Experiences Of General Practitioners Research Articles

Humanity in Healthcare: The heart and soul of medicine

This interesting, unusual and comprehensive book aims to examine practical ways in which the arts can help healthcare professionals to understand the experiences of suffering and illness. Written by an experienced general practitioner, it offers a broad perspective on the potential contribution of the arts towards fostering a humane approach to the care of those who are ill or suffering.

Off‐label prescribing to children: attitudes and experience of general practitioners

To identify experience with and attitudes towards paediatric off-label prescribing in primary care. A prospective questionnaire survey was sent to a sample of Scottish primary care practices (346 doctors in 80 general practices located throughout Scotland). Two hundred and two (58%) completed questionnaires were returned. Over 70% of GPs admitted to being familiar with the concept, and 40% to knowingly prescribing off-label. The most important sources of paediatric prescribing information were the British National Formulary (81%), personal experience (71%) and previous prescription notes (45%). The most common reason given by GPs for off-label prescribing was prescribing for a younger age than recommended, although prescribing data confirm that age is the least important and dose the most important reason for such prescribing. When asked to comment upon different causes for off-label prescribing, 80% of respondents expressed appropriate awareness of and concern for the described scenarios. Over 97% of GPs ranked development of paediatric formulations and clearer dosage information more highly than clinical trials as a means to reducing off-label prescribing. Despite high levels of off-label prescribing in primary care in the UK, the majority of GPs claimed to be familiar with the concept, although less than half were aware of this common practice. A clear disparity between perceived and actual reasons for off-label prescribing was noted, possibly due to a reliance on personal experience, colleague experience or previous patient prescription notes as a guide to prescribing.

Interpreters’ experiences of general practitioner–patient encounters

Objective. To study interpreters’ experiences of problems in cross-cultural communication with special regard to the general practitioner (GP)–patient encounter. Design. A focus-group interview with authorized interpreters was carried out. A phenomenographic method was used in the analysis.Setting. Primary health care.Results. The interpreters displayed a number of problems mainly related to the difficulty in balancing the triad relation (GP–patient–interpreter), the role of the interpreter in relation to other healthcare staff, the time aspects of the translation procedure, and the problems of diverse health beliefs and cultural inequalities.Conclusion. The interpreters notice a set of difficulties that need to be highlighted in order to improve consultations with cross-cultural GP–patient encounters.

General practitioners' perceptions of sharing workload in group practices: qualitative study

Objective To explore general practitioners' beliefs and experiences of distribution of workload and teamwork between doctors in general practice.Design Qualitative semistructured interview study.Setting South London.Participants 18 general practitioners from 11...

The effects of a patient shortage on general practitioners? future income and list of patients

The literature on physician-induced demand (PID) suffers from an inability to distinguish between the effect of better access and the effect of patient shortage. Data from the Norwegian capitation trial in general practice give us an opportunity to make this distinction and hence, study whether service provision by physicians is partly income-motivated. In the capitation trial, each general practitioner (GP) has a personal list of patients. The payment system is a mix of a capitation fee and a fee for service. The data set has information on patient shortage, i.e. a positive difference between a GP’s preferred and actual list size, at the individual practice level. From a model of a GP’s optimal choice we derive the GP’s optimal practice profile contingent on whether the GP experiences a shortage of patients or not. To what extent GPs, who experience a shortage, will undertake measures to attract patients or embark on a service-intensive practice style depends on the costs of the various measures relative to their expected benefit. The model classifies GPs into five types. In the empirical analysis a panel of GPs is followed for 5 years. Hence, transitory effects should have been exhausted. We show that GPs who experience a shortage of patients have a higher income per listed person than their unrationed colleagues.

The effects of a patient shortage on general practitioners’ future income and list of patients

The literature on physician-induced demand (PID) suffers from an inability to distinguish between the effect of better access and the effect of patient shortage. Data from the Norwegian capitation trial in general practice give us an opportunity to make this distinction and hence, study whether service provision by physicians is partly income-motivated. In the capitation trial, each general practitioner (GP) has a personal list of patients. The payment system is a mix of a capitation fee and a fee for service. The data set has information on patient shortage, i.e. a positive difference between a GP’s preferred and actual list size, at the individual practice level. From a model of a GP’s optimal choice we derive the GP’s optimal practice profile contingent on whether the GP experiences a shortage of patients or not. To what extent GPs, who experience a shortage, will undertake measures to attract patients or embark on a service-intensive practice style depends on the costs of the various measures relative to their expected benefit. The model classifies GPs into five types. In the empirical analysis a panel of GPs is followed for 5 years. Hence, transitory effects should have been exhausted. We show that GPs who experience a shortage of patients have a higher income per listed person than their unrationed colleagues.

