How do medical schools influence their students' career choices? A realist evaluation

INTRODUCTION

The career choices of medical graduates vary widely between medical schools in the UK and elsewhere and are generally not well matched with societal needs. Research has found that experiences in medical school including formal, informal and hidden curricula are important influences. We conducted a realist evaluation of how and why these various social conditions in medical school influence career thinking.

METHODS

We interviewed junior doctors at the point of applying for speciality training. We selected purposively for a range of career choices. Participants were asked to describe points during their medical training when they had considered career options and how their thinking had been influenced by their context. Interview transcripts were coded for context-mechanism-outcome (CMO) configurations to test initial theories of how career decisions are made.

RESULTS

A total of 26 junior doctors from 12 UK medical schools participated. We found 14 recurring CMO configurations in the data which explained influences on career choice occurring during medical school.

DISCUSSION

Our initial theories about career decision-making were refined as follows: It involves a process of testing for fit of potential careers. This process is asymmetric with multiple experiences needed before deciding a career fits ('easing in') but sometimes only a single negative experience needed for a choice to be ruled out. Developing a preference for a speciality aligns with Person-Environment-Fit decision theories. Ruling out a potential career can however be a less thought-through process than rationality-based decision theories would suggest. Testing for fit is facilitated by longer and more authentic undergraduate placements, allocation of and successful completion of tasks, being treated as part of the team and enthusiastic role models. Informal career guidance is more influential than formal. We suggest some implications for medical school programmes.

How well do UK assistantships equip medical students for graduate practice? Think EPAs

The goal of better medical student preparation for clinical practice drives curricular initiatives worldwide. Learning theory underpins Entrustable Professional Activities (EPAs) as a means of safe transition to independent practice. Regulators mandate senior assistantships to improve practice readiness. It is important to know whether meaningful EPAs occur in assistantships, and with what impact. Final year students at one UK medical school kept learning logs and audio-diaries for six one-week periods during a year-long assistantship. Further data were also obtained through interviewing participants when students and after three months as junior doctors. This was combined with data from new doctors from 17 other UK schools. Realist methods explored what worked for whom and why. 32 medical students and 70 junior doctors participated. All assistantship students reported engaging with EPAs but gaps in the types of EPAs undertaken exist, with level of entrustment and frequency of access depending on the context. Engagement is enhanced by integration into the team and shared understanding of what constitutes legitimate activities. Improving the shared understanding between student and supervisor of what constitutes important assistantship activity may result in an increase in the amount and/or quality of EPAs achieved.

Development and face validation of strategies for improving consultation skills

While formative workplace based assessment can improve learners' skills, it often does not because the procedures used do not facilitate feedback which is sufficiently specific to scaffold improvement. Provision of pre-formulated strategies to address predicted learning needs has potential to improve the quality and automate the provision of written feedback. To systematically develop, validate and maximise the utility of a comprehensive list of strategies for improvement of consultation skills through a process involving both medical students and their clinical primary and secondary care tutors. Modified Delphi study with tutors, modified nominal group study with students with moderation of outputs by consensus round table discussion by the authors. 35 hospital and 21 GP tutors participated in the Delphi study and contributed 153 new or modified strategies. After review of these and the 205 original strategies, 265 strategies entered the nominal group study to which 46 year four and five students contributed, resulting in the final list of 249 validated strategies. We have developed a valid and comprehensive set of strategies which are considered useful by medical students. This list can be immediately applied by any school which uses the Calgary Cambridge Framework to inform the content of formative feedback on consultation skills. We consider that the list could also be mapped to alternative skills frameworks and so be utilised by schools which do not use the Calgary Cambridge Framework.

A rural undergraduate campus in England: virtue from opportunity and necessity

The implementation of new curriculum at Keele University Medical School, UK has made heavy use of general practice as a locus for learning. This has necessitated a substantial expansion in the School's teaching network. The School's hinterland includes a large rural area with a number of excellent general practices and associated community hospitals that, to date, have been unable to teach undergraduates because of their inaccessibility. This article describes how the School and its partners articulated a vision to establish a rural campus with an associated rural accommodation hub, and the challenges involved in establishing and sustaining the campus.

GPs' perceptions of the service needs of South Asian people with chronic pain: a qualitative enquiry

This qualitative study describes GPs' experiences of and needs for management of people from a South Asian community who have chronic pain. Semi-structured interviews were conducted with 18 GPs from practices in two PCTs in Leicester. The data was analysed using grounded theory. The results indicate that managing patients from a South Asian community with chronic pain can be challenging due to differing pain expression and presentation. Emerging themes refer to shortages of services for these patients including the need for CBT, counselling, community support and GP education and training. Potential implications of the results for service provision are discussed.

