Professional conditions and satisfaction in general practice in 1993. Practice profile of Norwegian primary physicians

European study of General Practice (GP) task profiles was carried out in 30 European countries in 1993. We analyzed the Norwegian results. 164 primary care physicians, 51% of a random sample, answered a questionnaire. 147 kept a diary on their practice for one week. Compared with results from two earlier studies performed 15 years ago, the proportion of female GPs had doubled to 25%, there were more group practices, more time was spent on vocational training and continuous education, and night service was less frequent than in 1978. 45% were specialists in general practice and 7% in community medicine. Job satisfaction was high, and highest for women, fee-for-service GPs on contract, and GPs who cooperated with other health professionals.     

Dermatology in Germany

In Germany, dermatology has a long tradition as a medical specialization. The first dermatological university departments were established about 120 years ago. From the beginning, venerology was integrated in this field. Today it also covers andrology, allergy, medical cosmetology, mycology, dermatosurgery, phlebology and photodermatology. This broad spectrum more and more gives rise to competition with other medical fields. About 77% (n = 3281) of all German dermatologists (n = 4240 in 1997) work in private practices. The others are employed in clinical departments. The official number of working physicians in Germany in 1997 was 343,556; about 1.5% of them were dermatologists. This means that one dermatologist takes care of 20,000 people. The overwhelming majority of dermatological patients directly contacts the specialist and are not referred by general practitioners (GPs) who comprise about 40% of all German physicians. This is a great advantage over those countries in which patients primarily have to consult the GP. At present, there is a discussion initiated by GPs to change this system in Germany and to reestablish the GP's role as "gatekeeper". Dermatologists together with other specialists are trying to prevent this an to maintain the traditional broad spectrum of German dermatology.     

From frustration to red fury: a description of work-related anger in male registered nurses

This article is Part II of a three part article. Part I described work-related anger experiences of female registered nurses, and in this article findings from a companion study of male RNs are presented. In phenomenological interviews, male nurses describe their work environment as hostile, causing them to be on the defensive and less productive. Sources of angle included attacks from physicians, coworkers, and managers; lack of assistance and support from peers; and differential treatment based on gender. The men stated they were called upon for physical tasks rather than for their nursing knowledge. Severed relationships and feelings of guilt, powerlessness, isolation, humiliation, and incompetence were concomitant with, or consequences of, anger. Part III provides recommendations for channeling anger constructively.     

Clinical and analytical standardization issues confronting cardiac troponin I

This study sought to evaluate how the addition of a general practitioner (GP) surgery influences the utilization of an emergency department (ED). An intervention trial with historical control was conducted in a Swedish university hospital ED. A GP surgery was established in the ED by the addition of GP physicians without the addition of other personnel (nurses, secretaries, aids). The number of persons evaluated and managed by the GP physicians and ED physicians were quantified preintervention (April 1992 to October 1993) and postintervention (April 1994 to October 1995). Further information was obtained by questionnaires distributed to all physicians and patients during three sample study weeks: 1 week before intervention and 6 and 18 months after the intervention. Patient volume, percentages of inappropriate visits, and types of services were recorded. The addition of GP physicians increased the number of visits to the ED by 27% (4,694 per month to 5,952 per month). The percentage of patients managed in the ED who had nonurgent complaints (primary health care needs) increased with the intervention from 22% (95% confidence interval [CI] 19%, 25%) to 33% (95% CI 30%, 37%). The increased demand on the ED of patients with nonurgent complaints increased the average waiting time for patients with urgent or emergent complaints from 35 minutes to 40 minutes (14%). The introduction of GPs to an ED increased the number and proportion of patients presenting to the ED with nonurgent complaints.     

Quantitation of change in the medullary compartment in renal allograft by ultrasound