Managing or managed? Experience of general practitioners in English Primary Care Groups and Trusts.

This article presents findings from a wider UK Department of Health funded evaluation of English Primary Care Groups (PCGs) and Trusts (PCTs). It presents qualitative research into the experiences of general practitioners (GPs) in these PCG/Ts and explores the extent to which GPs manage, or are managed by, these new organizations. Using the framework of stratification theory, the paper explores whether there is any evidence to suggest PCTs will strengthen collective medical control over resource allocation whilst fending off management control of clinical decision-making. It also examines whether individual GPs not involved at board level feel a loss of control over decisions and their own clinical practice. A stratified random sample of 20 GPs was selected for in-depth interview. The in-depth interviews were designed to capture the full complexity and variety of GPs' experiences that routinely available data could not capture. GPs were anxious that clinical decisions were, or could, be overridden by other concerns such as cost control. The extent to which primary care professionals leading PCGs and PCTs could fend off managerial control was doubted. However, whilst GPs felt under threat, this was more an anticipated threat than a reality. GPs within PCG/Ts seem prepared to accept a degree of standardization if they feel that this is consistent with good clinical care. However, although there was the impression of greater central control, PCGs and PCTs and Government policies did not appear to have made an impression on clinical autonomy.

User satisfaction with a real-time automated feedback system for general practitioners: a quantitative and qualitative study

The GRIF automated feedback system produces real-time comments on the appropriateness of diagnostic tests ordered by general practitioners (GPs) based on recommendations from accepted national and regional practice guidelines. We investigated the experiences of GPs with this system and, more specifically, with the recommendations produced by the system as well as their views on using this system in daily practice. We tested the GRIF system in an experiment in a laboratory setting and in a daily practice trial. General practitioners. In the laboratory experiment, GPs used the GRIF system to assess the appropriateness of 30 request forms. Each of the GPs was confronted with requests they had submitted to the diagnostic unit of the hospital in the past. In the field trial, the GRIF system was applied during patient consultations for 1 year. We measured GPs' satisfaction with the system using a questionnaire, and also conducted group discussions (in the laboratory experiment) and in-depth interviews (in the field trial) to elicit GPs' opinions of and experiences with the system. In addition, we explored GPs' reasons for not accepting the comments offered by the GRIF system. The results show that the GPs in the laboratory experiment had more positive attitudes towards the system compared with participants in the field trial. All discussion groups and most of the GPs in the field trial regarded receiving the immediate feedback during the test ordering process as an important advantage. The most frequently mentioned reason to reject the recommendation was disagreement with the content and/or the recommendations in the practice guidelines. Apart from securing agreement on guideline content, a prerequisite for using GRIF in daily practice on a large scale is that more attention is paid to promotion of the guidelines and their adoption, and stimulation of a positive attitude towards the practice guidelines among the users.

The family practitioner family: the use of metaphor in understanding changes in primary health care organizations

Current UK health policy guidance locates primary care at the frontiers of health care modernization. New organizational structures have resulted in general practitioner (GP) practices being brought together in Primary Care Groups (PCGs) and Primary Care Trusts (PCTs) each serving a much larger population group than the traditional GP practice. These changes have been accompanied with a need to explore new ways of working and thinking. This paper draws upon the experiences of nurses and GPs participating in an evaluation of workforce planning issues in primary health care. It explores how practitioners working in PCGs across one geographical area were able to gain a better understanding of what these changes, to both the structure and process of practice, might involve. During this developmental process the respondents used ‘the family’ metaphor, as a form of ‘shorthand’ to orientate themselves to the new responsibilities, challenges and opportunities presented by these changes to primary health care. It was in the use of terms and constructs that were familiar to their ‘everyday life’ experiences that made taking the first tentative steps in the change process easier. This paper suggests that using metaphors may be a powerful tool for policy makers, practitioners,managers and for researchers as they seek to communicate a plan for change and in understanding what these changes might mean.

