Rectal bleeding in general practice patients

OBJECTIVE

To determine the prevalence of observed rectal bleeding in general practice patients, the health seeking behaviour of those with rectal bleeding, and what rectal bleeding 'means' to patients in terms of perceived health risk.

METHOD

Self administered questionnaire survey of general practice patients aged 50 years and over in northern Tasmania recruited as they visited their general practitioner (GP).

RESULTS

The reported lifetime prevalence of rectal bleeding in our sample was 33% (299 of 903 respondents). It was more common in younger people, becoming less common with increasing age. Many respondents do not examine for bleeding. Only 45% of respondents with rectal bleeding consulted their GP about the most recent bleed. Patients were more likely to consult if they reported blood in the toilet pan and if they sought advice from a family member. There were significant differences between the meaning of bleeding for GP consulters and non consulters. This may have important implications for health education.

CONCLUSION

Colorectal cancer (CRC) is a common problem managed by a combination of screening and case finding. With the high prevalence of rectal bleeding and low consultation rates for this problem there is potential to enhance the effectiveness of early detection of CRC through general practice based public health and education campaigns.

An evaluation of a surveillance system for patients discharged from the acute psychiatry unit in southern Tasmania

OBJECTIVES

The aim is to evaluate the current community follow-up, or health surveillance, system for patients discharged from the acute psychiatry unit into the community in southern Tasmania.

METHOD

We developed a conceptual model which considered community mental health follow-up as analogous to an epidemiological surveillance system. The surveillance system was evaluated by prospectively following recorded contacts between the system and a cohort of 100 patients consecutively discharged from the acute psychiatry unit. Main outcome measures were attendance at follow-up appointments, patient re-engagement and hospital readmission.

RESULTS

There is no formal system of follow-up and no policy relating to non-attenders of follow-up appointments after psychiatric hospitalisation. There is no defined role for private medical practitioners and agencies in the community. Of the 97 patients considered to need community follow-up, 11 patients were lost to follow-up after 3 months, while another 15 remained in the system because of hospital readmission. A further seven patients returned to the system during the following 2 years (six in year 1 and one in year 2) due to readmission. There is appropriate policy about the content and timing of discharge summaries; most summaries were sent promptly.

CONCLUSIONS

After discharge from the acute psychiatric unit, there was inadequate community follow-up of those patients for whom follow-up was considered necessary. Research is needed to determine whether increased patient follow-up is beneficial. Stakeholders should decide whether formal follow-up or health surveillance is necessary.

How do general practitioners manage rectal bleeding?

OBJECTIVE

To determine how general practitioners (GPs) in northern Tasmania manage rectal bleeding in terms of examination, referral, and patient investigation and estimate the value of early diagnosis of colorectal cancer (CRC).

METHOD

Self reported postal questionnaire survey sent to 100 randomly selected GPs in northern Tasmania.

RESULTS

Sixty-eight per cent of GPs responded. The clinical action proposed by GPs varied considerably according to patient age and type of rectal bleeding. The proportion of GPs who would refer a patient to a specialist varied from 15 to 100% depending on the specific scenario. Responses were not consistent with the available consensus guidelines and evidence. Most GPs believed that early diagnosis of CRC through screening and the early detection of rectal bleeding improved outcomes. However, fewer than half the respondents believed that there were clear guidelines about the management of a patient with rectal bleeding, emphasising the need for evidence-based guidelines which are effectively disseminated and clinically evaluated. Rural GPs indicated that distance from specialist investigation and referral centres would influence patient management.

CONCLUSIONS

There is a wide variation in the way GPs manage rectal bleeding and inconsistent knowledge about the existence of guidelines for managing rectal bleeding. Evidence-based education about the management of this common clinical problem, which is effectively disseminated and clinically evaluated, would seem appropriate.

