Academic General Practice Research Articles

Routes for GPs into clinical research

This article sets out to provide those considering speciality training in general practice, and those already established as GP trainees or GPs, with a framework to consider involvement in research. The world of academia can seem mysterious and inaccessible to the outsider, and this article aims to demystify the options for adding research to your career portfolio. Academic general practice can provide a complementary role to the busy, demanding challenges of clinical practice. Academic general practice brings something different to the day-to-day of clinical work, enabling us to think outside the confines of our consulting rooms, to engage with new ideas from a host of interdisciplinary perspectives, develop and contribute to change, shaping the context for future general practice.

The Organization of Academic General Internal Medicine Practice at the Top Primary Care Schools.

While prior studies have explored staffing infrastructure for primary care practices in general, little is known about the range of academic primary care practice models and supports available for academic general internists. To characterize the range of practice arrangements and expectations for attending academic physicians in general internal medicine (GIM) practices at the top 22 medical schools across the USA. Cross-sectional survey administered electronically between October 30, 2022, and December 28, 2022. Clinical leaders in GIM at the top 22 primary care medical schools, as identified by the 2023 US News and World Report Rankings. Clinical load, productivity expectations, cross-coverage, and team-based care models. Twenty-two leaders responded, representing 68% (15/22) of medical schools surveyed. The practices were mostly in urban locations (18/22, 82%) and 86% (19/22) included residents. Practices ranged from 7 to 200 PCPs and from 3 to 112 clinical FTEs. A full-time (1.0 FTE) clinical role for academic attending GIM physicians entailed a median of 9 (IQR 8, 10) weekly half-day clinic sessions, with a median panel size expectation of 1600 (IQR 1450, 1850) patients and a median yearly RVU expectation of 5200 (IQR 4161, 5891) yearly RVUs generated. Staff support was most commonly present for prescription refills and patient portal message checks. It was less commonly available for time sensitive form completion. Occasional clinical coverage for other physicians was an expectation at all practices. In this study, we characterize the organization of and supports available in academic GIM practices affiliated with the top primary care medical schools. Our findings provide comparative information for leaders of academic GIM practices seeking to enhance primary care delivery for their faculty and trainees. They also highlight areas where standardization may be beneficial across academic GIM.

Who do patients depend on as they age and for what medical needs? An exploratory study of Chinese and Latino primary care patients

BackgroundAs the U.S. population ages, family members increasingly act as informal caregivers, particularly for minority patients and those with limited English proficiency (LEP). However, physicians often do not identify or engage caregivers until there is a health crisis. This study aims to further our understanding of characteristics associated with having a caregiver present at a primary care visit, and better understand the specific roles family caregivers engage in to support older Chinese and Latino primary care patients.MethodsPrimary care patients were surveyed by telephone in a study of language access and communication. Participants included Chinese and Latino primary care patients (≥ 65 years old) from an academic general medicine practice. We asked patients if anyone was in the room with them during their most recent primary care visit (yes = caregiver accompanied). We asked about caregiving support for various needs, and examined associations of patient and visit characteristics with being accompanied, and frequency of caregiver support roles overall and by caregiver accompaniment.ResultsAmong 906 participants, 80% preferred a non-English language, 64% were women, 88% had Medicare, and mean age was 76 years (range 65–97). 43% were accompanied to their most recent visit. Speaking English ‘not at all’ vs. ‘very well’ was associated with being caregiver accompanied (OR 3.5; 95% CI 1.3–9.7), as was older age ≥ 75 vs. 65–74 (OR 2.7; 95% CI 2.0-3.7). The most common roles being supported by caregivers included: transportation to medical appointments (63%), helping with medical decisions (60%), and talking with the doctor about the patient’s medical care (54%). Even among unaccompanied patients, substantial proportions reported caregiver support with medical decisions (45%), talking with the doctor (33%), and medical needs at home (26%).ConclusionsOpportunities for physicians to engage caregivers who have active support roles may be missed, especially if those caregivers are not present at the visit. Future interventions should aim to help physicians identify which patients have caregivers and for what needs, so they may effectively engage caregivers before a health crisis occurs.