Copying GP referral letters to patients: the benefits and practical implications

The NHS Plan promises that letters about patients will be copied to them as of right. Yet, beyond a few small studies, little is known of the views of clinicians and patients about the process, and few have any experience of it. The aim of this study was to elicit the views of clinicians and patients about the idea of copying general practitioner (GP) referral letters to patients (part one), and to describe the experiences of GPs and patients actually involved in the process (part two). The setting was one health district in the north of England (part one) and three research practices in the same district (part two). A questionnaire survey was used to elicit the views of 214 consultants, 260 GPs and 584 patients (part one), and semi-structured interviews to assess the experience of 11 GPs and 48 patients involved in the process of copying referral letters (part two). The main outcome measures were the perceived and reported benefits and disadvantages of copying referral letters to patients and the practical implications of making this a routine activity. In the first part of the study, replies were received from 148 hospital consultants (70%), 144 GPs (55%) and all the patients in an opportunistic waiting-room sample. Seventy-six of these consultants (55%) but only 49 of the responding GPs (34%) thought that referral letters should be routinely copied to patients. This compares with 499 (85%) of the patients surveyed who were in favour of this in principle. Potential benefits suggested by clinicians included better informed patients and improved communication. There were concerns about making patients anxious and about the difficulty of writing letters that were both comprehensible to patients and informative to colleagues. In the second part of the study, GPs involved in copying letters to patients experienced no major problems in writing letters that patients could understand but which were also fully informative to consultants. There was some increase in administrative workload. A sense of increased openness in the communication process was reported. Patients valued seeing a copy of their referral letter and few admitted to any major problems in understanding its content. In general, they felt better informed about their illness and better prepared for their outpatient appointment −44 patients (91%) thought copying letters should become routine practice. In this study, carried out before the NHS Plan was published, a majority of consultants supported, with some reservations, the idea that patients should receive a copy of their GP referral letter. Surveyed GPs anticipated major difficulties in copying letters to patients, and most were not in favour of this becoming routine practice. Patients and GPs actually involved in copying letters reported important benefits but also identified issues which will need to be addressed before copying letters can be effectively implemented as a routine activity.

Rural General Practitioner Experience of Work‐Related Violence in Australia

To identify prevalence, precipitants and risk factors of violence and aggression towards Australian rural general practitioners (GPs). Six focus groups were held with GPs from rural Western Australia and from two rural Divisions of General Practice in New South Wales and Victoria. A questionnaire was developed and all GPs in these three geographical areas were surveyed. The survey results showed that 73% of respondents had experienced some form of violent or aggressive behaviour from patients and 20% had been subjected to physical abuse during their careers as rural doctors. Physical abuse mostly occurred after hours and in a hospital or multipurpose centre. Violence and aggression were often associated with patient drug and alcohol intoxication and psychological disorders. Workplace violence and aggression against rural GPs is a frequent problem. Adequate funding and safe facilities for after-hours care and training for GPs in managing dangerous situations should be provided.

When General Practitioners Become Patients

There is little known about the lived experiences of general practitioners (GPs) who become patients, despite good documentation of their health problems. This study provides a qualitative perspective on issues identified by GPs when they tell stories about their experiences of illness, including their interactions with attending physicians. Respondents articulated several tensions inherent in their experiences of being patients. These can best be described as competing discourses, both overt and covert, which intersect in ideas about patienthood, professionalism and competency. GPs are reluctant to admit to illness and find it difficult to relinquish control, while the consulting doctor knows the patient has medical expertise and is aware that his/her consulting style and choice of management will be scrutinized closely. Both doctors can experience role discomfort, even role ambiguity, but this is rarely articulated. This can lead to difficulties in shared management of the illness.

Financial incentives, competition and a two tier service: lessons from the UK National Health Service internal market

The experience of General medical practitioner (GP) fundholding is analysed for evidence of the response by family doctors to financial incentives. An analysis of consultant outreach, the local provision of out-patient services, in Scotland finds little evidence of a response, based on comparing the experience of fundholders with non-fundholders. At least in the case of hospital based services, financial incentives seem to be of secondary importance. Financial incentives for such services depend on consultant compliance which, arguably, was missing when it came to creating a two-tier service which deliberately favoured patients from fundholding practices.

Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners

Objective: To explore the suitability of a screening based intervention for excessive alcohol use by describing the experiences of general practitioners who tried such an intervention in their everyday practice.Design:...

The 3+ visit plan: history and rationale

The 3+ Visit Plan was developed by the National Asthma Council's General Practitioners' Asthma Group in response to the comments and experiences of General Practitioners that the Six Step Asthma Management Plan is difficult to apply in GP settings. The 3+Visit Plan is a re-working of those six steps of best asthma practice into the format of three (or more) consultations specifically for asthma. It is a proactive program, requiring a partnership between GP and patient with the aim of engaging both parties, so that all the elements of best asthma management are completed in a structured, logical and timely way. This is in contrast to the more usual reactive care, e.g. providing rescue medication when the patient visits with exacerbations or dealing with asthma as an “add-on” issue in a consultation which was primarily for another reason. The resources consist of a doctor's aide memoire, with the recommended steps for each visit and illustrations to assist in patient education, and a pad of tear-off sheets for patients. The patient resource sets out the steps per visit in clear, layperson's English and also contains illustrations. It also includes space for appointment times. This initiative of the National Asthma Council has now been taken up, and substantially funded by, the Australian government and a national implementation plan is currently underway.