Breathing exercises for asthma: a randomised controlled trial

BACKGROUND

The effect of breathing modification techniques on asthma symptoms and objective disease control is uncertain.

METHODS

A prospective, parallel group, single-blind, randomised controlled trial comparing breathing training with asthma education (to control for non-specific effects of clinician attention) was performed. Subjects with asthma with impaired health status managed in primary care were randomised to receive three sessions of either physiotherapist-supervised breathing training (n = 94) or asthma nurse-delivered asthma education (n = 89). The main outcome was Asthma Quality of Life Questionnaire (AQLQ) score, with secondary outcomes including spirometry, bronchial hyper-responsiveness, exhaled nitric oxide, induced sputum eosinophil count and Asthma Control Questionnaire (ACQ), Hospital Anxiety and Depression (HAD) and hyperventilation (Nijmegen) questionnaire scores.

RESULTS

One month after the intervention there were similar improvements in AQLQ scores from baseline in both groups but at 6 months there was a significant between-group difference favouring breathing training (0.38 units, 95% CI 0.08 to 0.68). At the 6-month assessment there were significant between-group differences favouring breathing training in HAD anxiety (1.1, 95% CI 0.2 to 1.9), HAD depression (0.8, 95% CI 0.1 to 1.4) and Nijmegen (3.2, 95% CI 1.0 to 5.4) scores, with trends to improved ACQ (0.2, 95% CI 0.0 to 0.4). No significant between-group differences were seen at 1 month. Breathing training was not associated with significant changes in airways physiology, inflammation or hyper-responsiveness.

CONCLUSION

Breathing training resulted in improvements in asthma-specific health status and other patient-centred measures but not in asthma pathophysiology. Such exercises may help patients whose quality of life is impaired by asthma, but they are unlikely to reduce the need for anti-inflammatory medication.

Effect of patient completed agenda forms and doctors' education about the agenda on the outcome of consultations: randomised controlled trial

OBJECTIVE

To assess the effect of patient completed agenda forms for the consultation and doctors' education on identifying patients' agendas on the outcome of consultations.

DESIGN

Randomised controlled trial.

SETTING

General practices in Leicestershire and Nottinghamshire, United Kingdom.

PARTICIPANTS

46 general practitioners and 976 patients.

INTERVENTIONS

Education for general practitioners, with an embedded clustered randomised controlled trial of a patient agenda form.

MAIN OUTCOME MEASURES

Number of problems identified, time required to manage each problem, duration of consultations, number of problems raised after the doctor considered the consultation finished ("by the way" questions), and patient satisfaction.

RESULTS

Data were available from 45 doctors (98%) and 857 patients (88%). The number of problems identified in each consultation increased by 0.2 (95% confidence interval 0.1 to 0.4) with the agenda form, by 0.3 (0.1 to 0.6) with education, and by 0.5 (0.3 to 0.7) with both interventions. The time required to manage each problem was not affected. The duration of consultations with the agenda form was increased by 0.9 minutes (0.3 to 1.5 minutes) and with the combined intervention by 1.9 minutes (1.0 to 2.8 minutes). Patient satisfaction with the depth of the doctor-patient relationship was increased with the agenda form. The occurrence of "by the way" presentations did not change.

CONCLUSION

A patient completed agenda form before the consultation or general practitioner education about the agenda form, or both, enabled the identification of more problems in consultations even though consultations were longer.

Strengths and weaknesses in the consultation skills of senior medical students: identification, enhancement and curricular change

INTRODUCTION

This paper seeks to describe the consultation strengths and weaknesses of senior medical students, the explicit and prioritised strategies for improvement utilised in student feedback, and curriculum developments informed by this work.

METHODS

Prospective, descriptive study of students on clinical placements in general practice. All were observed directly by 2 assessors in consultation with 5 patients in a general practice setting. Performance was judged against 5 categories of consultation competence and 35 component competences as contained in a modified version of the Leicester Assessment Package. Specific strategies for improvement were selected from a list of 69 previously formulated strategies.

RESULTS

Data from 1116 students were included. The consultation competences identified most frequently as strengths related to interpersonal skills, while weaknesses were mainly in the domain of clinical problem-solving. The median number of key strengths identified per student was 5, with 5 additional but lesser strengths. A median of 3 key and lesser weaknesses were identified. The average number of strategies selected to address an identified weakness was 1.2. Students rated the assessment process and its impact very positively.