PURPOSE: This study was completed to determine the current knowledge and documentation patterns of nursing staff in the prevention of pressure ulcers and to identify the prevalence of pressure ulcers. METHODS: This pre-post intervention study was carried out in three phases. In phase 1, 67 nursing staff members completed a modified version of Bostrom's Patient Skin Integrity Survey. A Braden Scale score, the presence of actual skin breakdown, and the presence of nursing documentation were collected for each patient (n = 43). Phase II consisted of a 20-minute educational session to all staff. In phase III, 51 nursing staff completed a second questionnaire similar to that completed in phase I. Patient data (n = 49) were again collected using the same procedure as phase I. RESULTS: Twenty-seven staff members completed questionnaires in both phase I and phase III of the study. No statistically significant differences were found in the knowledge of the staff before or after the educational session. The number of patients with a documented plan of care showed a statistically significant difference from phase I to phase III. The number of patients with pressure ulcers or at risk for pressure ulcer development (determined by a Braden Scale score of 16 or less) did not differ statistically from phase I to phase III. CONCLUSION: Knowledge about pressure ulcers in this sample of staff nurses was for the most part current and consistent with the recommendations in the Agency for Health Care Policy and Research guideline. Documentation of pressure ulcer prevention and treatment improved after the educational session. Although a significant change was noted in documentation, it is unclear whether it reflected an actual change in practice.     

Contribution of METRO pathway localized molecules to the organization of the germ cell lineage

OBJECTIVES: A study of general practitioners' (GPs) perceptions of the health needs of women of South Asian descent who suffer from menorrhagia. METHOD: A qualitative study using semi-structured interviews with 50 GPs in two British towns. FINDINGS: This study suggest that some women of South Asian descent may not consult their GPs even though suffering severe menorrhagia. Moreover, some GPs perceive that women may suffer from anaemia as the result of such illness behaviour. One reason for this reluctance to consult for menorrhagia may be the fact that some women of South Asian descent prefer to be examined by female doctors, yet may attend practices that lack a female partner. The study also shows that South Asian women, who consult male GPs for menorrhagia, are sometimes referred to hospital outpatients without internal examinations, and that women may be reluctant to keep their hospital appointments because of the lack of female gynaecologists. The study also indicates that a shortage of female interpreters may make communication difficult between some health care professionals and their patients, particularly when a complex and sensitive subject such as menorrhagia needs to be discussed. CONCLUSION: Women of South Asian descent may suffer serious problems such as iron deficiency anaemia, partly due to untreated menorrhagia. Since this was a study of GPs' perceptions of the health needs of South Asian women, it is now important to interview women themselves, to learn more about their perceptions of menorrhagia, and their perceptions of any subsequent contact with health care professionals.     

Influence of two weeks of non-weight bearing on rat soleus motoneurons and muscle fibers

OBJECTIVES: To analyse the ethical implications of informing patients about their do-not-resuscitate status (DNR). DESIGN: Questionnaire. SETTING: Nationwide, 6 months after the publication of guidelines on DNR in 1994. SUBJECTS: A 10% random sample of the members of the Swedish Cardiac Society. 104 physicians and 196 nurses. MAIN OUTCOME MEASURES: To what extent are patients, physicians and nurses involved in decisions about DNR, and how should the ethical conflict involved in informing patients about their DNR status be described and analysed? RESULTS: Of 73% responding, 84% of the physicians and 8% of the nurses had made a DNR decision. The decision was regarded as ethically right and well timed and it was discussed with 33% of the competent patients. Half of the respondents believed that DNR orders should be discussed with the competent patient. but still only one third of the patients are involved. The ethical conflict is analysed using the principles of autonomy and nonmaleficence as value premises. CONCLUSIONS: Many physicians are still reluctant to find out what the patient wants. Being ignorant they risk harming the patient. It is recommended that information about DNR status should be given incrementally and that the attitudes of the old and chronically ill in-hospital patients are studied. Do they want to be informed, and if so, how and when do they want it to be done?     

Survey reveals physicians'' experiences with cults

In late June 1992, a stratified random sample of Pennsylvania physicians (5,400) were mailed a two-page questionnaire asking about experiences with destructive cults, either personal, professional, or both. Professional experience was defined as "with patients or their families," and personal experience was defined as "with self, family, or friends." The survey sample group was drawn from primary care physicians (family practice, general practice, internal medicine, and pediatrics) and psychiatrists. Surveys were returned by 1,396 participants, a 26 percent rate of return. A number of the returned surveys (173) included personal observations and comments.     