Identifying the active general practice workforce in one division of general practice: the utility of public domain databases

OBJECTIVE

To identify the non-specialist medical practitioner workforce engaged in active general practice in the region served by the Division of General Practice-Northern Tasmania and to determine the usefulness of public domain databases for enumeration of individual non-specialists providing general practice services.

METHODS

A masterlist of the active general practice workforce was compiled by obtaining the names and addresses/postcodes of all non-specialist medical practitioners who were listed in at least one of nine public domain databases and who were confirmed by selected local medical practitioners to be in active general practice in the three months prior to 30 June 1994. This masterlist was used in calculating the sensitivity and positive predictive value (PPV) of each of the nine databases for enumerating non-specialist practitioners in active general practice.

RESULTS

Combining the databases resulted in a list of 475 practitioners, which was refined to 139 practitioners who, by our criteria, were in active general practice. Databases had a range of sensitivities and PPVs, but those with high sensitivity tended to have low PPVs, and vice versa. The most useful database for enumerating these practitioners was the mailing list for Australian Family Physician (sensitivity, 94%; PPV, 0.79).

CONCLUSIONS

When used alone, no single database had both high sensitivity and high positive predictive value for identifying the active general practice workforce. Combining multiple databases may improve precision. Developing methods to identify recent departures from local active practice has the potential to improve the PPV of existing highly sensitive databases.

Attitudes toward sexual contact between general practitioners and their patients

AIMS

To examine attitudes toward sexual contact with patients including seductive and sexually demeaning verbal behaviour.

METHODS

Anonymous questionnaire mailed to a nationwide randomised sample of 217 general practitioners. A response rate of 88% was obtained.

MAIN OUTCOMES MEASURES

Attitudes were appraised through responses about the acceptability of sexual contact with current and former patients. Knowledge of colleagues engaging in sexual contact, seductive or sexually demeaning behaviour was also assessed. Disposition toward reporting colleagues was explored.

RESULTS

Ninety per cent of general practitioners indicated that it was never permissible to have sexual contact with a current patient. Twenty per cent agreed that it was never permissible to have sexual contact with a patient even when treatment had been terminated. While only 4% and 6% respectively knew of a general practitioner who had engaged in seductive or sexually demeaning verbal behaviour, 32% had personally known of a colleague who had engaged in sexual contact with a patient. Participants were divided in their attitudes toward reporting colleagues for sexual misdemeanours with patients.

CONCLUSION

The results have implications for the development of guidelines and the training of general practitioners.

Social and sexual contact between general practitioners and patients in New Zealand: attitudes and prevalence

BACKGROUND

Doctor-patient social and sexual contact is increasingly acknowledged as an issue of importance for the medical profession. However, there is little research concerning general practitioners on this topic.

AIM

A study was undertaken to obtain data on social and sexual contact between general practitioners and their patients.

METHOD

An anonymous questionnaire was mailed to a nationwide randomized sample of 217 general practitioners in New Zealand.

RESULTS

A response rate of 86% was obtained. Dating and sexual contact with patients was considered to be sometimes or usually acceptable to 35% and 10% of general practitioners, respectively. Of respondents, 6% reported having dated a patient, 4% reported having had sexual contact with a patient at some point during their career and 2% reported having engaged in sexual contact with a former patient. General practitioners who had personally known of a colleague who had engaged in sexual contact with a patient were more likely to believe this behaviour had negative consequences than general practitioners who themselves reported having engaged in sexual contact with a patient.

CONCLUSION

The study results have implications for developing behavioural guidelines and educational interventions for general practitioners.

Can one be a good doctor and have a sexual relationship with one's patient?