‘In the Family’: Experiences of General Practitioners in Wales on the Management of Individuals at Risk of Familial Cancer

A cancer genetics service for Wales was established in 1998. This study aimed to obtain baseline information about how often general practitioners (GPs) see patients with cancer genetic concerns, frequency of referral for specialist genetic assessment and knowledge of familial cancer risk. A questionnaire was sent to all GPs in two Local Health Groups in Wales. To determine GPs' management of individuals seeking advice regarding a family history of cancer, five hypothetical cancer history scenarios were presented, including breast, bowel and ovarian cancer. There was substantial variation in the number of patients seeking advice regarding a cancer family history, and a range in the proportion referred onwards for specialist genetic assessment. GPs are aware of the contribution that age of cancer diagnosis and number of affected relatives can have in the genetic risk assessment of an unaffected relative. However, there is uncertainty when a family history corresponds to moderate risk.

Book of the Month: Friends in Low Places

Book of the Month: Friends in Low Places

Experience of Norwegian general dental practitioners with solid state and storage phosphor detectors.

To evaluate the opinions of Norwegian dental practitioners regarding the use of solid state sensor and storage phosphor (SP) detectors for intra-oral radiography. A questionnaire received from 2199 dentists 309 (219 male, 86 female, four unknown) confirmed the use of digital radiography in their practices. Sixty-one per cent of dentists used a SP and 35% a sensor system; four (1.3%) used both. Approximately 50% of dentists had experienced technical problems and 33% had needed repairs. Almost all dentists stored their images on the hard disk (>97%) and 81% made a daily back-up. More sensor than SP users found difficulty with the positioning holder. Two-thirds of dentists reported digital image quality was the same or better than film. More Digora (Soredex, Helsinki, Finland) users reported better image quality than Denoptix (Gendex, Milan, Italy) or Digident (Digident, Nesher, Israel) users. Mean reduction in exposure time was 55% (range 2-90%), although 17 dentists stated that no reduction was achieved. Approximately half of the sensor users also used film and 38% of the SP users. Film was used more often for bitewing examination by the sensor users (27%) than by the SP users (4%). Mean time saved by the sensor users was 36 min/day (range 10-120) and by the SP users 25 min/day (range 5-120). The majority of dentists felt that digital image quality was the same or better than film and exposure and examination times were reduced. However, technical problems and repairs were common.

Survey of injectable methadone prescribing in general practice in England and Wales

Little is known about the extent and conduct of general practice prescribing of injectable methadone to opiate users in England and Wales. A postal questionnaire survey of general practitioners (GPs) was conducted in 1999 to ascertain how many GPs were prescribing injectable methadone, to describe their prescribing practices and to explore their perceptions of the service they provided. Four hundred and seven GP practices in 77 out of 105 health authorities were apparently prescribing injectable methadone. The difficulties in identifying, and obtaining a response from, GPs prescribing injectable methadone are discussed. Analysis of 93 usable returned questionnaires showed a range of GP characteristics and experience. The GPs were treating 211 patients with injectable methadone and a further 2003 patients with oral methadone. Prescribing practice and monitoring arrangements did not always follow national guidelines. A minority of GPs had received training in the management of drug dependency. They were most likely to decide to prescribe injectable treatment on the recommendation of a specialist drug agency, and to discontinue prescribing if there was a suspicion of diversion of prescribed ampoules. Although significant numbers of GPs felt unsure about their skills and the support available to them, most appeared to be managing their patients thoughtfully and with appropriate outcomes in mind. Recent policy documents from the Department of Health and the Home Office have questioned the place of injectable methadone in the treatment of opiate misuse, particularly in a general practice setting. A Home Office licence will shortly be required to prescribe injectable methadone. This survey suggests a minority of GPs would apply for such a licence. More research into the effectiveness of injectable methadone treatment in a range of settings is needed before conclusions can be drawn about the appropriateness of providing this treatment in general practice.

Prescribing analysis and cost tabulation (PACT) data: an introduction.

PACT (prescribing analysis and cost tabulation) data is a national data set which analyses prescribing data in terms of cost and number of items (volume). At an organizational level, PACT is used to monitor and control prescribing cost and to set prescribing budgets. At individual practitioner level, it is used as an educational and audit tool. The Prescription Pricing Authority (PPA) has sent general practitioners (GPs) quarterly summary reports of their own prescribing since 1988. From 2000 prescriptions written by nurse prescribers have been added to the national PACT data set, and health authorities, practices and trusts will now be analysing both nurse and GP prescribing quality. Because of differences in the way they work, nurse prescribers will not automatically receive individual reports of their own prescribing. However they should be able to access this information on request through their local health authority prescribing advisers and primary care group pharmacists. Based on GP experience, nurse prescribers should find PACT data a useful learning resource for individual and team practice development.