Complementary medicine use among people living with HIV/AIDS in Victoria, Australia: practices, attitudes and perceptions

There is limited evidence suggesting the underlying reasons for the use of complementary and alternative medicines (CAMs) by people with HIV/AIDS, or individual attitudes and beliefs about the use of CAMs. Using focus groups and a survey with 151 individuals attending the HIV Clinics at The Alfred Hospital, Melbourne, we aimed to provide insights into factors that influence the use of CAMs among people living with HIV/AIDS. Roughly half (49%) of the participants had used CAMs to manage their HIV/AIDs. Users of CAMs utilized a wide range of treatments in managing their condition, but costs of the CAMs meant that users were not necessarily able to use them as much as they might have liked. Use of CAMs was based on a desire to find something beneficial rather than on being dissatisfied with conventional medicine. Further research is needed into (a) the effects of CAMs and (b) the enhancement of communication and collaboration between patients, doctors and complementary medicine practitioners.

Type 2 diabetes continuing medical education for general practitioners: what works? A systematic review

AIMS

To perform a systematic review of studies that have assessed the effectiveness of interventions designed to improve healthcare professionals' care of patients with diabetes and to assess the effects of educational interventions targeted at general practitioners' diabetes management.

METHODS

A computer search was conducted using the Cochrane Library, PubMed, Ovid MEDLINE, Scopus, EMBASE, Informit, Google scholar and ERIC from the earliest date of each database up until 2013. A supplementary review of reference lists from each article obtained was also carried out. Measured changes in general practitioners' satisfaction, knowledge, practice behaviours and patient outcomes were recorded.

RESULTS

Thirteen out of 1255 studies met the eligibility criteria, but none was specifically conducted in rural or remote areas. Ten studies were randomized trials. Fewer than half of the studies (5/13, 38.5%) reported a significant improvement in at least one of the following outcome categories: satisfaction with the programme, knowledge and practice behaviour. There was little evidence of the impact of general practitioner educational interventions on patient outcomes. Of the five studies that examined patient outcomes, only one reported a positive impact: a reduction in patient HbA1c levels.

CONCLUSIONS

Few studies examined the effectiveness of general practitioner Type 2 diabetes education in improving general practitioner satisfaction, knowledge, practices and/or patient outcomes. Evidence to support the effectiveness of education is partial and weak. To determine effective strategies for general practitioner education related to Type 2 diabetes, further well designed studies, accompanied by valid and reliable evaluation methods, are needed.

Management of type 2 diabetes: Australian rural and remote general practitioners' knowledge, attitudes, and practices

BACKGROUND

The gap between current and evidence-based best practice management of chronic diseases in Australian general practice is widely acknowledged. This study seeks to explore some of the factors underpinning this gap in relation to type 2 diabetes management in rural and remote general practice settings.

METHODS

A cross-sectional survey of 854 general practitioners (GPs) currently practising in rural and remote Australian communities with populations between 10 000 and 30 000.

RESULTS

A total of 209 completed surveys were returned for an overall response rate of 24.5%. GPs reported on their education preferences, knowledge, attitudes and practices relating to type 2 diabetes. GPs indicated a strong preference for face-to-face education options such as conferences and seminars (75.2%). Whilst structured online education activities were less utilised than face-to-face options, GPs reported a desire to undertake more of their education online in the future. Survey findings revealed gaps in GP knowledge around the medical management of diabetes. The most prevalent self-reported learning needs related to pharmacological management (n=87, (45.5%)). Correspondingly, in the GP knowledge test, GPs received the lowest mean score for the section on medical management. GPs also reported having the least confidence in providing effective insulin treatment, compared with other aspects of diabetes management. GPs identified an array of difficulties encountered in providing best practice diabetes care, which were classified into three main categories: GP clinical management problems, patient-related challenges and health system-related difficulties.

CONCLUSIONS

This national survey highlights a number of barriers to GP provision of best practice diabetes care in rural and remote Australia. Despite the availability of education programs and clinical practice guidelines, GPs revealed deficits in knowledge and confidence in type 2 diabetes management. GPs identified numerous challenges to effective patient care, some but not all of which can be addressed through continuing professional development. GP preferences for continuing medical education and information may inform future activities, to specifically address the needs of GPs in rural and remote locations.

An examination of Australian general practitioners' knowledge, attitudes and practices in relation to sleep disorders

BACKGROUND

Sleep disorders represent an under-recognised public health problem and are reported to be under-diagnosed in general practices.

AIMS

To examine general practitioners' (GPs) attitude, knowledge and practice behaviour and identify barriers to detection, diagnosis and treatment of sleep disorders encountered in the Australian primary care setting.

METHOD

Using mixed methods, quantitative data from the Dartmouth Sleep Knowledge Questionnaire (DSKQ) were analysed using MS Excel 2007. Qualitative data were obtained from one focus group and eight interviews. Data were thematically analysed.

RESULTS

15 GPs participated; seven in a focus group and eight in interviews. Scores from DSKQ suggest gaps in GPs' knowledge. Qualitative analysis revealed that patients frequently presented with sleep disorders underpinned by mental health disorders. GPs agreed that prescribing pharmacological interventions was undesirable and behavioural interventions were preferred. Barriers included limited training for GPs, lack of resources, patient expectations and willingness to engage in lifestyle changes, and consultation time constraints.