Patterns of psychotropic drug prescriptions and general practice consultations among community-dwelling older people with dementia during the first two years of the COVID-19 pandemic

BackgroundThe COVID-19 pandemic and subsequent lockdown measures had serious implications for community-dwelling older people with dementia. While the short-term impacts of the pandemic on this population have been well studied, there is limited research on its long-term impacts. Quantifying the long-term impacts may provide insights into whether healthcare adaptations are needed after the acute phase of the pandemic to balance infection prevention measures with healthcare provision. This study aims to examine patterns of psychotropic drug prescriptions and general practice consultations in community-dwelling older people with dementia during the first two years of the pandemic.MethodsWe utilised routine electronic health records from three Dutch academic general practice research networks located in the North, East, and South, between 2019 and 2021. We (1) compared the weekly prescription rates of five groups of psychotropic drugs and two groups of tracer drugs, and weekly general practice consultation rates per 1000 participants, between the first two years of the pandemic and the pre-pandemic phase, (2) calculated changes in these rates during three lockdowns and two relaxation phases relative to the corresponding weeks in 2019, and (3) employed interrupted time series analyses for the prescription rates. Analyses were performed for each region separately.ResultsThe study population sizes in the North, East, and South between 2019 and 2021 were 1726 to 1916, 93 to 117, and 904 to 960, respectively. Data from the East was excluded from the statistical analyses due to the limited sample size. During the first two years of the pandemic, the prescription rates of psychotropic drugs were either lower or similar to those in the pre-pandemic phase, with differences varying from -2.6‰ to -10.2‰. In contrast, consultation rates during the pandemic were higher than in the pre-pandemic phase, increasing by around 38‰.ConclusionsThis study demonstrates a decrease in psychotropic drug prescriptions, but an increase in general practice consultations among community-dwelling older people with dementia during the first two years of the pandemic. However, reasons for the decrease in psychotropic drug prescriptions are unclear due to limited information on the presence of neuropsychiatric symptoms and the appropriateness of prescribing.

The under-representation of racially minoritised doctors in academic general practice training: a retrospective analysis.

General practice has one of the most diverse medical training programmes in terms of sex and ethnic background. However, this diversity of race and ethnicity is not reflected in academic GP careers, with just 17% (n = 81/473) of academic GPs being from racially minoritised groups, according to the Medical Schools Council. To determine whether GP academic clinical fellow (ACF) trainees from racially minoritised backgrounds are proportionally represented, compared with the non-academic training programme, using the annual GP ACF conference as a proxy. A retrospective analysis of conference programmes from national academic GP training conferences from 2018-2023 and demographic data obtained from Health Education England (HEE). Using conference programmes and online searches, demographic information on conference speakers was obtained and a freedom of information request was made to HEE for the demographics of GP ACFs for corresponding years. This was compared with demographic data of GP trainees and academics. On average, there were 40 speakers each year at the conference. White females (average 20.2 speakers each year) were the most well represented group, followed by White males (average 12.5), Asian females (average 3.3), Asian males (average 1.8), Black males (average 0.7), and Black females (average 0.3). HEE data from 2022 revealed that 27 (71.1%) of the 38 (excluding five who did not state their ethnicity) ACFs were White British. GP academia should be more representative of the non-academic GP training scheme. Work needs to be done to understand and overcome the structural barriers to recruiting from racially minoritised groups.

Variety is the spice of life: Academic general practice training

Variety is the spice of life: Academic general practice training

Establishment of a successful robotic pediatric general surgery practice.

Robotic-assisted surgery (RAS) has a variety of theoretical advantages, including tremor filtration, optimal visualization, and improvement of surgeon ergonomics. Though it has achieved wide application in pediatric urology, the majority of pediatric general surgeons do not employ RAS. This study reports our institution's experience with RAS on a pediatric general surgery team. Following IRB approval, a retrospective review of all pediatric patients at our academic children's hospital who underwent RAS between 2017 and 2022 for pediatric general surgical conditions was performed. Patient demographics, operation performed, operating time, complications, and recovery were evaluated. A total of 159 children underwent RAS, increasing from 10 patients in 2017 to 59 patients in 2022. The median age and weight were 15.3years and 76.4kg, and 121 (76.1%) were female. The application of RAS was successful in all cases. There were no intraoperative complications and no conversions to an open approach. Eleven patients (6.9%) had unplanned presentations to the emergency department within 30days. Five of these patients (3.1%) required admission to the hospital. This study demonstrates that the application of RAS in an academic pediatric general surgery practice is feasible and safe. The application of RAS to pediatric general surgery should continue to increase as operative teams increase their experience and comfort.Level of evidence Level IV.