CONCLUSION

The systematic assessment of the consultation competence of medical students by direct observation involving real patients is feasible and facilitates the 'educational diagnosis' of individuals and of their peer group. It has informed development of teaching and generated research hypotheses.

Measuring the quality of referral letters about patients with upper gastrointestinal symptoms

BACKGROUND

General practitioners state the reason for referring patients in referral letters. The paucity of information in these letters has been the source of criticism from specialist colleagues.

OBJECTIVE

To invite general practitioners to set standards for referral letters to gastroenterologists and to apply these standards to actual referral letters to one specialist gastroenterology unit.

METHODS

A scoring schedule was designed based on the responses to a questionnaire survey of a large sample of all general practitioners in one locality. Altogether 350 consecutive letters to a district general hospital about patients referred for an upper gastrointestinal specialist opinion were subsequently scored using the schedule.

RESULTS

102 practitioners responded to the survey. Their responses imply that colleagues assess and record findings on 18 potential features of upper bowel disease. In practice most referral letters address fewer than six features of upper bowel disease. The mean number of positive features of upper gastrointestinal disease reported in each letter was one.

CONCLUSIONS

This study reported a failure to meet "peer defined" standards for the content of referral letters set by colleagues in one locality. Referral letters serve many purposes, however, encouraging full documentation of specific clinical findings may serve to increase the pre-referral assessments performed in practice.

The relationship between measures of patient satisfaction and enablement and professional assessments of consultation competence

The authors examined the extent of the relationship between a Consultation satisfaction questionnaire and Patient enablement instrument scores and professionally assessed consultation competence scores of senior medical students. Three analyses were performed: (i) linear regression with mean overall competence score as response variable; (ii) sensitivity and specificity calculations using patient scores to classify competence; (iii) a repeated measures model with consultation-specific competence score as response variable. One hundred and nineteen students and 388 patients took part. Consultation satisfaction and enablement scores were weakly correlated with overall and consultation specific competence scores (correlation coefficient 0.16 to 0.44). 'Satisfaction with professional care' had a sensitivity of 0.68, specificity of 0.72 and positive and negative predictive values of 0.32 and 0.92 respectively. It is concluded that patient and professional assessments may complement, but do not replace, each other. Levels of patient satisfaction should not be used as proxy measures of the quality of consultation competence.

Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial

BACKGROUND

Functional breathing disorders may complicate asthma and impair quality of life. This study aimed to determine the effectiveness of physiotherapy based breathing retraining for patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing.

METHODS

33 adult patients aged 17-65 with diagnosed and currently treated asthma and Nijmegen questionnaire scores > or =23 were recruited to a randomised controlled trial comparing short physiotherapy breathing retraining and an asthma nurse education control. The main outcome measures were asthma specific health status (Asthma Quality of Life questionnaire) and Nijmegen questionnaire scores

RESULTS

Of the 33 who entered the study, data were available on 31 after 1 month and 28 at 6 months. The median (interquartile range) changes in overall asthma quality of life score at 1 month were 0.6 (0.05-1.12) and 0.09 (-0.25-0.26) for the breathing retraining and education groups, respectively (p=0.018), 0.42 (0.11-1.17) and 0.09 (-0.58-0.5) for the symptoms domain (p=0.042), 0.52 (0.09-1.25) and 0 (-0.45-0.45) for the activities domain (p=0.007), and 0.50 (0-1.50) and -0.25 (-0.75-0.75) for the environment domain (p=0.018). Only the change in the activities domain remained significant at 6 months (0.83 (-0.10-1.71) and -0.05 (-0.74-0.34), p=0.018), although trends to improvement were seen in the overall score (p=0.065), the symptoms domain (p=0.059), and the environment domain (p=0.065). There was a correlation between changes in quality of life scores and Nijmegen questionnaire scores at 1 month and at 6 months. The number needed to treat to produce a clinically important improvement in health status was 1.96 and 3.57 at 1 and 6 months.

CONCLUSION

Over half the patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing show a clinically relevant improvement in quality of life following a brief physiotherapy intervention. This improvement is maintained in over 25% 6 months after the intervention.

Meeting patient expectations of care: the major determinant of satisfaction with out-of-hours primary medical care?

BACKGROUND

Client or consumer expectation is considered to influence their satisfaction with the service provided, but its importance has not been quantified in health care.