DISCUSSION

Greater flexibility to investigate sleep related problems within the standard consultation and improved access to educational activities could assist GPs. Patient factors, such as adherence to management strategies, are paramount to successful management of sleep disorders; however, these obstacles to clinical practice may be difficult to overcome.

CONCLUSION

Providing education for GPs about sleep disorders, greater flexibility within consultations may improve patient care and patient engagement in management strategies may assist, yet a critical success factor in disease management includes patient engagement in management strategies.

Management of Chronic Heart Failure in Primary Care: What Evidence do we have for Heart Failure with Preserved Systolic Function?

Chronic Heart Failure (CHF) is a debilitating illness commonly encountered in primary care. Its prevalence in developing countries is rising as a result of an ageing population, and an escalating epidemic of hypertension, type 2 diabetes and coronary heart disease. CHF can be specifically diagnosed as Heart Failure with Reduced Systolic Function (HF-RSF) or Heart Failure with Preserved Systolic Function (HF-PSF). This paper illustrates a common presentation of HF-PSF in primary care; and critically appraises the evidence in support of its diagnosis, prognosis and management. Regardless of the specific diagnosis, long term management of CHF is intricate as it involves a complex interplay between medical, psychosocial, and behavioural factors. Hence, there is a pressing need for a multidisciplinary team management of CHF in primary care, and this usually takes place within the broader context of an integrated chronic disease management programme. Primary care physicians are ideally suited to lead multidisciplinary teams to ensure better co-ordination, continuity and quality of care is delivered for patients with chronic conditions across time and settings. Given the rising epidemic of cardiovascular risk factors in the Malaysian population, preventive strategies at the primary care level are likely to offer the greatest promise for reducing the growing burden of CHF.

Training program in the field of addiction medicine - an experience of learning while abroad

This paper illustrates the training program in the field of Addiction Medicine designed for primary care doctors by the Department of General Practice, School of Primary Care at Monash University in Melbourne. The nine month program was based around coursework, field visits and clinical observations. There were five modules that were completed and passed, twenty six Continuous Medical Education sessions attended, twenty nine field visits on Drug & Alcohol services, forty seven clinical visits and a total of three hundred and sixty clinical observations made. The comprehensive training program has benefited the first author in several ways to improve the Drugs & Alcohol services in Malaysia.

Physician Attitudes, Beliefs and Barriers towards the Management and Treatment of Adult Obesity: A Literature Review

The objective of this study was to review physician attitudes, beliefs, knowledge and barriers towards adult patients who are overweight and obese. Electronic searches were carried out on PubMed, Medline and Embase up to July 2007. The search terms were built around 'obesity', 'physicians', and 'attitudes'. Only peer-reviewed full papers in English were included. Each paper had to directly investigate the attitudes, beliefs or barriers towards overweight and/or obese adults by physicians only. Forty-three studies met the inclusion criteria. Studies meeting inclusion criteria were reviewed by two authors. Evidence was fairly consistent across studies indicating that, in general, physicians feel qualified and well-equipped to manage and treat overweight and obese patients, yet overall do not feel successful. Knowledge about obesity is poor, with a lack of understanding of minimum BMI for obesity and the use of waist circumferences as a measure of obesity evident. There also appears to be a lack of knowledge about the treatment options available when treating obesity and their effectiveness. Furthermore, negative attitudes towards overweight and obese individuals are present, with many physicians categorising overweight and obese individuals as lazy, and that a key barrier in successfully treating obesity being lack of patient compliance and motivation. The study indicates additional training is necessary to educate physicians in regard to treatment options for obesity and to address the persistent negative attitudes towards obese patients.

Self-monitoring of blood glucose among diabetes patients attending government health clinics

The aims of this study were (i) to determine the prevalence of self-monitoring of blood glucose (SMBG) among Type 2 diabetes patients attending government health clinics and (ii) to ascertain the factors influencing SMBG. Five hundred and fifty-six Type 2 diabetes patients from two government health clinics in Selangor and Negeri Sembilan were interviewed using a structured questionnaire. The total subjects of the study were 556 patients. Eighty-five patients (15.3%) of patients; performed SMBG. However, 170 subjects were included in the statistical analysis, 85 patients who were not self-monitoring were randomly selected and was compared with 85 patients who were self-monitoring. Among those who performed SMBG, the majority (83.5%) monitored less than once per day and only 16.5% monitored at least once a day. One-third of patients adjusted their medications based on their SMBG results. The higher patient's level of education (p= 0.024, CI 1.29 - 35.3); the higher total family income (p= 0.041, CI 1.26 - 4.79); the longer duration of diabetes (p<0.01, CI 2.22 - 7.29); and treatment regime which includes insulin (p< 0.001, CI 2.05 -9.24) were significant predictors of SMBG practice. Although SMBG is recognised to be useful and effective in achieving diabetes control, this study has found that only a minority of patients with diabetes performed SMBG. Hence healthcare personnel must increase awareness on the importance of SMBG and strongly promote the practice among diabetic patients.

