Psychiatric diagnosis in family practice: is the general health questionnaire an effective screening instrument?

The General Health Questionnaire has been considered an effective screening instrument in a family practice population. To evaluate its efficiency in identifying psychologic distress, 1,000 consecutive attenders at the Family Practice Clinic were given the 30 item GHQ. Of the patients from the sample, 35% were identified by the GHQ as having psychologic distress. In contradistinction, 14.8% of the group were given clinical psychiatric diagnoses by the physician. The presence of a positive GHQ score did not correlate with frequency of follow-up visits or other behavioral parameters. The presence of a psychiatric diagnosis, however, was significantly associated with frequency of follow-up visits. These findings do not invalidate the General Health Questionnaire but may reflect low case identification. The health behavior of patients with psychologic distress may be, in part, a function of the labeling process as well as the emotional illness itself.     

Negotiating the role of the practice nurse in general practice

The debate about the role of the practice nurse is not only about practice nursing per se, but raises broader issues about the organization of primary health care. Two related issues emerge as significant: the role of the practice nurse in providing primary health care; and the effective use of the practice nurse resource in the 'new' National Health Service. This paper, by drawing on material from a qualitative study, specifically examines the type of work performed by practice nurses and the factors that influence this. The responses of practice nurses, general practitioners, Family Health Service Authority (FHSA) advisers, community nurse purchasers and managers of community nursing provider units suggest that a consensus on the future development of practice nursing is unlikely. The different stakeholders emphasized different issues, reflecting their own priorities and backgrounds. Practice nurses' accounts of the future, for example, focused on professional issues. General practitioners stressed the importance of role development which met their General Medical Service responsibilities. Purchasing agencies, provider units and FHSAs adopted a wider perspective and were more concerned to develop an effective and integrated primary health care service. The tensions generated by their different interests and perspectives, and the subsequent organizational and policy initiatives that emerge, will provide the context in which the role of practice nurses will be negotiated.     

Gender differences in general practice consultations: methodological challenges in epidemiological research

The present study is an analysis of the frequencies of HFE mutations in patients with different forms of iron overload compared with the frequencies found in healthy subjects from the same region. The frequencies of HLA-A and -B antigens and HLA haplotypes were also analyzed in the same subjects. The study population included: 71 healthy individuals; 39 genetically and clinically well-characterized patients with genetic hemochromatosis (HH); and 25 patients with non-classical forms of iron overload (NCH), excluding secondary hemochromatosis. All subjects were HLA-typed and HFE-genotyped by the oligonucleotide ligation assay (OLA). The gene frequencies found for the C282Y and H63D mutations of HFE were respectively: 0.03 and 0.23 in healthy individuals, 0.86 and 0.04 in HH patients, and 0.08 and 0.48 in NCH patients. An expected significant association between HH and HLA-A3 was observed, which was found to be in linkage disequilibrium with the C282Y mutation. A new association was seen, however, between HLA-A29 and NCH, in linkage disequilibrium with the H63D mutation. Again as expected, the HLA-B antigen B7 was associated with HH in linkage disequilibrium with HLA-A3. In addition, the HLA-B antigen B44 was found to be associated with NCH but not in linkage disequilibrium with either A29 or the H63D mutation. In conclusion, a new association of the HFE H63D mutation with forms of hemochromatosis other than HH and a new association between the HLA phenotype A29 and the HFE H63D mutation were found in the same patients. These findings reinforce evidence for the involvement of the major histocompatibility class I in iron metabolism, supporting the notion of a physiological role for the immunological system in the regulation of iron load.     

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.     

The role of the triage nurse practitioner in general medical practice: an analysis of the role

A 2-year pilot study was undertaken in a group general practice to evaluate the nurse practitioner triage role. The study was undertaken in several stages which included a patient satisfaction questionnaire survey, follow-up interviews with 30 patients from the questionnaire survey, and analysis of the nurse practitioner's work at different points over the 2-year study period. This paper describes the work of the nurse practitioner in comparison with that of seven general practitioners in a group general medical practice over a 5-day period in February 1996 and included patients' perceptions of their consultation. In this particular group medical practice, as in others throughout the country, many patients request same day appointments, often for self-limiting conditions, social advice and health education. This study demonstrates that the nurse practitioner can deal with such patients effectively and is undertaking an expanded and extended role in order to provide an holistic service to patients with which they are highly satisfied. It can be concluded that given the right kind of education and training and a supportive framework within the practice, the nurse practitioner undertaking a triage role can provide a highly effective service to patients and is a valuable member of the primary health care team.     