OBJECTIVE

The aim of this study was to determine the effect of "patient expectations of care" on satisfaction with care provided by out-of-hours services.

METHODS

We surveyed 3457 patients who requested out-of-hours care from five practices, two general practice out-of-hours co-operatives and a deputizing service in an English health authority during late 1997. The independent variables were: the service providing the care (service type), where out-of-hours care was given (location of care) and whether the care met the patient's expectations. The independent variable was overall patient satisfaction with out-of-hours care.

RESULTS

Patients who received the care they hoped for (their idealized expectation was met) were more satisfied than those who did not. Patients who attended centres were more satisfied with the care received than those who had had home visits. Patients were more satisfied if they received care from the co-operative which did not employ assistants than from the deputizing service. Idealized expectation (care which was hoped for) match, location of care and service type explained 34, 2 and 4% of the variance, respectively. Age, sex, ethnicity, access to a car, normative/comparative expectation (care which was expected) and whether patients expected and received telephone advice, a home visit or domiciliary care, and the delay between request for care and care provision were not independently associated with satisfaction.

CONCLUSIONS

Meeting or failing to meet the care patients hoped for is an important predictor of patient satisfaction with out-of-hours care. Purchasers and providers of out-of-hours care should consider whether and how patient expectation of service can be managed. This may reduce patient dissatisfaction with the service they provide. These findings also have important implications for the design of studies which use patient satisfaction as an outcome variable.

GP stress and patient dissatisfaction with nights on call: an exploratory study. GP stress and patient satisfaction

OBJECTIVES

To compare the relative effects of being on or off duty at night on general practitioners' (GPs') levels of stress, and the satisfaction of their patients with daytime consultations surrounding these nights.

DESIGN

A within-subjects, counterbalanced design was used. Two "on-call" and two "off-duty" nights were studied per GP over 4 weeks.

SETTING

Primary health care in the UK.

PARTICIPANTS

26 GPs and their patients seen in consultations either side of nights studied.

MAIN OUTCOME MEASURES

GPs completed validated stress questionnaires at the beginning and end of the consultation sessions immediately before and after nights on call and off duty.

RESULTS

GPs experienced elevated levels of stress when on call, compared to when they were off duty. Patients seen in the consultation sessions before and after a night on call were less satisfied than patients seen before and after a night off duty.

CONCLUSION

Being on call at night raised GP stress levels from at least the start of the afternoon consultation session before until the end of the morning consultation after the night on call. Daytime patient satisfaction is also reduced in periods surrounding nights on call.

Audit in general practice: how much and how complete? Frequency of audit in general practice

The aim of this study was to determine the frequency of audit and the proportion completed in a group of practices. Data obtained by interviewing a member of each practice and inspecting practice records were independently coded by researchers. Practices initiated an average of 3.5 (range 1-7) audits in 2 years, of which an average of 0.9 (range 0-3) were completed. Ten of 16 completed audits were externally funded or facilitated. Few audits are completed in general practice and practices require continuing support for audit.

Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey

OBJECTIVES

To estimate the prevalence of dysfunctional breathing in adults with asthma treated in the community.

DESIGN

Postal questionnaire survey using Nijmegen questionnaire.

SETTING

One general practice with 7033 patients.

PARTICIPANTS

All adult patients aged 17-65 with diagnosed asthma who were receiving treatment.

MAIN OUTCOME MEASURE

Score >/=23 on Nijmegen questionnaire.

RESULTS

227/307 patients returned completed questionnaires; 219 (71.3%) questionnaires were suitable for analysis. 63 participants scored >/=23. Those scoring >/=23 were more likely to be female than male (46/132 (35%) v 17/87 (20%), P=0.016) and were younger (mean (SD) age 44.8 (14.7) v 49.0 (13.8, (P=0.05). Patients at different treatment steps of the British Thoracic Society asthma guidelines were affected equally.

CONCLUSIONS

About a third of women and a fifth of men had scores suggestive of dysfunctional breathing. Although further studies are needed to confirm the validity of this screening tool and these findings, these prevalences suggest scope for therapeutic intervention and may explain the anecdotal success of the Buteyko method of treating asthma.

Patient satisfaction with out of hours primary medical care

OBJECTIVES

To describe the relationship between patient satisfaction with out of hours care provided by deputising and practice doctors in four urban areas in England and characteristics of the service provided and patients, the care given, and health outcomes.

SETTING

-Fourteen general practices in four urban areas in England.

PARTICIPANTS

People who requested out of hours care.