Impact of Master of Family Medicine degree by distance learning on general practitioners' career options

INTRODUCTION

This study investigated the impact of a Master of Family Medicine degree (via distance education) on GPs' career options, and in particular, whether they were more likely to adopt university positions after the course. A secondary aim was to examine whether those who undertook a research project as part of their Masters took up different career options than Masters graduates who undertook a more clinically orientated course.

METHODS

A questionnaire survey was posted to all 192 graduates of the Master of Family Medicine degree. Approximately one fifth of these resided overseas, with the majority in Hong Kong.

RESULTS

The response rate was 68%. Graduates stated that they benefited from the course, particularly in the areas of clinical knowledge and improvement in 'academic' skills. Changes in careers, with increases in non-clinical appointments, did occur after the course for both the Research and Clinical Masters graduates.

DISCUSSION

Responses to the survey indicated that graduates benefited in completing the course and changes in their career direction following graduation. However, whether the Masters course provided new skills to enable career change, or the GPs were in the process of change anyway, cannot be determined with certainty. Further studies, including interviews, are required to establish the impact of a distance education higher degree.

CONCLUSION

The research output of general practice remains behind that of its specialist colleagues. Higher degrees for GPs might encourage them to undertake more academic pursuits, but the precise relationship still remains uncertain.

Part II. General practitioner-specialist referral process

This is the second of two articles that explore the general practitioner (GP)-specialist relationship. In this article, we explore the nature of the referral process, beginning with referrals frequently made by GPs in Australia and reasons for referral to specialists. In Australia, GPs commonly refer patients to specialists, particularly orthopaedic surgeons, ophthalmologists, surgeons and gynaecologists for a variety of reasons, including diagnosis or investigation, treatment and reassurance (reassurance for themselves as well as reassurance for the patient). GPs will choose a specialist after considering a variety of factors, such as the specialist's medical skill, their previous experience with the specialist, the quality of communication between them, office location and patient preferences. The referral is generally made by telephone or by letter, the latter of which is known to vary significantly in content and quality. The specialist, GP and patient expectations of the referral and the consultation process are also described. Specialists expect the GP to provide information about the problem to be addressed and adequate patient history, GPs expect a clear response regarding diagnosis and management as well as justification for the course of action, and patients expect clear communication and explanation of the diagnosis, treatment and follow-up requirements. When these expectations remain unmet, GPs, specialists and patients end up dissatisfied with the referral process.

Part I. General practitioner-specialist relationship

This article is the first of a two-part series that seeks to explore the relationship and interaction between general practitioners (GPs) and medical specialists. A historical account of the medical profession is given, beginning from the tripartite division (i.e. the physicians, surgeons or barbers and the apothecaries), the Apothecaries Act of 1815, and the Medical Act of 1858. An account is also given of factors that exacerbated the division and friction between GPs and specialists, and how general practice developed in Australia. The role of the GP is stated as the provision of primary care, preventive care, patient-centred care, continuing care, comprehensive care, and community-based care to individuals and their families. The role of the specialists on the other hand is that of a consultant to advise GPs who carry on the management after the patient leaves the specialist. The dynamics of the GP-specialist relationship are discussed in relation to power, interdependence, morale, public image, education and training, and support from the Colleges, and we conclude by discussing the importance of collaboration between professions.

Community attitudes toward living arrangements between the elderly and their adult children in Hong Kong

For hundreds of years, Chinese societies have been living in extended family settings. However, the import of Western cultures and values are challenging the traditional Chinese practices in Hong Kong. This study assesses the community attitudes to living arrangements between elderly and their adult children in Hong Kong and to identify the factors which influence these attitudes. A random sample of 888 adult Hong Kong residents were telephone-interviewed. They were asked about their attitudes to living arrangements when they turned 60, if disabled and non-disabled. The relationship between these attitudes and the social and demographic characteristics of the respondents was also analyzed. Nearly 59% of the respondents preferred to live with their children if non-disabled. However, 43.5% of the respondents would be unlikely to want to live with their children if disabled. If non-disabled at 60, females, professionals or those who had lived overseas before preferred not to live with their children. Females also preferred not to live with their children if disabled at 60. Other factors, such as age, social class, education level and experience in living with elderly or looking after elderly had no effect on the respondents' preference. This study provides important information on the community attitudes to living arrangements between the elderly and their adult children in Hong Kong. These attitudes will shed light on the provision of housing and institutional care to elderly, as well as the family relationship and care pattern of the elderly in the future decades in Hong Kong and other communities which are undergoing rapid growth and 'Westernization'.

Medico-legal knowledge of general practitioners: disjunctions, errors and uncertainties

This article discusses a survey of Victorian general practitioners which investigated doctors' legal knowledge, the impact of law on clinical practice, doctors' current medico-legal information sources and their legal education needs and preferences. Knowledge of legal standards was investigated in relation to three areas: disclosure of risk; ownership of, and access to, medical records; and proxy decision-making. Additionally, the impact of statutory reform in relation to proxy decision-making was explored. Further, doctors' past experience of medico-legal education, current sources of medico-legal information and preferences concerning future medico-legal information were explored. Results indicated that overall, respondents had a very inadequate understanding of relevant law and that relevant statutory standards have had little impact on clinical practice. Professional bulletins and journals were identified as major current legal information sources, whilst printed materials, seminars and conferences were preferred sources of legal information. The authors conclude that there is a significant disjunction between legal standards and doctors' awareness of those standards, thereby creating a significant source of liability for doctors. Results highlight an urgent need to develop legal education programs for general practitioners based on doctors' identified needs and preferences.