The under-representation of minority ethnic groups in academic general practice.

General practice has a diverse training programme. It is majority female (57%) and more than half of all trainees are from an ethnic minority, according to the GMC workforce report 2022. However, we are not seeing the same representation of ethnic minorities in academic general practice, with 85.1% of GP professors being White. To determine if ethnic minorities are fairly represented in general practice academia, using the National Academic GP Training Conferences as a proxy. The programmes of the last five National Academic GP Training Conferences were searched and demographic information about the speakers was sought through online sources. Data were compared to demographic data available of non-academic GPs. A freedom of information request was made to Health Education England (HEE) to determine the demographic data of GP academic clinical fellows (ACF). Between the years of 2018 and 2022 there was an average of 40 speakers at the conference. The majority of speakers were White females, appearing an average of 20.2 times. Black females were the least represented, appearing an average of 0.4 times. Data available from HEE on the demographics of new ACFs for 2022 revealed that 27 (71%) of the 38 (excluding 5 who did not state their ethnicity) were White. With such a diverse training scheme, we need to have a better representation of ethnic minorities in GP academia. There is a clear problem recruiting or attracting people from ethnic minorities to an academic career and work needs to be done to understand and overcome those barriers.

Tinnitus cases after COVID-19 vaccine administration, one institution's observations

ObjectiveAfter the role out of the COVID-19 vaccine in the United States, there has been increase in case reports of tinnitus attributed to the vaccine reported. We present our institution's experience over the initial 13 month period the vaccines were available. Study designRetrospective chart review. SettingTertiary academic otology and general otolaryngology practice. PatientsPatients who received a COVID-19 vaccine and a tinnitus diagnosis code. InterventionsObservation, steroids (oral and intratympanic), diagnostic imaging and audiometry. Main outcome measuresPatients who received a COVID-19 vaccine in the time frame of 12/1/2020–12/31/21 with a diagnosis of tinnitus, an audiogram, and at least one visit with one of our Otolaryngologists were included in the study. Twenty-seven of the 1254 patients identified met these criteria. The patients ranged in age from 41 to 84 years old including seven male and twenty female patients. Sixteen received the Pfizer vaccine, seven received the Moderna vaccine and four patients received the Janssen vaccine. ConclusionsNo definite correlation could be established between COVID-19 vaccine and tinnitus. Any concurrent sudden hearing loss should be treated as usual with oral or intratympanic steroids. Health care providers should be aware of the tinnitus onset and if new or recent onset, to refer for prompt audiogram and Otolaryngology evaluation.

Success of close cooperation between academic family medicine and general practices

Success of close cooperation between academic family medicine and general practices

Prevalence and Bother of Postvoid Dribbling and Urine Spraying or Splitting: Survey of a General Gynecology Population.

Postvoid dribbling is described well for men in urologic literature but is poorly defined for women, especially in those not presenting for urogynecologic care. The objective was to assess prevalence and bother of postvoid dribbling, urine spraying (ie, deviation of the urine stream), and other bothersome voiding/storage symptoms in a general gynecology population. This was an anonymous cross-sectional survey study of women presenting to academic general gynecology practices for benign gynecologic care or well-woman visits; patients were not presenting for urinary incontinence or voiding dysfunction. A questionnaire was used to assess the presence and perceptions of voiding behavior and urinary symptoms with an emphasis on postvoid dribbling and urine spraying. The questionnaire included both the validated Questionnaire for Urinary Incontinence Diagnosis and nonvalidated questions. Nonpregnant adult women (N = 355) were surveyed. The median age was 43 years (interquartile range, 33-51 years). The sample was 45% White, 23% Black, 3% Asian, and 13% other. Furthermore, 39% were Latina; 68%, parous; and 28%, postmenopausal. The prevalence (95% confidence interval) of immediate postvoid dribbling was 186 of 327 or 57% (51-62%), and of these, it was at least somewhat bothersome in 37% but moderately-to-quite-a-bit bothersome in 8%. Urine spraying occurred in 222 of 333 or 67% (61-72%), and of these, it was at least somewhat bothersome in 53% but moderately-to-quite-a-bit bothersome in 17%. Approximately 20% reported stress and/or urgency urinary incontinence; both postvoid dribbling and urine spraying were highly associated with these symptoms. This study of women seeking benign gynecologic care shows a high prevalence of postvoid dribbling and urine spraying symptoms. However, moderate-or-greater bother was relatively uncommon.

