Multiskilling: a survey of occupational therapy practitioners' attitudes

OBJECTIVE: Multiskilling has been identified as one means of reducing she cost of health care. This study examined occupational therapy practitioners' knowledge of multiskilling, how it is affecting service delivery and quality of care, and how therapists believe the addition of skills should occur. METHOD: A questionnaire was constructed for the survey and mailed to a random sample of 200 occupational therapists and occupational therapy assistants, all of whom were members of the American Occupational Therapy Association. RESULTS: The 117 respondents had a moderate understanding of multiskilling. They responded that multiskilling is beneficial to both the occupational therapy profession and the clients it serves, but they were also aware of its potential risks or disadvantages. According to respondents, multiskilling occurs formally through defined protocol and; more commonly, informally, driven by necessity and the desire to treat the client most effectively. CONCLUSION: The results indicate a need for the occupational therapy profession to define multiskilling and cross training; develop ways of serving clients that respond to administrative needs and constraints while preserving the uniqueness of occupational therapy; and monitor treatment outcomes of all service delivery methods to provide information regarding efficiency, effectiveness, and client satisfaction.     

General practitioners' management of acute back pain: a survey of reported practice compared with clinical guidelines

OBJECTIVE: To compare general practitioners' reported management of acute back pain with 'evidence based' guidelines for its management. DESIGN: Confidential postal questionnaire. SETTING: One health district in the South and West region. SUBJECTS: 236 general practitioners; 166 (70%) responded. OUTCOME MEASURES: Examination routinely performed, 'danger' symptoms and signs warranting urgent referral, advice given, and satisfaction with management. RESULTS: A minority of general practitioners do not examine reflexes routinely (27%, 95% confidence interval 20% to 34%), and a majority do not examine routinely for muscle weakness or sensation. Although most would refer patients with danger signs, some would not seek urgent advice for saddle anaesthesia (6%, 3% to 11%), extensor plantar response (45%, 37% to 53%), or neurological signs at multiple levels (15%, 10% to 21%). A minority do not give advice about back exercises (42%, 34% to 49%), fitness (34%, 26% to 41%), or everyday activities. A minority performed manipulation (20%) or acupuncture (6%). One third rated their satisfaction with management of back pain as 4 out of 10 or less. CONCLUSIONS: The management of back pain by general practitioners does not match the guidelines, but there is little evidence from general practice for many of the recommendations, including routine examination, activity modification, educational advice, and back exercises. General practitioners need to be more aware of danger symptoms and of the benefits of early mobilisation and possibly of manipulation for persisting symptoms. Guidelines should reference each recommendation and discuss study methodology and the setting of evidence.     

Service-mix in general dental practice in Japan: a survey in a suburban area

The authors describe a supernumerary muscle in each orbit of an elderly male subject. There appear to be no previous reports of this muscle; most reports of anomalies of extraocular muscles describe hypoplasia or aplasia. Thirty-five formalin-fixed cadavers assigned to medical students for dissection were studied. The orbits were dissected by a superior approach which involved removal of the orbital plate of the frontal bone and the superior orbital margin. A supernumerary extraocular muscle was seen in each orbit of one cadaver, located between the superior oblique and levator palpebrae superioris muscles. It originated on the inferior surface of the lesser wing of sphenoid bone and was inserted into the skin of the medial one-third of the upper eyelid. It was innervated by a branch from the superior division of the oculomotor nerve. The insertion of the muscle into the upper eyelid produced a crease running obliquely upwards and medially, from the junction of the medial one-third and lateral two-thirds of the lid margin, towards the medial part of the superior orbital fold. The authors suggest the name levator palpebrae superioris accessorius for this muscle in view of its topography and action as tested in the cadaver. The significance of the findings is discussed and the literature on the development of the muscles supplied by the oculomotor nerve is reviewed.     