DESIGN

Analysis of data from a study of out of hours care. Patients were interviewed within 5 days of their request for out of hours care. Data on the service provided were obtained from medical records and all other data were collected at interview. Satisfaction was measured using a valid reliable instrument.

RESULTS

2152 patients were recruited to the study and 1466 were interviewed. Satisfaction data were available on 1402 patients. "Overall satisfaction" was associated with age, doctor type, lack of access to a car at the time of the request, and health outcome. The relationships between satisfaction subscales and patient characteristics (age, sex, ethnicity, and access to a car at the time of the request), service characteristics (doctor type and delay between the request and visit), whether a prescription was given, and health outcome were variable. If an expected home visit was not received, "overall satisfaction" and satisfaction with "communication and management", "doctor's attitude", and "initial contact person" were reduced.

CONCLUSION

Patient satisfaction is dependent on many factors. Mismatch between patient expectation and the service received is related to decreased satisfaction. This may increase as general practitioners delegate more out of hours care to cooperatives and deputising services.

Formative assessment of the consultation performance of medical students in the setting of general practice using a modified version of the leicester assessment package

OBJECTIVE

To evaluate the use of a modified version of the Leicester Assessment Package (LAP) in the formative assessment of the consultation performance of medical students with particular reference to validity, inter-assessor reliability, acceptability, feasibility and educational impact.

DESIGN

180 third and fourth year Leicester medical students were directly observed consulting with six general practice patients and independently assessed by a pair of assessors. A total of 70 practice and 16 departmental assessors took part. Performance scores were subjected to generalizability analysis and students' views of the assessment were gathered by questionnaire.

RESULTS

Four of the five categories of consultation performance (Interviewing and history taking, Patient management, Problem solving and Behaviour and relationship with patients) were assessed in over 99% of consultations and Physical examination was assessed in 94%. Seventy-six percent of assessors reported that the case mix was 'satisfactory' and 20% that it was 'borderline'; 85% of students believed it to have been satisfactory. Generalizability analysis indicates that two independent assessors assessing the performance of students across six consultations would achieve a reliability of 0.94 in making pass or fail decisions. Ninety-eight percent of students perceived that their particular strengths and weaknesses were correctly identified, 99% that they were given specific advice on how to improve their performance and 98% believed that the feedback they had received would have long-term benefit.

CONCLUSIONS

The modified version of the LAP is valid, reliable and feasible in formative assessment of the consultation performance of medical students. Furthermore, almost all students found the process fair and believed it was likely to lead to improvements in their consultation performance. This approach may also be applicable to regulatory assessment as it accurately identifies students at the pass/fail margin.

Student perceptions of a new integrated course in clinical methods for medical undergraduates

CONTEXT

In line with recent General Medical Council recommendations a new, 8-week integrated course in clinical methods has been introduced into the undergraduate curriculum at Leicester University.

OBJECTIVES

To describe student perceptions of the course and to identify areas for improvement.

DESIGN

A questionnaire survey.

SETTINGS

These were 50 general practices, three teaching hospitals and the academic Department of General Practice and Primary Health Care.

SUBJECTS

A total of 180 third- and fourth-year medical students.

RESULTS

The questionnaires were completed by 93% of students. The latter expressed higher satisfaction with practice teaching compared with hospital teaching, on a 5-point scale, with regard to questions on 'teaching content' (4.0 vs. 2.7, P < 0.0001) and 'teaching process' (4.1 vs. 2.7 P < 0.0001), which was reinforced by free text comments. Of the respondents, 92% agreed that their teaching practice had satisfied the required teaching timetable and 87% of students found their departmental tutor enthusiastic and stimulating.

CONCLUSION

It is possible to deliver an integrated course in clinical methods, teaching generic clinical skills, in a mix of hospital and practice settings. Nevertheless there were substantial differences in student perceptions of the relative quality and impact of teaching in the two settings. This may be related to the more detailed programme of preparation of practice teachers and the greater extent to which practice teachers were required, and able, to create protected time for the teaching task. These differences should be minimized if hospital teachers undergo similar preparation for the teaching task and have similar levels of protected teaching time.

What do patients want from doctors? Content analysis of written patient agendas for the consultation

BACKGROUND

Although much has been written about what patients want when they contact their general practitioner (GP), there are no published data from large cohort studies of what patients expect.

AIM

To describe the expectations of a large group of patients who consulted with their GPs.