A comparative study of venlafaxine with a focused education and psychotherapy program versus venlafaxine alone in the treatment of depression in general practice

The efficacy of a focused education and psychotherapy program (FEPP) plus antidepressant was compared with that of usual psychosocial treatment and antidepressant in a general practice setting. The FEPP comprised interpersonal counselling (IPC) delivered in a modified way to suit the general practice setting, together with patient education and selected cognitive behavioural techniques. All patients were treated with venlafaxine-XR. Thirty-one patients entered the study, three withdrawing before completion of the 12 week trial. Both treatments produced a statistically significant reduction in BDI and POMS scores from baseline, with greater improvement evident in the FEPP plus antidepressant group. Copyright 2001 John Wiley & Sons, Ltd.

Depressive disorders in elderly Chinese patients in Macau: a comparison of general practitioners' consultations with a depression screening scale

OBJECTIVE

The objectives of this study were to identify the prevalence of depressive symptomatology in an elderly population using a screening scale; to assess general practitioner (GP) recognition of depression; to determine patient reasons for consultation; and to relate depression to social and demographic factors.

METHOD

An analytical cross-sectional study was carried out on a systematic sample of elderly Chinese patients currently resident in Macau, who presented to general practices in December 1997. Data collected included patient demographics, economic and social supports, patient depressive status assessed using the Hospital Anxiety and Depression scale (HAD), reason for attendance, and the reason for the consultation. Clinical records were analysed in order to collect GP-registered morbidity and recent relevant management.

RESULTS

Data were collected from 386 elderly Chinese patients of 31 GPs (97% patient response rate). Patients presented with somatic symptoms rather than psychological issues. Using HAD cut-off score of >8, 47% of the population studied were depressed; with a HAD subscale score >11, 26.2% were depressed. Depression was detected more often in women (59%) and being female was associated with depressive status (p = 0.010). Age (greater than 75 years) was also associated with being depressed, as was not having someone to talk to (p = 0.037), and being from low social class (p = 0.050). Not having someone willing to listen to their problems, difficulties and worries, was significantly related to depression (p = 0.041). There were no referrals or antidepressive medications detected in the clinical charts.

CONCLUSION

Participants' characteristics such as being over 75 years of age, being female and socially isolated were related to depression. General practitioners can play an important role in the early detection and management of psychological disorders. Although studies on a sample of Chinese patients in Macau cannot be generalized to Chinese populations elsewhere, awareness of somatic presentation of psychological illness is crucial in detecting depression in this and possibly other Chinese populations.

Chinese attitudes to institutional care of their aged. A study of members from the Chung Wah Association, Western Australia

OBJECTIVE

To examine Chinese attitudes to institutional care of their aged and to identify the factors that influence these attitudes.

METHOD

A cross sectional survey of 815 randomly selected members of the Chung Wah Association, Western Australia was undertaken in 1997 using a mailed self administered questionnaire. The survey instrument was developed through a literature review, interviews and pilot testings and consisted of categorical and noncategorical items. The data were analysed using the SAS (V 6.12) software package. Factor analysis, logistic regression and Chi-square analysis were used on the data. The statistical significance level was set at p < or = 0.05.

RESULTS

A total of 431 (53%) completed responses were received. The study showed that 86% of the respondents agreed that the disabled elderly should be institutionalised. Age contributed mainly to the respondents' attitudes to institutionalising the disabled elderly, while the respondents' sex, education, occupation, country of origin and length of residence in Australia did not. Social responsibilities together with the health factors of the elderly had important effects on these attitudes. About 55% of respondents agreed that their Chinese culture influenced their attitude. Only 21% of the respondents agreed that the nondisabled elderly should be institutionalised, 54% disagreed, while 24% remained neutral. Respondents who were likely to institutionalise their disabled elderly were also unlikely to live with their children when they became disabled. A majority of respondents were in favour of government funding of institutions and care givers of the elderly.

CONCLUSION

The study provided several important observations and information for health planners and general practitioners to identify the aged at risk of institutionalisation and make arrangements for community support for effected families so that the aged can be encouraged to remain with their families.

Distance education. Part 2. Student characteristics, program characteristics, administration and future direction

INTRODUCTION

A descriptive analysis of student and program characteristics was undertaken.

METHOD

Data were obtained using student enrollment forms, periodic surveys and regular feedback which formed part of the formative evaluation.

RESULTS

In the five year period 1992-1996, 433 doctors enrolled in the Graduate Diploma, of which 56 proceeded onto Masters. Of the 433, 60% were male. The mean age of students was 41 years, with rural (49%) and solo (45%) practitioners over-represented; 20% held the FRACGP and 15% resided outside Australia. Around 20% deferred or withdrew during the five year period. Of the 56 Masters enrollments, 16 had completed the degree in minimum time, with a further 30 completing within two years. Reasons for enrollment were largely professional with many students expressing the need to overcome isolation and gain intellectual stimulation.