This paper presents a qualitative exploration of social and sexual contact between general practitioners and their patients. Social contacts have been implicated in the development of sexual relationships between members of the mental health professions and their patients. However, there has been little examination of the implications for general practitioners. Six focus groups were conducted by teleconference with New Zealand general practitioners. Participant anonymity was maintained. Questions focused on issues of social and sexual contact in general practice. Major themes were extracted from the data. A range of definitions of 'patient', 'sexual contact' and 'social contact' were offered by the participants which demonstrated that 'grey areas' existed for them in relation to social and sexual relationships with patients. Mandatory reporting of colleagues for alleged sexual misconduct was not supported, informal mechanisms being preferred. General practitioners need to be aware of potential boundary violations in their practice. These issues are also important to address in the teaching of medical students, continuing medical education, and in the development of appropriate guidelines for general practice.

Attitudes of general practitioners in New Zealand to pharmaceutical representatives

BACKGROUND

Pharmaceutical representatives are a vital component of the marketing of pharmaceutical products and an important source of prescribing information for general practitioners.

AIM

A study was undertaken to explore the attitudes of New Zealand general practitioners to pharmaceutical representatives.

METHOD

A questionnaire survey of 100 general practitioners was undertaken to which 67 general practitioners responded.

RESULTS

The provision of practical prescribing advice by representatives and gifts relevant to medicine were seen as desirable activities by many respondents. However, gifts of value considerably greater than suggested acceptable in recent guidelines for general practitioners were also highly favoured by some practitioners.

CONCLUSION

Current ethical guidelines setting out the relationship between pharmaceutical representatives and medical practitioners are inadequate and should be based on the need for the general practitioner to become an unbiased promoter of patient health.

Reliability of consumer assessment of communication skills in a postgraduate family practice examination

Examinations of competence which may affect career prospects require measures which are of high reliability, and which can be demonstrated to be valid. In a New Zealand summative postgraduate examination of competence in family practice the doctor-patient communication skills of candidates were assessed by nonmedically trained nominees of community organizations. The assessments were based on direct observation of the candidates' encounters with simulated patients. To estimate the reliability of the consumer examiner, after the examination the examiners re-scored a random selection of video-taped candidate encounters. The test-retest correlations of consumer scoring were demonstrated to be at a level consistent with adequate examination reliability (confidence interval 0.59-0.98). Consumers may be valuable as a resource for the training and assessment of the communication skills of medical practitioners.

The prevalence of bad headaches including migraine in a multiethnic community

AIM

Overall and ethnic specific prevalences of bad headache including migraine, for the New Zealand population, are unknown. A study was carried out in South Auckland to estimate prevalence and to explore ethnic differences in doctor attendance for the diagnosis and management of bad headaches.

METHODS

Telephone interviews were administered to respondents selected by random digit dialing of households.

RESULTS

40.6% of the respondents suffered from bad headaches. 54.5% of these had the characteristics of bad headache with features symptomatic of migraine. Trends in the prevalence of bad headache with features symptomatic of common migraine, peaked between the ages of 30-49 years in both men and women. A difference was seen in the prevalence of bad headache with aura, with or without common migraine features, when ethnic groups and gender were examined. The difference in prevalence of aura was particularly noticeable between Pacific Island men and women. Although there was no difference between ethnic groups in doctor attendance, headaches were more likely to be labelled as migraine in Europeans than in the Polynesian groups.

CONCLUSION

Ways in which people perceive and report their bad headaches have a bearing on management by general practitioners. Although no overall ethnic predominance was seen, there was a gender difference amongst Pacific Island people in reporting bad headaches with aura. The labelling process, and thus the management by general practitioners does demonstrate likely ethnic differences.

The effect of a warning about putative adverse events on drug prescribing in general practice

Many studies have looked at factors influencing doctors' prescribing. None have done this during a time when prescribers have been just made aware of potential serious adverse events that might be caused by a commonly prescribed medication. A controversy over the safety of Fenoterol (Boehringer Ingelheim) in 1989 provided an opportunity for such a study in general practice. Practitioners were exposed to conflicting and changing views from authoritative sources, patient concerns raised by the coverage of the issue in the news media, and a need to maintain patients on effective therapy. The study demonstrated that the majority of general practitioners would act promptly and conservatively when faced with uncertainty about the safety of the medication they prescribed.