METHOD

A GP and a social sciences graduate carried out a content analysis of written agenda forms completed by 819 patients who consulted 46 randomly selected GPs. Inter- and intra-rater reliabilities were confirmed.

RESULTS

A total of 756 (92%) agenda forms were returned. Inter-rater reliability was satisfactory (kappa > 0.6 for all but two main themes). Almost all patients had requests they wished to make of their doctor, 60% had their own ideas about what was wrong, and 38% had considered explanations about why they were unwell. Forty-two per cent and 24% of patients had consulted because they had reached the limit of their anxiety or tolerance respectively. Seven per cent, 4%, and 2% had comments, which were usually negative, to make about previous management, communication with doctors, or time in the consultation.

CONCLUSION

These data demonstrate that most patients come to the consultation with a particular agenda. Failure to address this agenda is likely to adversely affect the outcome of many consultations.

Change in the use of and attitude to peak flow measurement among general practitioners in Northern Ireland between 1989 and 1994

In 1994 we repeated a study first performed in 1989 to assess the change in general practitioners' use of and attitudes to peak flow measurement. Of 232 general practitioners surveyed, 199 (86%) and 192 (83%) responded in 1989 and 1994 respectively. The percentage who reported having patients using domiciliary peak flow monitoring rose form 58.3 (95% confidence limits 51.4 to 65.2)% to 97.9 (95.9 to 99.9)%. The percentage who reported 'usually' using peak flow measurements for the diagnosis and management of asthma rose from 81.9 (76.5 to 87.3)% to 93.2 (89.6 to 96.8)% and from 83.3 (78.1 to 88.5)% to 95.8 (92.9 to 98.7)% respectively. An unchanged proportion took peak flow meters on house calls. General practitioners have become more aware of the potential of peak flow measurements but are still unlikely to have a meter available to assess patients seen at home. They are therefore likely to be ill-equipped to manage acute exacerbations of asthma in this setting.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. II: The outcome of care

OBJECTIVE

To compare the outcome of out of hours care given by general practitioners from patients' own practices and by commercial deputising services.

DESIGN

Randomised controlled trial.

SETTING

Four urban areas in Manchester, Salford, Stockport, and Leicester.

SUBJECTS

2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals in general practice) who responded to the requests.

MAIN OUTCOME MEASURES

Health status outcome, patient satisfaction, and subsequent health service use.

RESULTS

Patients seen by deputising doctors were less satisfied with the care they received. The mean overall satisfaction score for practice doctors was 70.7 (95% confidence interval 68.1 to 73.2) and for deputising doctors 61.8 (59.9 to 63.7). The greatest difference in satisfaction was with the delay in visiting. There were no differences in the change in health or overall health status measured 24 to 120 hours after the out of hours call or subsequent use of the health service in the two groups.

CONCLUSIONS

Patients are more satisfied with the out of hours care provided by practice doctors than that provided by deputising doctors. Organisation of doctors into large groups may produce lower levels of patient satisfaction, especially when associated with increased delays in the time taken to visit. There seem to be no appreciable differences in health outcome between the two types of service.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. I: The process of care

OBJECTIVE

To compare the process of out of hours care provided by general practitioners from patients' own practices and by commercial deputising services.

DESIGN

Randomised controlled trial.

SETTING

Four urban areas in Manchester, Salford, Stockport, and Leicester.

SUBJECTS

2152 patients who requested out of hours care, and 49 practice doctors and 183 deputising doctors (61% local principals) who responded to those requests.

MAIN OUTCOME MEASURES

Response to call, time to visit, prescribing, and hospital admissions.

RESULTS

1046 calls were dealt with by practice doctors and 1106 by deputising doctors. Practice doctors were more likely to give telephone advice (20.2% v 0.72% of calls) and to visit more quickly than deputising doctors (median delay 35 minutes v 52 minutes). Practice doctors were less likely than deputising doctors to issue a prescription (56.1% v 63.2% of patients) or to prescribe an antibiotic (43.7% v 61.3% of prescriptions issued) and more likely to prescribe genetic drugs (58.4% v 32.1% of drugs prescribed), cheaper drugs (mean cost per prescription pounds 3.28 v pounds 5.04), and drugs in a predefined out of hours formulary (49.8% v 41.1% of drugs prescribed). There was no significant difference in the number of hospital admissions.

CONCLUSIONS

By contrast with practice doctors, deputising doctors providing out of hours care less readily give telephone advice, take longer to visit at home, and have patterns of prescribing that may be less discriminating.