CONCLUSION

This Diploma/Masters course which has a strong clinical component has attracted considerable interest among established general practitioners. The program appears to have succeeded because of its flexible delivery, lack of exclusive research orientation and its firm grounding in general practice.

Distance education. Part 6. Evaluation of a core subject within the Graduate Diploma/Masters in Family Medicine. Principles of general practice

AIM

To evaluate 'Principles of General Practice' (formerly known as the Academic Basis of General Practice), a core unit of the Graduate Diploma/Masters in Family Medicine.

METHOD

Content analysis of feedback sheets and transcripts from teleconferences were analysed to facilitate the process evaluation of this core unit. Content analysis of qualitative responses to the question: 'What did you learn?' at the end of the course formed the impact evaluation.

RESULTS

GPs who participated in the evaluation of the Principles of General Practice highlighted four learning outcomes in response to the question: 'What did you learn?' Categories included discipline specific and patient specific. Personal and professional outcomes were further divided into the following subcategories: affirmation of current practice; confidence in dealing with uncertainty; engaging in reflective practice; overcoming professional isolation; and providing opportunities for career change.

CONCLUSIONS

The most cited reasons for participating in this course were the professional and personal. Students found that the course clarified their roles, raised self-esteem and confidence, and provided them with a sense of pride in their profession. The reflective learning style resulted in students gaining insight into themselves and their therapeutic roles, with reported changes in clinical practice, including more confidence in dealing with uncertainty. In addition to meeting course objectives there were a number of unanticipated outcomes identified. The most surprising was the recognition that general practice was a medical specialty, supported by a body of literature. For some, this assisted them to overcome feelings of professional isolation and alienation. A number of students saw this course as a stimulus to blending their clinical work with a teaching role to enhance professional growth and satisfaction.

Distance education. Part 7. Evaluation of the Graduate Diploma of Family Medicine. Does a distance education course for GPs influence their reported clinical and professional practice?

INTRODUCTION

Course evaluation is essential for continuous enhancement of teaching. This evaluation aimed to assess the impact of the Graduate Diploma of Family Medicine on the clinical practices, community activities, learning styles and personal lives of its graduates.

METHODS

Cross-sectional postal questionnaire survey of all 1993 to 1997 graduates of the Graduate Diploma in Family Medicine (n = 233).

RESULTS

A response rate of 70% was achieved. Male respondents felt that they treated a greater variety of conditions (p = 0.04), had undertaken more procedural work (p = 0.03), and had increased procedural confidence (p = 0.009) compared to female respondents, while the female respondents referred more (p = 0.03). Solo practitioners tended to look for evidence in clinical decision making (p = 0.006) and applied critical appraisal techniques when reading medical information provided by pharmaceutical representatives (p = 0.04). Group practitioners tended to participate in more research projects (other than drug trials) than solo practitioners (p = 0.03). There was a difference between full and part time general practitioners, even after controlling for gender, with the former more certain that general practice is where they wanted to be (p = 0.005), they also felt more competent in interpreting data, e.g. ECGs (p = 0.013). More male students indicated they preferred a reflective learning style than females (p = 0.04).

CONCLUSION

The clinical electives of the Graduate Diploma in Family Medicine had the most significant impact on the clinical practices of full time GPs who were predominantly male graduates. Gender differences were apparent in styles of practice as males tended to conduct more procedural work, while female graduates preferred the gatekeeper role and referred more. The course also impacted on the students' approach to evidence in their clinical decision making. They were more critical of medical information provided by pharmaceutical representatives who are one of the major sources of CME for many GPs. Future evaluations should be based on experimental and quasi-experimental designs in order to measure changes in student perceptions and clinical practice, as well as more objective measures of learning styles.

Distance education. Part 3. Assessment of and feedback to students at a distance

INTRODUCTION

Assessment of students at distance, in a course with over 20 units (subjects), provides special challenges in providing timely, accurate and detailed feedback both formatively and summatively.

METHOD

A description of assessment practices including reflective journals, essays, critical appraisal of literature, case studies or teaching presentations in video and written format, clinical audits, and large research projects is provided. The impact of a multitude of criterion-referenced methods of students, teachers and administrative services as well as quality assurance issues are measured.

CONCLUSION

Students preferred multiple levels of formative and summative assessment using criterion referencing to exams. These methods were thought to be contextually relevant to clinical practice and examined knowledge, cognition and performance appropriately. Length of assessment task, difficulty with English as a second language and lack of detail or clarity on written feedback posed problems for a number of students. Quality assurance procedures have been put into place to rectify some of these problems.

Distance education. Part 1. Conceptualization and development

INTRODUCTION

The Graduate Diploma/Masters in Family Medicine were developed at Monash University as distance education courses from a previous on-campus version of a Masters course in response to real and perceived needs for more flexible forms of delivery.

METHOD

Conceptualization and development involved consultation with experts in distance education and the application of adult learning principles, phenomenology and constructivism in course design.