The role of the general practitioner in postnatal care: a survey from Australian general practice

BACKGROUND: Despite the practice of routine postnatal check-ups, many women experience problems in the months after childbirth. General practitioners (GPs) are involved in routine postnatal care, yet little research has been undertaken to explore this role. AIM: To report the views of Australian GPs as to what physical examination and discussion should take place at the routine six week postnatal check-up and to determine the influence of gender on the approach to the check-up. METHOD: Postal survey of 1104 Australian GPs, yielding an eligible sample of 1022. RESULTS: A total of 715/1022 (70%) usable surveys returned. Over 65% of GPs recommend routine examination of the abdomen, blood pressure, perineum, vagina, pelvic floor, and breasts at the six week check-up. Fewer than a half the sample believed that physical problems (urine and bowel symptoms, back problems), sexual issues, relationship and parenting issues should be routinely discussed. After controlling for age, practice location, obstetric practice, and qualifications, the sex of the GP remains an important factor influencing the GP's approach to postnatal care. Female GPs are three times more likely to believe that maternal feelings should be discussed routinely and about twice as likely to believe that infant sleeping/behaviour, maternal sleeping/diet/tiredness, coping with other children, relationship with partner, and household work should form part of the routine discussion with all recent mothers. CONCLUSIONS: Sex of practitioner and older age (60 years or more) are the two most important influences on a GP's approach to postnatal care. This study indicates a need for GPs to shift their focus from routine examination to indicated examination to allow more time to discuss common postnatal problems.     

Bereavement care in general practice: a survey in South Thames Health Region

BACKGROUND: Studies have shown that bereaved individuals suffer increased rates of physical and mental ill health. Bereavement support has recently been advocated as an area of prevention in primary care, with suggestions that general practitioners (GPs) should adopt protocols for the active follow-up of their bereaved patients, which relies on the early notification of deaths by hospitals and hospices. Little is known about the routine care currently provided by GPs and primary health care teams (PHCTs) to support their bereaved patients. AIMS: To explore GPs' perceptions of patient death notifications by hospitals and hospices. To describe practice policies relating to patient deaths and the provision of bereavement support. METHOD: Postal questionnaires were sent to senior partners of a random sample of 500 general practices in South Thames Health Region. RESULTS: Three hundred and fifty-three practitioners responded (71%). Hospitals were perceived to be significantly slower than hospices in notifying deaths (P < 0.0001). One hundred and ninety-six practices (56%) kept death registers, 230 (65%) discussed deaths together, and 142 (40%) identified bereaved relatives. One hundred and thirty-seven practices (39%) routinely offered bereaved relatives contact with a PHCT member; while 133 (38%) supported only those who asked for help. Routine support was significantly more likely to be provided by practices that kept a death register, discussed deaths together, identified bereaved relatives, and had a special interest in palliative care. CONCLUSIONS: GPs perceive hospitals to be slower than hospices at notifying deaths, particularly in the first 24 hours. They are divided over whether bereavement support should be proactive or reactive. Keeping a practice death register, discussing deaths together, and identifying newly bereaved relatives are activities related to providing routine bereavement care.     

A survey of audit activity in general practice

BACKGROUND: Since 1991, all general practices have been encouraged to undertake clinical audit. Audit groups report that participation is high, and some local surveys have been undertaken, but no detailed national survey has been reported. AIM: To determine audit activities in general practices and the perceptions of general practitioners (GPs) regarding the future of clinical audit in primary care. METHOD: A questionnaire on audit activities was sent to 707 practices from 18 medical audit advisory group areas. The audit groups had been ranked by annual funding from 1992 to 1995. Six groups were selected at random from the top, middle, and lowest thirds of this rank order. RESULTS: A total of 428 (60.5%) usable responses were received. Overall, 346 (85%) responders reported 125.7 audits from the previous year with a median of three audits per practice. There was no correlation between the number of audits reported and the funding per GP for the medical audit advisory group. Of 997 audits described in detail, changes were reported as 'not needed' in 220 (22%), 'not made' in 142 (14%), 'made' in 439 (44%), and 'made and remeasured' in 196 (20%). Thus, 635 (64%) audits were reported to have led to changes. Some 853 (81%) of the topics identified were on clinical care. Responders made 242 (42%) positive comments on the future of clinical audit in primary care, and 152 (26%) negative views were recorded. CONCLUSION: The level of audit activity in general practice is reasonably high, and most of the audits result in change. The number of audits per practice seems to be independent of the level of funding that the medical audit advisory group has received. Although there is room for improvement in the levels of effective audit activity in general practice, continued support by the professionally led audit groups could enable all practices to undertake effective audit that leads to improvement in patient care.     