Reliability and validity of a new measure of patient satisfaction with out of hours primary medical care in the United Kingdom: development of a patient questionnaire

OBJECTIVE

To develop a reliable, valid measure of patient satisfaction with out of hours care suitable for large scale service evaluation.

DESIGN

Focus group meetings and semistructured interviews with patients to identify issues of importance to patients and possible questionnaire items; interviews and two pilot studies to test and identify new questionnaire items; modification or removal of items to eliminate ambiguity and reduce non-response and skewed responses; questionnaire survey of out of hours care.

SETTING

Greater Manchester and Leicester.

SUBJECTS

11 general practice patients participated in the focus groups and 28 in the semistructured interviews; 41 in the preliminary interviews; 41 and 378 in the postal pilots; and 1466 in the survey of out of hours care.

RESULTS

A 32 item questionnaire was developed. Component analysis indicated seven scales (satisfaction with communication and management, doctor's attitude, continuity of care, delay until visit, access to out of hours care, initial contact person, telephone advice) related to overall satisfaction and containing issues identified as important to patients. Levels of reliability were satisfactory, Cronbach's alpha correlation coefficient exceeding 0.60 for all scales.

CONCLUSION

A reliable, valid measure of patient satisfaction has been developed, suitable for large scale evaluation of out of hours care.

Undergraduate teaching in the community: can general practice deliver?

BACKGROUND

All UK medical schools are revising their curricula following the General Medical Council recommendations to increase general practice involvement in undergraduate education. However, workload in general practice has increased in recent years, raising questions about its ability to maintain, let alone extend, its educational activities.

AIM

The aim of this study was examine whether recent changes in general practice have affected delivery of practice-based undergraduate education and to assess the extent to which practices will be able to increase their involvement in teaching.

METHOD

A postal questionnaire survey was conducted of the lead clinical teachers and their partners in the practices to which students from Leicester Medical School had been attached in the last 2 years.

RESULTS

The questionnaire was completed by 32 out of the 39 lead teachers and 134 of the 150 partners, an overall response rate of 88%. There was widespread support for departmental teaching requirements, but only 17 lead teachers (44%) felt that the suggested reduction by 25% of patients seen per session while teaching was feasible. A total of 14 lead teachers (47%) felt that the ability of their practice to deliver high-quality teaching had declined since 1990. Altogether, 113 (87%) of all doctors in teaching practices felt that time pressures had increased during this period, and 139 (88%) felt that present levels of remuneration were inadequate. The majority of these doctors felt that general practice was the preferred location for learning generic clinical skills and were interested in participating. Nevertheless, most were not prepared to increase their involvement in teaching under present arrangements.

CONCLUSION

Practice-based teachers appreciate the need for quality teaching, remain enthusiastic about teaching and are, in principle, willing to take an increased teaching load. However, recent changes have made delivery of teaching more difficult, and if an expansion in practice-based teaching is to occur, more realistic levels of funding and support are a prerequisite.

Consultation competence in general practice: testing the reliability of the Leicester assessment package

BACKGROUND

An acceptable assessment must be both valid and reliable; the face validity of the Leicester assessment package has already been established.

AIM

This study set out to test the reliability of the Leicester assessment package, and the factors influencing it, when used by multiple assessors to assess performance in general practice consultations.

METHOD

Six randomly selected course organizer assessors simultaneously used the package to conduct independent assessments of the performance of five doctors of widely varying abilities in consultation with six simulated patients. The scores allocated were subjected to generalizability analysis.

RESULTS

The mean scores allocated for consultation performance of individual doctors ranged from 51% to 70%, with the lower scores being allocated to the less experienced doctors. Scores of each assessor across the cases were examined for internal consistency and five of the six assessors consistently scored the doctors with an alpha coefficient of the minimum accepted level of 0.80 or greater. The other assessor had a consistency of only 0.22. Measurements of consistency within cases between markers indicated that the first case produced unreliable results (alpha coefficient 0.25) but all other cases were scored consistently. Two independent assessors scoring eight consultations are the requisite numbers to achieve acceptable levels of reliability in a formal assessment process; seven consultations produce the minimum acceptable generalizability coefficient of 0.80 plus the first 'non-counting' consultation.

CONCLUSION

Required levels of reliability can be achieved when the package is used by multiple markers assessing the same consultations over a wide range of consultation performance. To achieve reliability only two hours of assessment time are required using the Leicester package compared with the previously regarded minimum of 32 hours. Although assessors can produce reliable scores with minimal training, intra-assessor reliability cannot be taken for granted and all assessors should be trained and calibrated before being sanctioned to conduct assessments, particularly for regulatory purposes. The Leicester assessment package has now been shown to be valid, reliable, feasible and easy to use in practice. It can, therefore, be recommended for use in both formative and summative assessment of consultation competence in general practice.