CONCLUSION

Despite initial difficulties and delays, course objectives were met through the application of standardised distance learning and teaching methods applied to four core and 15 clinical elective subjects. These were developed within a three year period for delivery in a predominantly paper based format.

Distance education. Part 5. Family medicine research at a distance. Guidelines for supervisors

INTRODUCTION

This paper recommends guidelines for the supervision of Masters degrees or similar postgraduate courses, in which research projects are supervised at a distance.

METHODS

The guidelines are based on the experiences of the authors with a five year old Masters of Family Medicine degree and a formative evaluation conducted by questionnaire survey among its students, graduates and supervisors.

RESULTS

It is important to establish ground rules for communication at an early point in the supervisory process. Supervisors need to take into account psychosocial, pedagogical and organisational aspects of their mentorship of students.

DISCUSSION

These guidelines are relevant to courses where there remains a strong one-to-one relationship between supervisors and students. In these cases, 'distance' need not be a barrier provided that both sides are aware of and committed to maintaining good patterns of communications with each other.

Distance education. Part 4. Supervision of family medicine research at a distance. A formative evaluation

INTRODUCTION

A survey on supervision of research projects was undertaken among current general practitioner students, recent graduates and supervisors of a Masters of Family Medicine degree. The aim was to describe and compare the experience of the three groups and, in particular, to identify the problems associated with distance supervision.

METHODS

A self-administered questionnaire survey was distributed to current students (n = 21), graduates (n = 16) and current supervisors (n = 7).

RESULTS

Forty out of 44 doctors returned completed questionnaires. Distance was a relatively minor barrier to successful supervision, provided that the student and supervisor established good communication patterns and were able to respond to each other with minimal delay. The commencement of the study and its final write-up were critical phases in the supervision process.

DISCUSSION

Communication, including emotional and psychological support, was at least as important as expert opinion in helping Masters students to successfully complete their research projects. Attention must be paid to establishing good understanding and regular means of communication at the beginning of the supervisory process.

The attitudes of Australian GPs to evidence-based medicine: a focus group study

BACKGROUND

Over the last 6 years there has been an exponential increase in the publication of medical literature on evidence-based medicine. In Australia, as in many other parts of the world, there have been calls for an increase in the practice of evidence-based medicine. In general practice, two major themes of criticism have been the lack of relevant research evidence in primary care and the failure of evidence-based medicine to take into account the complexity of the consultation.

OBJECTIVE

We aimed to explore the attitudes of Australian GPs to evidence-based medicine.

METHODS

We conducted a qualitative study using evidence-based guidelines as a model to explore attitudes within focus group interviews. Focus group data were analysed using grounded theory methodology. The study was set in the Australian cities Melbourne, Adelaide and Darwin. The subjects were 27 GPs in five focus groups.

RESULTS

Data were used to generate a model illustrating factors affecting the consideration and use of evidence within consultations. Prior beliefs and experience had a strong influence on decision-making. Overall, the GPs had a positive attitude to evidence-based medicine and stated that this could be a helpful strategy for meeting their information needs. These needs arose during the consultation and were frequently generated by patients. The evidence-based approach was regarded as particularly useful when patients required validation of their management or had specific queries. However, the GPs also expressed some concerns, such as the application of evidence from clinical trials to individuals, and the appropriateness of using research evidence with certain patients. They also feared a move away from the 'art of medicine'. None of the GPs expressed a need for critical appraisal skills.

CONCLUSIONS

The Australian GPs in this study had mixed views about the increasing profile of evidence-based medicine, and the use of this paradigm in practice. Acceptability was more likely to be influenced by relevance to general practice and local contextual and patient factors than by the strength, or critical quality of the evidence.

Preventive health behaviour among general practitioners in Victoria

This study describes the preventive health behaviour of general practitioners in Victoria, with particular emphasis on hepatitis B prevention, and their use of medical services, and seeks to explain these behaviours.

METHODS

Cross sectional postal questionnaire survey of a 10% random sample (n = 544) of all GPs in Victoria, Australia.

RESULTS

A valid response rate of 58.5% was achieved. Only 4% of the sample smoked, 93% had a blood pressure check in the past 3 years, and 64% had a cholesterol check in the past 3 years. About half followed a 'healthy' diet and 20% took a high level of physical exercise. With regard to hepatitis B prevention, 87% had completed vaccination, and 49% had confirmed immunity. Needlestick injuries had been suffered by 49% in the previous year, and half of the respondents would take no action after such an event. Over two-thirds (69%) reported having no GP. Psychological factors were associated with preventive health behaviour independent of age and gender. Internal locus of control and health value were positively associated with whether the doctor would take any action after needlestick injury, had a blood pressure or cholesterol test in the past 3 years or had their own GP.

CONCLUSION

This study shows that GPs in Victoria have a relatively high level of preventive health activity although they have a low level of utilisation of their GP colleagues in service provision. There are measurable differences in psychological variables between doctors that are associated with their level of preventive care. Plans to improve their personal health care should concentrate on psychological well being.