NMDA receptor-mediated inspiratory off-switching in pneumotaxic-disconnected cats

BACKGROUND: National morbidity surveys provide valuable data for monitoring the health needs of populations, health policy planning and design of medical curricula. In order to meet a long-standing need for such information in Sri Lanka, a nationwide general practice morbidity survey was conducted for the first time in 1996. OBJECTIVES: We aimed to identify people's needs by determining the reasons for encounter or the demand for care with GPs/family physicians, to illustrate the pattern of morbidity in general practice and to determine the average daily workload of GPs in Sri Lanka. METHOD: A random sample of 75 GPs were requested to complete a Practitioner Profile Questionnaire (PPQ) and to record on an encounter form (EF) the reason/s for encounter (RFE) and problems managed during all consultations on 4 July. Central coding of the RFEs and problems defined was done using the International Classification of Primary Care (ICPC). RESULTS: Forty GPs (53.3%) completed the PPQ, while the EF received a response from 34 (43.3%). The GP profile showed a male to female ratio of 7:1, none below 35 years and none qualified after 1984. The average daily workload was 74. It was estimated that GPs handle at least 26.5% of the primary care morbidity. Children accounted for 32% of consultations. There was a significantly higher proportion of children (P < 0.0001) and of the elderly (P < 0.05) in the consulting population compared with the general population. In 2068 encounters, 3448 RFEs and 2087 problems had been recorded. Respiratory and General chapters included 55% of the RFEs. By ICPC rubrics, 27 of the top thirty RFEs were for common symptoms. In addition to acute illnesses, asthma, hypertension and diabetes as well as preventive care activities were within the top 12 problems managed. CONCLUSIONS: The fact that many common illnesses, chronic diseases and preventive treatments are dealt with in general practice shows the necessity to include family medicine in the undergraduate curriculum of all medical schools. Undergraduate and postgraduate training in family medicine should concentrate more on child care and care of the elderly. Suitable incentives may be necessary to motivate younger doctors to become GPs to meet the medical care needs of the community.     

Symptoms and functional status of patients with disseminated cancer visiting outpatient departments

Considerable research has focused on pain and other symptoms in terminal cancer patients referred to hospices and palliative care services. These patients differ from Dutch cancer patients in the palliative stage of their disease because the latter are cared for by general practitioners at home and medical specialists in outpatient departments. To clarify the experience of these Dutch patients, a study was started to investigate the prevalence and severity of pain and other symptoms as well as the functional status of consecutive patients visiting oncology outpatient departments for follow-up. After randomization, one group (I) of patients was interviewed at home by a general practitioner using structured questionnaires. The other group (II) received the questionnaires by mail, and scored the symptoms independently. The results of the symptom assessment show that patients in groups I and II suffered 2.4 (SD = 1.7) and 2.8 (SD = 2.0) symptoms, respectively. Between 30% and 40% of all patients reported constipation, nausea, loss of appetite, coughing, and dyspnea. These percentages were 50% lower when only moderate, severe, or extremely distressing symptoms were included. Sixty percent of all patients had pain, and 20% indicated a daytime pain score of 5 or greater on a scale of 0 to 10. Functional status was measured by the COOPWONCA charts; the mean score for the charts "physical fitness" and "daily activities" was 1.5 points lower for cancer patients than a random sample from the community of the same age and gender. The findings of this study should motivate doctors to put more energy in symptom assessment and interventions in palliative care.     

Validation of a model of psychosocial determinants of occupational health of geriatric nurses

The purpose of this study was to verify a model of relationships between psychosocial factors and health for 8066 francophone nurses working in geriatric care in Québec. A random sample of 1990 subjects was drawn and a participation rate of 77.9% and 55% was obtained for the two-time study taken twelve months apart. Based on the theory of Maddi and Kobasa (1984), the model was reproduced for the two-time periods with the aid of structural equations. The analyses showed that three variables exert a direct influence on psychological distress: professional burnout, occupational stressors and hardiness. Also, variables have a direct effect on burnout: listed in order of importance, these are hardiness, occupational stressors, work support, active strategies of coping and employment status. In dealing with the work stressors, the nurses who are hardy make use of active strategies of coping and look for support form their colleagues. The results of the study help to better understand the psychological and social resources that best favor adaptation of working women in highly demanding work environments. The fallout of the study converges towards the quality of life of helping professionals and towards the cost and quality of health and social services.     