Establishing a Deep End GP group: a scoping review.

GPs working in deprived areas, where all-cause mortality rates are higher compared to less deprived areas, face unique challenges. Despite 50 years passing since Tudor Hart's seminal 'inverse care law' paper, the health inequities gap remains wide. Deep End GP groups are frontline GP-led initiatives working to close this gap and improve the health and lives of those most in need. To use scoping methodology to map out the process of creating a Deep End GP group. A scoping review using Arksey and O'Malley's framework. MEDLINE, Embase, Web of Science, and CINAHL databases, as well as non-peer reviewed publications, were searched and articles extracted, reviewed, and analysed according to iterative inclusion criteria. From an initial search number of 35 articles, 16 articles were included in the final analysis. Key steps in starting a Deep End GP group were: quantifying patients and practices in areas of deprivation; establishing GP-led objectives at an initial meeting; regular steering group meetings with close collaboration between academic and frontline general practice, as well as the wider multidisciplinary team; and adopting a local Deep End logo. Deep End GP groups have made advances to reduce health impacts of systemic health inequities. Starting a Deep End GP group involves a multidisciplinary approach, beginning with the identification of patients and practices in areas of highest need. The findings and key themes identified in this scoping review will guide interested parties to start the journey to do the same in their locality and to join the Deep End movement.

Patient characteristics and utilization of an online patient portal in a rural academic general internal medicine practice

BackgroundOnline patient portals have the potential to improve patient engagement and health care outcomes. This is especially true among rural patient populations that may live far from their health care providers and for whom transportation is a barrier to accessing care. This study compared the characteristics of active users of an online patient portal to non-users and assessed utilization among users in a rural academic primary care clinic to identify disparities in adoption and use.MethodsWe conducted a cross sectional study of 28,028 patients in a general internal medicine clinic between June 2019 and May 2020 to assess (a) characteristics of patients who had an online patient portal account and used the patient portal compared to those who did not register for an account, and (b) the frequency of use of the patient portal (number of logons and number of messages sent and received) by patients over the study period. We compared results based on demographic characteristics, focusing on gender, age, race, presence or absence of nine chronic illnesses, smoking status, and BMI.ResultsIn the study cohort of 28,028 patients, 82% were active users of the patient portal. Females, patients aged 41–65, and non-smokers were more likely to use the portal than their counterparts. In total, patients with eight out of nine chronic illness groups studied (heart failure, cerebrovascular disease, history of a myocardial infarction, peripheral vascular disease, and renal disease) were less likely to use the patient portal than patients without these chronic conditions. On average, patients log onto the patient portal 25 times per year and send and receive 6 messages to and from the clinic. We found that females, patients older than 65, former smokers and obese patients logged on and sent and received more messages compared to the overall cohort. Although the sample size was small, on average Black patients logged onto the patient portal 19 times and sent and received 3.6 messages compared to White patients who logged on 25 times with 5.8 messages on average over the yearlong study period.ConclusionsIn a rural academic internal medicine clinic, female patients, aged 41–65, non-smokers, and those without certain chronic conditions were more likely to use an online patient portal. Recognizing and addressing barriers to patient portal use is essential for robust and sustained patient portal uptake and ensuring that the benefits of portal use are equally distributed among all patients.

Caring for Children With Medical Complexity in the Early COVID-19 Pandemic in an Ambulatory Primary Care Setting.

BackgroundChildren with medical complexity (CMC) have multiple chronic conditions and require a high level of coordinated healthcare. The risk of COVID-19 among CMC is unclear.ObjectivesWe aim to identify and describe the prevalence and experience of COVID-19 among CMC and their caregivers during the initial weeks of the COVID-19 pandemic in the NY metropolitan area.MethodsWe performed a cross-sectional study of children enrolled in a structured clinical program for CMC at a large urban, academic general pediatrics practice in NY.ResultsIn our patient population (n = 132), 16 patients had a known exposure with parents being the most common exposure in 37.5% (n = 6). Two patients were hospitalized for COVID-19 while the remainder of the confirmed or suspected COVID-19 cases were managed as an outpatient.ConclusionsCommon sources of COVID-19 exposure were family members and home care providers. Almost all of our patients experienced interruption of medical care including missed therapies and visits.