Targeting the right journal

While research is scientific, publication is a mixture of science and political pragmatism. Targeting the right journal is influenced by the following factors: the discipline that best represents the subject; the purpose of the message; the audience who are to be recipients of the message; the realities of geographic parochialism; the desire of authors to maximise personal and professional opportunities. If the originally targeted journal rejects the article, authors should have alternative publication strategies that give them professional recognition without requiring them to compromise the message or their ethics.

Gastroesophageal reflux and quality of life. Patient's knowledge, attitudes and perceptions

INTRODUCTION

Gastroesophageal reflux (GER) is one of the most common conditions seen in general practice. The objective of this study was to determine patients' knowledge and attitudes about GER and its effects on their stated quality of life.

METHODS

A cross sectional survey using a self administered questionnaire of a random sample of 400 patients, from the principal author's practice in outer western Sydney.

RESULTS

GER affected 53% of this sample of patients with Asians and manual workers being overrepresented. In 62% of these, GER was shown to adversely affect quality of life. Most patients in this study (70%) were unaware of the potentially serious complications of GER.

CONCLUSION

The prevalence of GER and the impact of the condition on sufferers' quality of life is generally unknown but requires further research. A history of cough and hoarse voice with no known cause, should be investigated for GER. Most patients are unaware of the serious complications of GER and should be educated about these.

Near-patient testing for serum cholesterol: attitudes of general practitioners and patients, appropriateness, and costs

OBJECTIVE

To determine the attitudes of general practitioners (GPs) and patients to near-patient testing (NPT) for serum cholesterol level, the appropriateness of NPT, and cost compared with testing in a specialist pathology laboratory.

DESIGN

A descriptive survey of registered Category 5 general practices in Victoria, 1994. Matched questionnaires were completed by GPs providing NPT and patients being tested.

PARTICIPANTS

13 GPs performing NPT and 206 patients having NPT.

RESULTS

Thirteen of the 17 Victorian Category 5-accredited practices participated in this study (77%), and 203 of the 260 GP questionnaires and 206 of the 260 patient questionnaires were returned. NPT of serum cholesterol level was found to be appropriately used by GPs, and recommended management guidelines for lowering cholesterol level were followed. Both GPs and patients strongly supported the role of NPT in general practice on the basis of convenience, issues of patient care, quality, efficiency and cost, but GPs felt the registration and quality assurance fees were unreasonably high. We identified potential cost savings for patients and the Health Insurance Commission with NPT of cholesterol level by GPs compared with testing at specialist pathology laboratories.

CONCLUSIONS

NPT appears to be of benefit to both GPs and patients and to provide cost savings. However, the registration charges and quality assurance fees for NPT laboratories may be limiting GPs' use of NPT.

General practitioner experience of clinical self audit

OBJECTIVE

To record the experience of 87 general practitioners who undertook a two phase clinical self-audit of their recording of risk factors for cancer and cardiovascular disease and the acceptability of the audit process to them.

METHOD

Participants were members of two Victorian Divisions of General Practice, one rural and one metropolitan. Each practitioner completed a clinical self-audit with a pre and post audit questionnaire. The post audit questionnaire was a repeat of the pre audit questionnaire with the addition of specific questions to measure their experience of the audit process.

OUTCOME MEASURES

Likert scale and qualitative response.

RESULTS

The results indicate that general practitioners thought the process was sound and taught them something about their actual rather than perceived practice, but were wary of sampling techniques and whether the audit reflected the recording of risk factors rather than preventive practice.

CONCLUSION

The potential of clinical self audit in Australian general practice is highlighted particularly in the light of Practice Assessment as a compulsory component of vocational registration.

Clinical audit--linking continuing medical education (CME) and practice assessment (PA)

The Quality Assurance (QA) Program of the Royal Australian College Of General Practitioners has required doctors to engage in practice assessment (PA) activities. Clinical audit is one of these activities and has been used as an assessment tool in the Graduate Diploma in Family Medicine at Monash University, in impact evaluation of educational programs as well as a means of pooling morbidity data for research purposes and peer review. Examples of these uses of clinical audit are cited, with discussion in greater detail in relation to a dermatology course, cardiovascular risk factor detection and ongoing management of congestive cardiac failure. Doctors participating in these audit activities have almost invariably described them as a valuable reflective educational exercise with changes in clinical practice occurring after the audit in a number of instances.

Depression in general practice

Depression is the most common, serious psychological disability presenting to general practitioners. Its prevalence varies from 0.6 to 36% of GP encounters depending on the method of diagnosis. Apart from methodological differences, some of this variability relates to barriers in the diagnostic process. These include 'doctor barriers' both personal and professional, 'consultation barriers', and real or perceived 'patient barriers'. Education and training of GPs to recognise and manage depression in all its guises is only one way of overcoming these barriers. Other ways include raising community awareness through public health campaigns and raising patient and doctor awareness by screening for depression in the course of seemingly unrelated consultations in 'at risk patients'. As 95% of depression is capable of being managed in general practice, GPs will need to be more active in this field to reduce the considerable burden of morbidity and mortality attributed to this condition.

HIV: patients attitudes to GPs

OBJECTIVES

To describe the characteristics of HIV-infected patients attending hospital HIV outpatient clinics in Melbourne and to measure their attitudes to general practitioners.