Changes of endothelin-1 and atrial natriuretic peptide during dobutamine stress echocardiography

The aim of this study was to test the hypothesis that plasma endothelin-1 (ET-1) and atrial natriuretic peptide (ANP) concentrations in patients with ischemic heart disease are related either to myocardial ischemia or left ventricular (LV) dysfunction during dobutamine stress echocardiography. Plasma concentrations of ET-1 and ANP were measured in three patient groups. Group I (n = 21) patients had normal stress echocardiography and a resting LV ejection fraction (LVEF) of 40% or more. Group II (n = 32) had positive stress echocardiography and a resting LVEF of more than 40%. Group III (n = 18) had positive stress echocardiography with a resting LVEF of less than 40%. All three groups were subjected to thallium 201 scintigraphy and coronary angiography studies. The resting LV end-diastolic pressure was significantly higher in groups II and III than in Group I. The LVEF decreased significantly in group III compared to groups I and II. In the resting state, groups II and III had higher ET-1 concentrations than Group I (p = 0.021 and p = 0.039, respectively). The plasma ANP concentration was higher in group III than in groups I and II (p = 0.005 and p = 0.054, respectively). During peak dobutamine infusion, the ET-1 concentration dropped 8.7% from the baseline in group I, 10.2% in group II, and 10.5% in group III. The ANP concentrations were increased in all three groups but only the increase in Group II reached statistical significance. In conclusion, in patients with suspected ischemic heart disease, the concentrations of ET-1 and ANP may predict significant anatomic and functional coronary artery disease. However, ET-1 does not play a pathophysiologic role during an ischemic attack.     

Physician perspectives on the ethical aspects of disability determination

OBJECTIVE: To evaluate physician's attitudes and responses to the ethical conflicts involved in certifying patients for welfare disability. DESIGN: A mailed questionnaire survey that used case scenarios and general questions. SETTING: Massachusetts. PARTICIPANTS: A random sample of 347 internists and family practitioners and a convenience sample of 100 neighborhood health center physicians from three large cities (NHC sample). The response was 53% and 76%, respectively. MEASUREMENTS AND MAIN RESULTS: Physician responses to case scenarios representing difficult decisions about patient requests for welfare disability determination and general questions about the welfare disability system. Physicians reported a willingness to exaggerate clinical data to help a patient they thought deserving of welfare disability benefits (39% random sample; 56% NHC sample). Physicians did not report confidence in their ability to determine who was disabled as measured by a visual analog scale (4.4 cm random sample, 4.6 cm NHC sample; 0 = very confident, 10 = very uncertain). They did feel burdened by their participation in welfare disability determinations when compared with other administrative chores as measured on a visual analog scale (2.8 cm random sample, 2.5 cm NHC sample; 0 = more burdensome, 10 = less burdensome). Eighty-two percent of the random sample physicians and 86% of the NHC sample physicians thought that filling out a disability form could adversely affect the physician-patient relationship, and 62% of physicians in each sample thought that it represented a conflict of interest. Eighty percent of physicians in both samples thought that it would be better if an independent group of physicians were designated to determine disability. CONCLUSIONS: Physicians perceive an ethical bind as they try to satisfy the conflicting demands of patients and the welfare disability system. They will frequently decide in favor of their patient's interests. This has implications for welfare policy planners.     

How well do general practitioners and hospital consultants work together? A qualitative study of cooperation and conflict within the medical profession

BACKGROUND: The professional relationship between general practitioners (GPs) and hospital consultants (sometimes referred to as 'specialists') is important in a health care system based upon the generalist as the first point of contact for patients and the gatekeeper for hospital services. This relationship has been the subject of considerable interest over the years, but little empirical research has been carried out. AIM: To investigate the professional relationship in terms of the balance between cooperation and conflict between GPs and specialists in clinical contact. METHOD: A qualitative study using 24 semistructured interviews and four focus group interviews with a purposeful sample of clinicians working in the south-west of England. A content analysis of the data was performed. RESULTS: There is a high level of mutual respect and cooperation between the two branches of the profession and a strong desire to build a personal relationship over a long period of time. There are few areas of significant disagreement; indeed, most members of both branches of the profession try hard to deal with, or avoid, potential conflict. CONCLUSION: The professional relationship between GPs and specialists is better than the literature and anecdotal stories might suggest.     