The use of and attitude to peak flow measurement in general practice

The use of and attitudes to peak flow meters and monitoring were surveyed in a random sample of general practitioners in Northern Ireland. There was an 87% response. Almost all general practitioners had a peak flow meter or spirometer in their practice but only 48% usually took a meter on home visits. The meters were more likely to be used for the diagnosis and management of asthma than chronic obstructive airways disease. General practitioners felt that meters were more useful when used in the consulting room than for domiciliary monitoring and that domiciliary monitoring was more useful in the management than the diagnosis of asthma. Although 79% of general practitioners felt that domiciliary peak flow measurement was useful for the management of asthma, only 3% of all asthmatic patients were using it. General practitioners' attitudes to peak flow monitoring are positive but they are not actually using them as much as they could.

Consultation competence in general practice: establishing the face validity of prioritized criteria in the Leicester assessment package

AIM

This study set out to test the face validity of prioritized criteria of consultation competence in general practice as contained in the Leicester assessment package.

METHOD

A questionnaire was sent to a geographically stratified random sample of 100 members of the United Kingdom Association of Course Organisers to seek their views on the categories, components and weightings contained in the Leicester assessment package and to determine the proportion of respondents who rejected or suggested a new category, component or weighting or reallocated components to other categories or amended weightings. Their views were sought on a six-point scale (strongly approve, approve, tend to approve, tend to disapprove, disapprove and strongly disapprove).

RESULTS

There was a 73% response rate. Of the respondents 99% either strongly approved or approved of the overall set of categories of consultation competence. Only two respondents (3%) expressed any disapproval of individual categories. Thirty five of the 39 suggested components of consultation competence were supported by more than 80% of respondents. There was minimal support for excluding any categories or components of consultation competence, for moving any components to different categories or for the inclusion of new categories or components. Eighty eight per cent of respondents were in favour of the need to identify priorities between any agreed categories of consultation competence and 79% expressed approval of the suggested weightings. Although 42% of respondents indicated a wish for some alteration in weightings, the mean values for all consultation categories suggested by all respondents were almost identical to the original weightings in the Leicester package.

CONCLUSION

The face validity of the categories and components of consultation competence contained in the Leicester assessment package has been established, and the suggested weightings of consultation categories have been validated. Consequently, the criteria contained in the Leicester package can be adopted with confidence as measures against which performance can be judged in formative or summative assessment of consultation performance in general practice.

Validity of peak expiratory flow rate variability for the diagnosis of asthma

1. The aim of this study was to determine the validity of various numerical indices of peak flow variability as tests for asthma. 2. Normal (n = 24) and asthmatic (n = 123) subjects aged 10-70 years were recruited from the community. Asthma was diagnosed by full clinical assessment and was active during the previous year. Subjects recorded their peak flow immediately after rising in the morning, at 18.00 hours and just before retiring at night for 12 days. 3. The most discriminating index was the highest peak flow variability which occurred within any 1 day during the 12-day recording period, calculated as the difference between the maximum and minimum peak flows expressed as a percentage of the minimum peak flow on that day (the proposed index). This index was < 20% (90th centile) in 96% of the normal subjects and > or = 20% in 89% of the asthmatic subjects. 4. Standard indices of mean peak flow, the forced expiratory volume in 1.0 s and its responsiveness to salbutamol, had much lower sensitivities than peak flow variability. 5. It is concluded that numerical indices of peak flow variability are highly valid tests for asthma. Using an upper limit of normal of 20%, the proposed index of peak flow variability discriminates better than other indices between asthmatic and normal subjects.

Teaching and assessment in the consultation. A workshop for general practice clinical teachers

A faculty development programme for general practice clinical teachers offered a skills development workshop which specifically addressed the skills needed when teaching and assessing students consulting with patients. The course was sequential, that is, a group moved on to a new skill only when its members could demonstrate mastery of a lower-order skill. Participants practised skills and received feedback on their performance from peers and learners (students and trainees). Participants comments about the course were highly favourable and the majority foresaw a general improvement in their own personal consultation skills as a result. They recognized that the use of a valid and reliable set of criteria (the Leicester Assessment Package) was essential in order to make correct judgements about consultation performance before instituting remedial teaching.