Patient Satisfaction with Telephone Versus Video-Televisits: A Cross-Sectional Survey of an Urban, Multiethnic Population

To examine differences between telephone and video-televisits and identify whether visit modality is associated with satisfaction in an urban, academic general urology practice. A cross sectional analysis of patients who completed a televisit at our urology practice (summer 2020) was performed. A Likert-based satisfaction telephone survey was offered to patients within 7 days of their televisit. Patient demographics, televisit modality (telephone vs video), and outcomes of the visit (eg follow-up visit scheduled, orders placed) were retrospectively abstracted from each chart and compared between the telephone and video cohorts. Multivariate regression analysis was used to evaluate variables associated with satisfaction while controlling for potential confounders. A total of 269 patients were analyzed. 73% (196/269) completed a telephone televisit. Compared to the video cohort, the telephone cohort was slightly older (mean 58.8 years vs. 54.2 years, P=.03). There were no significant differences in the frequency of orders placed for medication changes, labs, imaging, or for in-person follow-up visits within 30 days between cohorts. Survey results showed overall 84.7% patients were satisfied, and there was no significant difference between the telephone and video cohorts. Visit type was not associated with satisfaction on multivariable analyses, while use of an interpreter [OR:8.13 (1.00-65.94); P=.05], labs ordered [OR:2.74 (1.12-6.70); P=.03] and female patient gender [OR:2.28 (1.03-5.03); P=.04] were significantly associated with satisfaction. Overall, most patients were satisfied with their televisit. Additionally, telephone- and video-televisits were similar regarding patient opinions, patient characteristics, and visit outcome. Efforts to increase access and coverage of telehealth, particularly telephone-televisits, should continue past the COVID-19 pandemic.

Impact of a medical scribe on clinical efficiency and quality in an academic general internal medicine practice

BackgroundScribes have been proposed as an intervention to decrease physician electronic health record (EHR) workload and improve clinical quality. We aimed to assess the impact of a scribe on clinical efficiency and quality in an academic internal medicine practice.MethodsSix faculty physicians worked with one scribe at an urban academic general internal medicine clinic April through June 2017. Patient visits during the 3 months prior to intervention (baseline, n = 789), unscribed visits during the intervention (concurrent control, n = 605), and scribed visits (n = 579) were included in the study. Clinical efficiency outcomes included time to close encounter, patient time in clinic, and number of visits per clinic session. Quality outcomes included EHR note quality, rates of medication and immunization review, population of patient instructions, reconciliation of outside information, and completion of preventative health recommendations.ResultsMedian time to close encounter (IQR) was lower for scribed visits [0.4 (4.8) days] compared to baseline and unscribed visits [1.2 (5.9) and 2.9 (5.4) days, both p < 0.001]. Scribed notes were more likely to have a clear history of present illness (HPI) [OR = 7.30 (2.35–22.7), p = 0.001] and sufficient HPI information [OR = 2.21 (1.13–4.35), p = 0.02] compared to unscribed notes. Physicians were more likely to review the medication list during scribed vs. baseline visits [OR = 1.70 (1.22–2.35), p = 0.002]. No differences were found in the number of visits per clinic session, patient time in clinic, completion of preventative health recommendations, or other outcomes.ConclusionsWorking with a scribe in an academic internal medicine practice was associated with more timely documentation.

By accident or design? An exploration of the career pathways, experiences and identities of academic GPs using composite narratives

ABSTRACT At a time when UK general practice is facing significant challenges and departments of academic general practice in UK universities are in decline, this cross-sectional qualitative case study examines the experiences of general practitioner (GP) academics in a Scottish university department of general practice undergraduate education. The study explores GPs’ reasons for entering academic careers, their routes into academic careers and their experiences of balancing clinical and academic work through examining the individual narratives of GP academics. Data were gathered through autobiographical written narrative, individual interviews and an autoethnographic study, and were analysed using a thematic narrative approach. Findings are presented as composite narratives synthesising the predominant experiences of three distinct groups of GPs who entered academia at different stages of their careers. GP academics described limited understanding of academic general practice prior to taking up an academic post. Entry to academic general practice was associated with an interest in teaching and was often prompted by a dissatisfaction with clinical practice. Academic GPs described concerns about career prospects and changing professional identity but valued the scholarship and creativity associated with their academic roles. This study provides insights into the motivations of academic GPs and the factors influencing academic career progression.

