questionnaire on 'sterilization and disinfection' was sent to all 144 nurse members of the British Association of Health Services in Higher Education (BAHSHE). Forty-nine (34%) completed valid questionnaires were returned. Despite the majority of practices performing minor surgical procedures such as cervical cytology (N= 40, 82%), ear syringing (N= 44, 90%) and wound dressing (N= 49, 100%), only 11 (22%) had access to a sterile supply department (SSD), and the definitions of sterilization and disinfection were only identified by 23 (52%) and 14 (32%) of the respondents, respectively. Forty-one (84%) respondents had a benchtop sterilizer (30 had a benchtop sterilizer, 11 a vacuum sterilizer and two had both), although there was considerable confusion on their appropriate use and maintenance. Just over half had written procedures for sterilizer use, no practice changed the sterilizer water on a daily basis as recommended by the Medical Devices Agency (MDA), few kept a sterilizer logbook and even fewer had read the MDA Device Bulletin on benchtop sterilizers. The majority of respondents voiced an interest in attending a workshop on sterilization and disinfection. We conclude that despite the location of the general practices within an academic environment, the concept of infection control is clearly not understood by university health service staff. As the implications of a failure to implement proper infection control procedures are potentially serious, the need for adequate education and training of staff is of critical importance.

Do textbooks agree on their advice on ice?

OBJECTIVE

To study ice therapy guidance in sports medicine textbooks.

DATA SOURCES

A systematic search of a convenience sample of textbooks.

STUDY SELECTION

45 general sports medicine texts were included in the study.

DATA EXTRACTION

The indices and chapter headings of each text were searched using key words "ice," "cryotherapy," "soft tissue injury," "muscle," and "bruise."

DATA SYNTHESIS

In 17 of the textbooks, there was no guidance on the duration, frequency, or length of ice treatment or on the use of barriers between ice and the skin. Advice on treatment duration was given in 28 texts but recommendations differed depending on the particular ice therapy, injury location, or severity. There was considerable variation in the recommended duration and frequency of advised treatments.

CONCLUSION

There was little guidance in the standard textbooks on ice application, and the advice varied greatly. There is a need for evidence-based sport and exercise medicine with a consensus on the appropriate use of ice in acute soft tissue injury.

Sport and exercise medicine: building the foundations of a new discipline

New disciplines emerge as medicine evolves. But, to be recognised as a clinical discipline we must be prepared to measure ourselves against established criteria; there should be consensus on the core content of the discipline and an identifiable body of knowledge to allow us to deal with common clinical problems. At this developmental stage in our evolution we have general agreement on what defines sport and exercise medicine but, as most of our clinical skills developed empirically, research is relatively underdeveloped. The volume and quality of this research does not yet reflect a vibrant research culture. The validity of our clinical method is supported by research evaluating the sensitivity and specificity of clinical tests but the evidence supporting other areas of clinical practice is uncertain. Some aspects of prevention have become integrated into clinical practice without sufficient evidence and, screening has been introduced without critical evaluation. To ensure the future success of our discipline and achieve recognition of its value in the wider medical community, we must nurture an evaluative culture and ensure that clinical practice is built on firm foundations of research evidence.

Hospitals do not inform GPs about medication that should be monitored

BACKGROUND

General practitioners are now asked to prescribe drugs that, due to possible risks and side effects, had previously been prescribed almost exclusively at hospital.

OBJECTIVE

To assess the quality of hospital letters as the key communication between hospitals and GPs.

METHOD

Hospital letters examined using a predetermined protocol.

RESULTS

Of 224 patients identified who were taking drugs that required regular monitoring, 173 were commenced in hospital. Fewer than one in five (30; 17%) hospital letters indicated that there was a risk associated with the drug or that it should be routinely monitored. Monitoring frequency was identified on only 14 occasions and the majority of letters (129; 74. 6%) did not state who was to be responsible for ongoing monitoring (either GP or hospital). Information was slow to arrive at the practice and, in 12% of cases, the hospital letter had not arrived within 14 days of commencement of medication.

CONCLUSION

The information provided in hospital letters is insufficient to allow GPs to put structures in place to monitor drug therapy.