Obstetric practice amongst Queensland general practitioners: a survey of needs and attitudes

A survey of Queensland general practitioners was carried out to assess their needs and attitudes regarding obstetric practice. Less than half of the respondents now practise obstetrics, and many general practitioners felt a lack of support from specialist obstetricians, paediatricians, and anaesthetists. Many of the respondents expressed needs for further obstetric training, especially in labour ward management and neonatal care; however, few were able to attend extended courses.     

Four years' experience of a senior house officer rotation in general medicine including general practice

A four-month post in general practice was included as an option available to doctors applying for a year-long medical senior house officer (SHO) rotation since August 1993. This study sought the views of SHOs before and after undertaking the general practice post. SHOs gained an understanding of modern general practice and changed their views about certain aspects of general practice. They reported gaining a range of generic skills, which included communication, consultation, and clinical skills. These perceived benefits suggest that such experience merits wider adoption and further evaluation.     

Values in psychotherapy: A survey of practitioners' beliefs.

Investigated whether psychotherapists believe their values influence treatment and, if so, how they should be communicated to the patient. Questionnaires completed by 319 experienced psychotherapists (average age 43.9 yrs) indicated that 89% agreed that values of the therapist have a direct influence on therapy. 43% agreed and 37% disagreed that the therapist's values should influence therapy, with behaviorally and humanistically oriented Ss more likely to agree than psychoanalytically oriented Ss. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sample survey methods as a quality assurance tool in a general practice immunisation audit

AIMS: In a multidoctor family practice there are often just too many sets of patients records to make it practical to repeat an audit by census of even an age band of the practice on a regular basis. This paper attempts to demonstrate how sample survey methodology can be incorporated into the quality assurance cycle. METHODS: A simple random sample (with replacement) of 120 from 580 children with permanent records who were aged between 6 weeks and 2 years old from an Auckland general practice was performed, with sample size selected to give a predetermined precision. The survey was then repeated after 4 weeks. RESULTS: Both surveys were able to be completed within the course of a normal working day. An unexpectedly low level of under 2 years olds that were recorded as not overdue for any immunisations was found (22.5%) with only a modest improvement after a standard telephone/letter catch up campaign. Seventy-two percent of the sample held a group one community services card. CONCLUSIONS: The advantages of properly conducted sample surveys in producing useful estimates of known precision without disrupting office routines excessively were demonstrated. Through some attention to methodology, the trauma of a practice census can be avoided.     

A study of general practitioners' skin surgery in Canterbury

AIMS: To evaluate skin surgery done by general practitioners in Christchurch. METHODS: Twenty-eight general practitioners performing regular skin surgery were studied. Their clinical accuracy and completeness of excision was analysed. Skin lesions referred for specialist treatment were also studied. RESULTS: Three hundred and three lesions were sent to the laboratory for analysis by participating practitioners. Sixty-one malignancies were present comprising 29 basal cell carcinomas, 28 squamous cell carcinomas, three malignant melanomas and one cutaneous lymphoma. Nineteen of the 61 malignant lesions were incompletely excised. Twenty eight further lesions were referred to specialists for treatment. CONCLUSIONS: General practitioners in Canterbury perform more skin surgery and remove more malignant lesions than their British counterparts. Although the adequacy of their skin surgery is better than other groups studied overseas there is considerable room for improvement.     