Focus on medical education research in primary care: an undergraduate medical education faculty’s journey

ABSTRACT This paper provides a viewpoint on medical education research in primary care from undergraduate medical educators, discussing the issues and questions shared with other institutions, the role of medical education research in raising the profile of academic general practice, the challenges and opportunities faced and how education-based research can form an evidence-based approach to teaching.

From Theory to Reality: Establishing a Successful Kidney Genetics Clinic in the Outpatient Setting.

Genetic testing in nephrology is increasingly described in the literature and several groups have suggested significant clinical benefit. However, studies to date have described experience from established genetic testing centers or from externally funded research programs. We established a de novo kidney genetics clinic within an academic adult general nephrology practice. Key features of this effort included a pipeline for internal referrals, flexible scheduling, close coordination between the nephrologist and a genetic counselor, and utilization of commercial panel-based testing. Over the first year, we examined the outcomes of genetic testing, the time to return of genetic testing, and out-of-pocket cost to patients. Thirty patients were referred and 23 were evaluated over the course of five clinic sessions. Nineteen patients underwent genetic testing with new diagnoses in nine patients (47%), inconclusive results in three patients (16%), and clearance for kidney donation in two patients (11%). On average, return of genetic results occurred 55 days (range 9-174 days) from the day of sample submission and the average out-of-pocket cost to patients was $155 (range $0-$1623). We established a kidney genetics clinic, without a pre-existing genetics infrastructure or dedicated research funding, that identified a new diagnosis in approximately 50% of patients tested. This study provides a clinical practice model for successfully incorporating genetic testing into ambulatory nephrology care with minimal capital investment and limited financial effect on patients.

P61 Trajectories of foot pain severity over seven years and relationship to potential prognostic factors: the clinical assessment study of the foot

Abstract Background Foot pain is common and disabling in older adults however little is known about its course. The objective of this study was to identify foot pain trajectories over seven years and examine the associations between progressive symptom trajectories and potential prognostic factors. Methods All adults aged ≥50 years registered with four general practices in North Staffordshire, UK were mailed a health survey at baseline. Those reporting foot pain in the previous 12 months were invited to attend a research clinic that included a standardised interview, physical examination, and plain radiographs of the feet. Follow-up was by repeated postal surveys at 18 months, three years, 54 months, and seven years. Trajectories of repeated measures of foot pain severity in the previous month (10-point numerical rating scale) were identified using Latent Class Growth Analysis (LCGA). Logistic regression was undertaken to explore the relationship between these trajectories and both person-level and foot-level prognostic factors adjusted for covariates (age, gender, and body mass index). Results Of 560 adults with foot pain attending baseline research clinics, 425 (76%) provided data at baseline and ≥two follow-up time-points and were included in the analysis. The optimum LGCA model for foot pain severity was a 4-class model with the following trajectories: mild improving pain (n = 109, 26%); moderate improving pain (n = 179, 42%); moderate persistent pain (n = 122, 29%); severe persistent pain (n = 15, 4%). Compared with individuals with mild/moderate improving pain trajectories, those with moderate/severe persistent pain trajectories over 7 years did not differ significantly by age, sex, foot posture or radiographic foot OA phenotype at baseline, but were more likely to be overweight/obese. After adjustment for covariates, these less favourable long-term trajectories were associated with lower socioeconomic position, poorer physical and mental health, catastrophising, greater foot-specific functional limitation (Manchester Foot Pain and Disability Index), and self-reported hallux valgus at baseline (Table 1). Conclusion Over a 7-year period, one-third of individuals had persistent moderate to severe pain. Targeting interventions to modifiable prognostic factors such as obesity and hallux valgus may have the potential to improve long-term outcomes in people with foot pain. Disclosures M. Marshall None. M. Blagojevic-Bucknall None. T. Rathod-Mistry None. M.J. Thomas None. J.J. Edwards Other; JJE is part of The Keele Academic General Practice which has received funding from Bristol-Myers Squibb to develop and evaluate a quality improvement tool in anticoagulation. G. Peat None. H.B. Menz None. E. Roddy None.