Continuity of care and trust in one's physician: evidence from primary care in the United States and the United Kingdom

BACKGROUND AND OBJECTIVES

Patients' trust in their physician to act in their best interest contributes to the effectiveness of medical care and may be related to the structure of the health care system. This study explored the relationship between continuity of care and trust in one's physician, particularly in terms of differences between the United States and the United Kingdom (UK).

METHODS

We conducted a cross-sectional survey of adult patients (n = 418 in the United States and n = 650 in the UK) who presented in outpatient primary care settings in the United States (Charleston, SC, and Lexington, Ky) and in the UK (Leicester and Exeter).

RESULTS

A high percentage of both groups of patients reported having a usual place of care and doctor. A total of 69.8% of UK patients and 8.0% of US patients have had their regular physician for > or = 6 years. US patients (92.4%) are more likely than UK patients (70.8%) to value continuity with a doctor. Both groups had high levels of trust in their regular doctor. Trust was related to one continuity measure (length of time for the relationship) but not to another (usual provider continuity index more than 1 year). In a multivariate model, country of residence had no independent relationship with trust, but continuity of care was significantly related.

CONCLUSIONS

Higher continuity is associated with a higher level of trust between a patient and a physician. Efforts to improve the relationship between patients and physicians may improve the quality and outcomes of care.

Dietary advice in British General Practice

Diet is a major determinant of health. It is now clear that at least as far as reducing the content of fat and sugar and increasing the content of fruit and vegetables is concerned, considerable gains can reasonably be expected if populations can be persuaded to alter their life style. In Western societies family medicine/general practice forms the front line of the Health Service and in the United Kingdom the contact rate between the population and primary care doctors now averages five encounters a year and relationships last an average of eleven years. This gives primary care, particularly in the form of multiprofessional teams of doctors and nurses, a substantial opportunity to explain the principles of healthy eating. Primary care worldwide is increasingly taking on responsibility for advising on life style, for example with smoking, immunisation, family planning etc. The provision of dietary advice in primary care is already common in the management of many chronic diseases, like hypertension and hyperlipidaemia, where over 90% of patients are exclusively managed in family medicine. It is probable that the provision of dietary advice will in future extend beyond diseased patients and will play a much higher role in relation to healthy patients.

Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care

OBJECTIVES

To examine the effect of patients' causal attributions of common somatic symptoms on recognition by general practitioners of cases of depression and anxiety and to test the hypothesis that normalising attributions make recognition less likely.

DESIGN

Cross sectional survey.

SETTING

One general practice of eight doctors in Bristol.

SUBJECTS

305 general practice attenders.

MAIN OUTCOME MEASURE

The rate of detection by general practitioners of cases of depression and anxiety as defined by the general health questionnaire.

RESULTS

Consecutive attenders completed the general health questionnaire and the symptom interpretation questionnaire, which scores style of symptom attribution along the dimensions of psychologising, somatising, and normalising. General practitioners detected depression or anxiety in 56 (36%; 95% confidence interval 28% to 44%) of the 157 patients who scored highly on the general health questionnaire. Subjects with a normalising attributional style were less likely to be detected as cases; doctors did not make any psychological diagnosis in 46 (85%; 73% to 93%) of 54 patients who had high questionnaire and high normalising scores. Those with a psychologising style were more likely to be detected; doctors did not detect 21 (38%; 25% to 52%) of 55 patients who had high questionnaire and high psychologising scores. The somatisation scale was not associated with low detection rates. This pattern of results persisted after adjustment for age, sex, general health questionnaire score, and general practitioner.

CONCLUSIONS

Normalising attributions minimise symptoms and are non-pathological in character. The normalising attributional style is predominant in general practice attenders and is an important cause of low rates of detection of depression and anxiety.

The discipline and literature of general practice

In response to a review recently carried out by the Royal College of General Practitioners, the British Journal of General Practice is soon to be issued in a new and expanded format. While continuing to develop its primary role as a leading scientific journal of record, the journal will accommodate a monthly selection of integrated news, information and features. The editorial board welcomes the opportunities provided by these changes, but wishes to emphasize the continuing importance of general practice as a scientific discipline in its own right and to reaffirm its commitment to the publication of high-quality, peer-reviewed original research papers. It is hoped that the newlook journal will have a wide appeal. But, as the first-and still the foremost-journal of general practice in the world, it will continue to be a journal of record serving both its authors and the academic community worldwide.

Spiral Processes of Becoming: Women's Experiences Within the Context of Doctoral Education

The purpose of this qualitative study was to explore women's experiences of being a doctoral student. We report on interviews from 11 women, 8 of whom were Caucasian and 3 of whom were African-American. Participants in the study described their experiences as doctoral students in ways that reflected a spiraling process of becoming. This process included experiences of confidence, support and self-discovery. This research has implications for nursing faculty and women engaged in doctoral education as well as for women who anticipate entering doctoral programs.

Heterosexism in Nursing Education

If we are to take seriously the challenge of teaching nursing students skills in critical thinking, as nurse educators we must examine the most difficult issues facing society and nurses. Heterosexism and the resulting homophobia are such issues. This article provides an introduction to the concepts of heterosexism and homophobia and describes how they intersect and are revealed in nursing education. The consequences of heterosexism and homophobia are illustrated using examples from our experiences as lesbian and heterosexual nurse educators. We conclude with an action plan for undermining heterosexism and homophobia.