Physicians'' experiences and beliefs regarding informal consultation

CONTEXT: Efforts to control medical expenses by emphasizing primary care and limiting specialty care may influence how physicians use informal or "curbside" consultation. OBJECTIVE: To understand physicians' use of and beliefs about informal consultation. DESIGN: Survey mailed in July 1997. PARTICIPANTS: Of a random sample of Massachusetts general internists, pediatricians, cardiologists, orthopedic surgeons (n=300 each), and infectious disease specialists (n=200) surveyed, 1225 were eligible and 705 (58%) responded. MAIN OUTCOME MEASURES: Self-reported use of and beliefs about informal consultation. RESULTS: Generalist physicians requested more informal consultations than specialists (median, 3 vs 1 per week; P<.001) and were asked to provide fewer (2 vs 5 per week; P<.001). In multivariate analyses, physicians in a health maintenance organization, multispecialty group, or single-specialty group requested more informal consultations than those in solo practice (82%, 40%, and 28% more, respectively; all P<.001) and were more often asked to provide them (43%, 63%, and 14% more, respectively; all P<.05). Physicians with at least 30% of their income from capitation requested 38% more and were asked to provide 46% more informal consultations than those with little or no income from capitation (both P<.001). Generalists' overall approval of informal consultation was greater than specialists' (mean 5.9 vs 5.1 on a 7-point Likert scale; P<.001), and approval was strongly associated with beliefs about how informal consultation affects quality of care (P<.001). CONCLUSIONS: Use of informal consultation is common, varies by specialty, practice setting, and capitation, and therefore may increase with current trends toward group practice and managed care. Because overall approval of informal consultation is strongly associated with beliefs about how it affects quality of care, this issue should be carefully considered by physicians who participate in informal consultation.     

Pentaerithrityl tetranitrate and its phase I metabolites are potent activators of cellular cyclic GMP accumulation

This study was designed to examine the optimal time of injection of a small dose of fentanyl during anesthetic induction to attenuate circulatory responses to laryngoscopy and tracheal intubation. One hundred seventy patients were randomly assigned to one of five groups. In Groups II, III, IV, and V, patients received fentanyl (2 microg/kg) 1, 3, 5, or 10 min before tracheal intubation, respectively. Group I patients did not receive fentanyl and served as the control group. In Groups III and IV, blood pressures were not increased, except diastolic pressure in Group III, significantly postintubation compared with preinduction values; but Groups I, II, and V showed a significant increase (P < 0.05). The 1-min postintubation values of systolic, diastolic, and mean arterial pressure in Groups III and IV were less than those in the control group (P < 0.05). Increases of heart rate in Group IV were less (P < 0.05) than those in the control group, but significant differences were not observed in Groups II, III, and V. The number of patients with tachycardia and dysrhythmia was significantly smaller in Group IV than in the control group (P < 0.05). We conclude that the most effective time to administer fentanyl to protect circulatory responses to laryngoscopy and tracheal intubation is 5 min before tracheal intubation. IMPLICATIONS: Fentanyl is often used to reduce the hemodynamic response to tracheal intubation. However, large doses may cause unwanted side effects. Administration of fentanyl at the optimal time reduces the dose required. Our results indicate that optimal injection time of fentanyl for intubation is 5 min before intubation.     

Analysis of the terms used by general practitioners to characterize patients considered by them as depressed. A prospective study on 682 patients

The aim of the study was to investigate the terms used by general practitioners (GPs) to describe the patients considered by them to be depressed. 682 patients were diagnosed as depressed by 79 GPs selected at random in four regions of France. The frequency of the diagnosis of depression made by GPs in the total patient population was 3.6-5%. The GPs were asked to describe the main symptoms of these patients on a plain chart. The percentage of use of each term was calculated in each region. In all the regions, the most frequent symptoms were insomnia (31.8%), fatigue (29.9%) and anxiety (24.6%). The results suggest that the three main terms used by GPs to describe depression differ from those used by psychiatrists.     

Factorial structure and prognostic significance of premorbid adjustment in schizophrenia.

A sample of 291 resident male schizophrenic patients were rated on the Becker revision of the Elgin Prognostic Scale and on the Phillips Prognostic Rating Scale. 28 items drawn from both scales were factor analyzed. The factors were rotated to both varimax orthogonal solution and to biquartimin oblique solution. The 2 methods yielded a high degree of factorial similarity. 7 factors were: I, Social Withdrawal, Few Interests; II, Inadequate Heterosexual Relationships; III, Socially Undesirable Ward Behavior; IV, Rigid, Flat Affect. and Apathy; V, Insidious Onset; VI, Stubborn and Egocentric; and VII, Chronic Poor Physical Health. Correlations with a measure of chronicity (for 3 social class groupings) indicated that Factors I, II, III, and V have important prognostic power. These findings emphasize the need for a multivariate research approach to premorbid adjustment and the inclusion of the new and prognostically significant Factor III (Socially Undesirable Ward Behavior). (27 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)