Subcutaneous sumatriptan in acute treatment of migraine: a multicentre New Zealand trial

AIM

To assess the effectiveness of subcutaneous sumatriptan (4 mg) in the acute treatment of migraine.

METHODS

A randomised, double-blind, placebo controlled study was conducted in four New Zealand centres. On developing an acute attack of migraine, patients attended a centre where they were given either sumatriptan 4 mg or placebo by subcutaneous injection. Headache severity and clinical disability were measured over a 2 hour period.

RESULTS

Fifty-one patients, aged 19-58 years with common or classical migraine were treated. Twenty-eight patients received 4 mg sumatriptan and 23 patients received placebo. Pretreatment headache severity was graded moderate in 76% and severe in 24%. Thirty-two percent of patients were sufficiently disabled to require bed rest and a further 48% had severe impairment of working ability. Sumatriptan was significantly more effective than placebo in relieving or reducing headache severity after 30 minutes. Sixty-four percent improved on sumatriptan compared to 27% on placebo. Functional disability, nausea, vomiting and photophobia were also greatly reduced. Adverse effects occurred in 17% of patients receiving placebo, and 82% receiving sumatriptan, the commonest being injection site reactions.

CONCLUSION

Subcutaneous sumatriptan 4 mg is an effective and well-tolerated acute treatment in adult patients with moderate to severe common or classical migraine. The efficacy rate of 64% is lower than that found in recent controlled studies using a higher dose.

Consumer assessment of interview skills in a family practice certification examination

BACKGROUND

In New Zealand, the family practice certification examination includes an assessment that uses simulated patients. In 1990, for the first time, consumers participated in evaluating the performance of examinees in the simulated-patient section of the examination.

METHODS

The consumer examiners and medically trained examiners observed the candidates during interactions with simulated patients. The consumers, medical examiners, and simulated patients independently scored the candidates' performances. One hundred and nine examination candidates participated in two simulations each, and the scoring behavior of each rater was compared.

RESULTS

Consumer and medical examiners showed significant differences in their scoring behaviors, disagreeing on whether the candidate should pass or fail in 7.8% of interviews. In comparing the scores given by consumers, medical examiners, and the simulated patients, low inter-observer correlations were noted.

CONCLUSION

Medical personnel, consumer observers, and simulated patients all provide a different perspective on the communication skills of physicians.

Management options for elderly ill patients who present in the weekend

An informal impression that there was a shortage of facilities for elderly patients who presented, with a routine illness, to a weekend duty doctor was studied by interviewing duty doctors and providers. The duty doctors stated that the major problems were the deficit in support from friends, relatives and neighbours and the lack of remuneration for the duty doctors. The doctors said that the main supports, paradoxically were friends, relatives and neighbours, and the acute medical ward. The recommended facilities included an urgent district nurse and a short-stay, assessment unit. Among providers only the medical ward and the private laboratories were willingly offering more than a minimal service.

Case specificity of performance with simulated patients

In the part one examination for membership of the Royal New Zealand College of General Practitioners (MRNZCGP) patient simulations are used to assess candidates' communication and management skills. In the 1989 examination two different scoring proformas were used to determine if the scoring method contributed significantly to the degree of case specificity that has been observed. The results of this study demonstrate significant differences in performance between cases, while interexaminer rating of performance within cases showed no significant difference. Such results indicate that the between cases differences in measured performance are indicative of real differences and are not reducible by manipulation of the scoring method.

An assessment of a postgraduate examination of competence in general practice: Part 2: Validity

The 1987 part one examination of the Royal New Zealand College of General Practitioners was evaluated. This assessment of competence assumes that the results of the assessment truly reflect the competence of the candidate in real life. The degree to which the assessment achieves this is a measure of its fairness and accuracy. This report discusses the methodology and results of the evaluation of the validity of the part one examination.