A historical decline of educational perioperative clinical experiences

This historical study identifies sociocultural and economic influences that have contributed to the decline of educational perioperative clinical experiences. Three themes were identified: the professional versus the technical role of OR nurses debate, the nurse generalist versus the nurse specialist debate, and the relative lack of control that nursing has over its own destiny. Recommendations to reverse this trend include increasing the visibility of perioperative nurses to the public and within the profession of nursing, structuring efforts to capitalize on the changes occurring in nursing education, and promoting a stronger affiliation between nursing academia and practice settings.

Patients who do not receive continuity of care from their general practitioner--are they a vulnerable group?

BACKGROUND

Continuity of care is much valued by general practitioners but little is known about those patients who do not receive continuity of care.

AIM

This study set out to identify and describe a group of patients who did not receive continuity of care from the general practitioner with whom they were personally registered.

METHOD

A total of 110 patients (71 female and 39 male) were identified, who did not receive continuity of care, defined as four consecutive face to face consultations which did not take place with the doctor with whom they were registered. This group was compared with an age and sex matched control group who did receive continuity of care, using general practice records, for demographic characteristics, morbidity, relationship problems, number of 'difficult' consultations, failure to attend appointments, and use of an accident and emergency department and of open access clinics.

RESULTS

Patients in the study group were more likely to be under the age of 65 years than all patients on the doctor's list. Study patients were more likely than control patients to be in social class 4 or 5 living in a council house. Patients in the study group were more likely than controls to be depressed. Women patients in the study group were more likely to suffer from vaginal discharge. Men patients in the study group were more likely to complain of non-cardiac chest pain. The study group had more marital problems, parent-child relationship problems, and problems involving violence in the family, as well as other relationship problems. Relationship problems included the relationship with the doctor, since a third of all the consultations in the study group were recorded as 'difficult', compared with 3% in the control group. The study group patients were more likely than controls not to attend appointments which they had made, to use the accident and emergency department repeatedly, and to have used other open access clinics.

CONCLUSION

Lack of continuity of care is associated with some additional morbidity, an increased number of relationship problems, 'difficult' consultations, and non-attendances, and an increase in the use of open access clinics. The characteristics of this group of patients represent a syndrome which merits further study.

Use of warfarin in non-rheumatic atrial fibrillation: a commentary from general practice

Seven randomized trials published in the last six years have shown that warfarin reduces the risk of ischaemic strokes and death in patients with atrial fibrillation. The annual rates of major bleeding episodes in all these trials were low and, as a result, doctors in primary and secondary care are being encouraged to consider using warfarin for patients with atrial fibrillation unless there are obvious contraindications. However, the populations used in these studies were highly selected and rigorously monitored throughout the trial period to minimize the risk of bleeding in a way which probably could not be expected in routine primary care. Although the rates of major bleeding episodes were uniformly low, the rates of minor bleeding episodes were much higher and these could impact substantially on patients' views of the treatment and on the workload of the primary care team. Evidence is now at hand which allows the stratification of risk in patients with atrial fibrillation which should enable those who are at greatest risk to be considered for this form of treatment. Patients may develop risk factors over time which could render them unsuitable for continuation of warfarin therapy. The general practitioner is centrally placed to make the decision about initiating or continuing treatment or indeed stopping it. Several models for decision making in warfarin treatment from primary and secondary care are proposed.

Careers in academic general practice: problems, constraints, and opportunities

Changing priorities in the NHS have underlined the crucial importance of academic general practice in providing quality training and research to underpin developments in general practice. Unfortunately, several problems and constraints mean that the full potential of general practitioners to make a contribution to teaching and research has not been realised. These issues are examined and recommendations for improvements are made. Obstacles to career development for academics in general practice should be removed. The funding of academic general practice should be the same as for other medical disciplines. Vocational training for general practice should be extended to include research and audit methods, particularly for doctors interested in an academic career. Above all, the long term objective should be to integrate undergraduate and post-graduate general practice to increase the overall effectiveness of teaching and research and hence the quality of service general practice.

Health in Old Age

The elderly are the fastest growing section of the population and have a greater volume of medical needs than any other in society. The challenge of providing care for them is therefore of considerable interest to the health professions and to governments.

The academic base for general practice: the case for change

University departments of general practice and the postgraduate education system for general practice have developed separately over the past 30 years. This separation is now impeding the academic development of the discipline and causes difficulties with recruitment and career progression. These problems could be eased by the creation of integrated departments. This would establish a critical mass for research and educational development, allow human and other resources to be used more flexibly and effectively, and provide a strong base for undergraduate education, vocational training, higher professional training, and continuing education. It could encourage collaborative ventures with other disciplines and also lead to higher standards of patient care.

Role Modeling: A Method for Teaching Caring in Nursing Education

This study focused on the belief of some nurse educators that caring cannot be taught directly and is learned by students from faculty role-modeling and faculty student interactions in clinical, classroom, and other situations. The purpose was to further explore these beliefs to determine if nursing students perceived that they learn caring behaviors through observing role-modeling by faculty, as well as to explore students' perceptions of other means by which they learn about caring. Since opportunities for faculty to model nurse caring behaviors in the clinical setting are varied and serendipitous, a videotaped scenario simulating a patient care situation, using professional actors, was created and shown to nursing students. The videotape was seen by 137 BSN and ADN students who then recorded their perceptions on a two-page open-ended questionnaire developed by the researchers. Results from this study indicated that students do learn about caring from faculty role-modeling, as well as from health care staff they encounter, often in a very paradoxical way. Many interesting and unintended results also occurred through the use of this research approach.