DESIGN

Data were collected by attending physician and by a self administered anonymous questionnaire given to patients sequentially and returned by prepaid envelope.

SETTING

Tertiary hospital HIV outpatient clinics.

PATIENTS

HIV-infected patients willing and able to participate.

RESULTS

Response rate 61%. This sample had high occupational status and functional capacity, and 63% had had GP care before hospital attendance. Only a small number of GPs are involved, and their involvement declined after hospital care commenced. There was strong overall support for shared care, although only 7% supported predominant care by a GP in the terminal phase, and only 39% supported predominant care by a GP when completely well. The major factors determining attitude toward GPs were the GPs' attitude, confidentiality and service, with knowledge and skills being more important for GPs who have a special interest in HIV care.

CONCLUSIONS

This group of patients have particular concerns about GPs that need to be addressed if GPs are to increase their involvement in HIV care.

Health assessment for commercial driving. The general practitioners' role

Death and injury rates associated with commercial vehicle driving are unacceptably high. Pre-existing medical conditions may contribute to road accidents and the National Road Transport Commission (NRTC) has developed a set of uniform guidelines, based on best available evidence, which might preclude at risk individuals from holding commercial licences. Standardised clinical examinations performed by general practitioners (GPs) will be used to assist regulatory authorities in their licensing procedures. This article sets out the process of development of the guidelines as well as the construction and use of a medical assessment form to be used by GPs in facilitating the licensing process in each State.

Hypertension: are we getting the message?

Hypertension remains the commonest condition requiring ongoing medical treatment in general practice and yet treatment and follow up still pose major difficulties. The author explores the reasons for these difficulties and suggests ways to overcome them.

Hearing loss in the elderly. A survey in general practice

OBJECTIVE

To determine the prevalence of undiagnosed hearing impairment in people aged 60 years or over in a general practice setting.

DESIGN

A self-administered questionnaire followed by physical examination and audiometry.

SETTING

A group general practice in the Melbourne suburb of Moorabbin.

PATIENTS

Two hundred and one people aged 60 years or over who were not known to be hearing impaired.

OUTCOME MEASURE

Results of air-conduction audiometry.

RESULTS

Seventy-five of the 201 people had undiagnosed hearing loss (37%). The assessments of hearing ability by the patients and their relations were good predictors of the outcome of the audiogram (P < 0.001). Occupational history, medical history and physical examination were poor predictors (P > 0.05).

CONCLUSIONS

The use of audiometry for screening for hearing impairment in older general practice patients is likely to have a high yield. A large proportion of people with abnormal audiograms will, however, refuse a hearing aid.

Preventive care in general practice

Preventive care is an integral component of general practice teaching in all Australian medical schools. While curriculum time and teaching methods vary, the overriding emphasis remains on integrating both epidemiological and behavioural science approaches into the primary care setting. Preventive aspects are stressed during attachments with general practitioners. Use of appropriate theoretical frameworks and models allows the role of the general practitioner in disease prevention to be formalized. Undergraduate teaching is further reinforced by programs within the Family Medicine Programme at a vocational training level, and the Royal Australian College of General Practitioners at a continuing medical education level.

Hospital interns' and residents' perceptions of rural training and practice in Victoria

OBJECTIVE

To examine the attitudes of junior hospital doctors toward rural training and practice in Victoria.

DESIGN AND PARTICIPANTS

A cross-sectional survey of 300 randomly selected Victorian hospital interns, junior and senior resident medical officers was undertaken in 1988 using a mailed self-administered questionnaire. The questionnaire was developed after a literature review, interviews and pilot testing and consisted of categorical and non-categorical items.

STATISTICAL METHODS

Responses to the questionnaire were subjected to univariate, bivariate and factor analysis of variables. Testing for differences between those doctors choosing to train and work in rural areas and those choosing metropolitan areas was carried out by chi 2 test for discrete variables and Student's t test for means.

RESULTS

A 64% response rate was achieved (n = 192). Only 15% indicated a preference for rural training the following year. Those from a rural background were more likely to express intention to train and practise in the country (P less than 0.05). The most important determinants in choosing a rural training post to emerge on factor analysis were the perceived quality of education and training facilities and the view of the doctors' partners or spouses. The decision to practise in the country was more likely to be influenced by "family" than "professional" factors (P less than 0.05).

CONCLUSION

Perceptions regarding the academic status of rural hospitals as well as failure to address the needs of doctors' spouses or partners were major deterrents to rural training. These areas need to be addressed if the shortage of rural practitioners is to be reversed.

Perceptions of the FRACGP examination. A study of Victorian candidates

It is proposed that by 1995 Fellowship of the Royal Australian College of General Practitioners will be the only recognised endpoint of vocational training in general practice in Australia. Currently however only one in six eligible general practitioners and one in three college members holds the FRACGP in Victoria. This case-controlled study carried out by survey questionnaire was designed to compare and contrast perceptions of the FRACGP examination of a group of candidates with a group of demographically matched non candidates. The study suggested that those who sat the examination did so to improve their self esteem, and wished their knowledge, competence and skills to be 'peer reviewed'.