An assessment of a postgraduate examination of competence in general practice: Part 1--Reliability

The 1987 part one examination of the Royal New Zealand College of General Practitioners was subjected to an evaluation. The format of the examination and the scope of the review is described. This paper describes the assessment of the reliability of components of the examination. Simulations showed acceptable reliability, however the reliability of the written paper was less satisfactory. The ways in which such reliability may be enhanced are described.

What future for solo general practice?

Marketing theory predicts that solo general practitioners are disadvantaged financially when compared to doctors practising in groups. This is supported by a 1985 random survey of Auckland general practitioners. This shows solo practitioners to have had a significantly lower net and gross income than did group practitioners in the time period 1981-82 to 1984-85. The difference is due to the combined effect of solo practitioners charging marginally lower fees, and seeing less patients weekly than did group practitioners. These results are discussed from a marketing perspective.

Prepaid health care in general practice: acceptability and effect on utilisation

A prepaid child health scheme was offered to the patients of a rural practice in January 1988. The acceptability of the scheme was monitored in terms of entry and exit rates. The effectiveness of the scheme was measured in terms of its effect on the rates of consultation for acute illness and prevention, and the cost of the scheme to the practice and to patients was assessed. The scheme reduced the annual cost of general practice services for those children enrolled in the scheme by $73.68. There was no evidence that the scheme improved access for the low users of child health care. The scheme was a financial loss for the practice.

Oral acyclovir in the treatment of herpes zoster in general practice

A double-blind, randomised trial evaluated the efficacy of oral acyclovir, 800 mg 5 times daily for 7 days, in acute herpes zoster and postherpetic neuralgia. Forty patients aged 16 years or over, presenting to their general practitioners within 3 days of rash onset, received acyclovir, while 43 patients received placebo. Acyclovir reduced the extent and duration of the rash, the spread of the rash to adjacent dermatomes and the incidence of disseminated lesions. It shortened the period of new lesion formation and reduced the incidence of ulceration. The weekly prevalence of pain was reduced on acyclovir by the fourth week, with a reduction in the monthly prevalence of chronic pain in the second and third months and a reduction in associated local neurological symptoms between months 3-6. Total analgesic use in the first 4 weeks was reduced by acyclovir, but during follow up there was no difference in the prevalence of analgesic use between groups. There were slightly fewer medical events on acyclovir in the second week, but the frequency was the same in each group for the rest of the 6 months. Biochemical and haematological tests showed no adverse effects of treatment.

The variability of general practitioners' fees

A random sample of the general practitioners in the Auckland urban area was surveyed in 1985. Data on fee levels, costs and workload was collected. Analysis of this data shows the variability of doctors' fees is not easily explained in terms of indicators of quality of practice, workload, practice structure or the location of the practice.

Does the computerisation of a general practice increase doctor's fees?

While few Auckland general practitioners had inpractice computers before 1981-2, many installed computers after 1981-2. In order to assess some of the determinants of the computerisation of practices and the outcomes of computerisation, data was collected on a random sample of Auckland urban area general practitioners for the financial years 1981-2 and 1984-5. The characteristics of those installing computers and the effect of computerisation on practice costs, fees and workloads was explored. No significant difference in fees was seen between computerised and noncomputerised general practitioners, but differences were observed in practice costs and practice workstyles. The cost of the purchase of a computer by a practice does not appear to be directly passed on to the consumer in higher patient fees.

Workloads in Auckland general practice 1981/82 to 1984/85

A random sample of Auckland general practitioners was surveyed in 1985. Data describing their workload, practice style and practice finances for the years 1981/82 and 1984/85 was collected and analysed. The trends in general practice during this time were studied, and the results compared to national data from various sources and to data from the Department of Health for the years 1984/85 and 1986/87. The workload of practitioners has appeared to remain static despite decreasing patient: doctor ratios. The real income of general practitioners is falling.