Access to complementary medicine in general practice: survey in one UK health authority

Complementary therapy (CT) has become increasingly popular with the general public and interest from the health professions has been rising. There has been no study focusing on the pattern of availability of CT within urban and inner-city general practice. We aimed to describe the prevalence and pattern of access to complementary therapy in this setting, identifying the characteristics of practices offering CT and the perceived barriers to service provision. We sent a postal questionnaire to all 254 general practices on the Birmingham Family Health Services Authority list. Practices were asked whether they offered any access to CTs, how services were organized and which therapies were available and to identify any barriers to provision. 175 practices (68.9%) responded. Half of the practices offered access to CT. Of these, half offered an in-house service, usually provided by the doctor (81.8%). Of GPs practising therapies themselves, 58% began in or after 1990. Seventeen separate therapies were offered, most commonly acupuncture, osteopathy, chiropractic, hypnotherapy and homoeopathy. Practices significantly more likely to offer access to CT were of larger list size and training or teaching practices. They were equally likely to be fundholders or non-fundholders. Practices offering an in-house service tended to be fundholding, training and of larger list size. Finance was perceived as the major barrier. In the area studied, many patients now have some access to CT within primary care, often within their own practice. In the main, therapies offered are the 'medically acceptable face' of complementary medicine.     

Prevalence of fatigue and chronic fatigue syndrome in a primary care practice

BACKGROUND: Our goals were to determine the prevalence of unusual, debilitating fatigue and the frequency with which it was associated with the chronic fatigue syndrome (CFS) or other physical or psychological illness in an outpatient clinic population. METHODS: We prospectively evaluated a cohort of 1000 consecutive patients in a primary care clinic in an urban, hospital-based general medicine practice. The study protocol included a detailed history, physical examination, and laboratory and psychiatric testing. RESULTS: Five patients who came because of CFS studies were excluded. Of the remaining 995, 323 reported fatigue, and 271 (27%) complained of at least 6 months of unusual fatigue that interfered with their daily lives. Of the 271, self-report or record review revealed a medical or psychiatric condition that could have explained the fatigue in 186 (69%). Thus, 85 (8.5%) of 995 patients had a debilitating fatigue of at least 6 months' duration, without apparent cause. Of these patients, 48 refused further evaluation, and 11 were unavailable for follow-up; 26 completed the protocol. Three of the 26 were hypothyroid, and one had a major psychiatric disorder. Of the remaining 22 patients, three met Centers for Disease Control and Prevention criteria for CFS, four met British criteria, and 10 met the Australian case definition. The point prevalences of CFS were thus 0.3% (95% confidence interval [CI], 0% to 0.6%), 0.4% (95% CI, 0% to 0.8%), and 1.0% (95% CI, 0.4% to 1.6%) using the Centers for Disease Control and Prevention, British, and Australian case definitions, respectively. These estimates were conservative, because they assumed that none of the patients who refused evaluation or were unavailable for follow-up would meet criteria for CFS. CONCLUSIONS: While chronic, debilitating fatigue is common in medical outpatients, CFS is relatively uncommon. Prevalence depends substantially on the case definition used.     

Dialogue medicine: a health-liberating attitude in general practice

The threespine stickleback Gasterosteus aculeatus is an important model in evolutionary and ethologic studies. Its utility would greatly be increased by the availability of molecular markers distinguishing individuals and populations. Such markers can be provided by the major histocompatibility complex (Mhc) genes, which are well known for their extensive polymorphism. In the present study, both class I and class II B Mhc genes have been identified and sequenced. Fifteen distinct class I exon 2 and exon 3 sequences were obtained and assigned to 12 loci on the basis of intron 2 length differences. Some of the loci appear to be related to class I loci identified previously in cichlid fish. The intron 2 sequences and insertions/deletions in exon 2 group the loci into three families (with one family divided further into two subfamilies) derived from different ancestral genes. The ancestors presumably diverged from one another before the divergence of Gasterosteiformes from Perciformes. The 12 distinct class II B sequences may be derived from six loci, which are, however, closely related to one another in both exonic and intronic parts and may have diverged from a single common ancestor after the divergence of Gasterosteiformes from Perciformes. The intron 2 of some of the class I genes contains two microsatellites that can be used as markers, in addition to the polymorphism of the Mhc genes in their exonic regions.