The university department of general practice: its function and role

The need is stressed for university departments of general practice to examine their role and create a philosophy which will guide their function. The success of a department depends upon clear objectives, teamwork, and integration with the teaching given by other clinical departments in the medical school. The contribution of general practice to undergraduate training is discussed and problems associated with the recruitment of staff are indicated.     

Development of a postal health status questionnaire to identify people with dyspepsia in the general population

OBJECTIVE: To develop and validate a postal health status questionnaire which will identify people with dyspepsia in the general population. DESIGN: Validation against telephone interview and post re-post determination of reliability. SETTING: A general practice population in the north of England. SUBJECTS: A random sample of adults aged 20-69 years inclusive chosen from the general population. MAIN OUTCOME MEASURES: Validity has been checked against telephone interview. A kappa statistic has been calculated for each question and clinical category. RESULTS: Compared with interview the questionnaire is a valid, comprehensive and easily understood record of symptomatology. The kappa statistics (mean value 0.92) indicate a very reliable questionnaire. CONCLUSION: The questionnaire accurately and reliably identifies people with dyspeptic symptoms.     

Using health status surveys in medical consultations

The goal of this research was to identify patients' preferences for physician inquiry into various aspects of health status and to examine whether the preconsultation availability of health status data (collected from the SF-36 Health Status Questionnaire) influenced the physician's conduct during the consultation. Results from 58 prenatal patient visits yielded the following findings. First, patients expressed strong preferences for physicians to ask about the patient's perceptions of health in general and about physical dimensions of health status such as pain, vitality, and role limitations due to physical functioning. Patients also were more satisfied when doctors were perceived as having asked about these issues. Second, patients varied considerably in their preferences for physician inquiries into psychosocial issues such as social functioning, mental health, and role limitations due to emotional problems. Approximately half the patients wanted these matters discussed, whereas the remainder either did not care or preferred that doctors not ask about these topics. Third, the preconsultation availability of health status information had little effect on the degree to which physicians asked about the patient's health-related quality of life. Clinical implications are discussed.     

The general practice of psychology.

Psychology has developed a variety of specific techniques that are applicable to specific emotional problems, thus enabling brief psychotherapy to be particularly effective. In the past it was said that therapist and patient had only one chance to solve present and future emotional distress, a criterion applied to no other form of intervention. By combining dynamic and behavioral therapies into intervention designed to ameliorate the presenting life problem, using a multimodal group practice, professional psychology can define its own area practice. This general practice of psychology postulates that throughout the life span the client has brief, available, effective interventions designed to meet specific conditions as these may or may not arise. When such techniques are available, brief psychotherapy is the treatment of choice for about 85% of those seeking help, leaving long-term therapy for those clients who are best benefited by a protracted intervention. (11 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social class in childhood and general health in adulthood: questionnaire study of contribution of psychological attributes

OBJECTIVE: To determine the contribution of psychological attributes (personality characteristics and coping styles) to the association between social class in childhood and adult health among men and women. DESIGN: Partly retrospective, partly cross sectional study conducted in the framework of the Dutch GLOBE study. SUBJECTS: Sample of general population from south east Netherlands consisting of 2174 men and women aged 25-74 years. Baseline self reported data from 1991 provided information on childhood and adult social class, psychological attributes, and general health. MAIN OUTCOME MEASURE: Self rated poor health. RESULTS: Independent of adult social class, low childhood social class was related to self rated poor health (odds ratio 1.67 (95% confidence interval 1.02 to 2.75) for subjects whose fathers were unskilled manual workers versus subjects whose fathers were higher grade professionals). Subjects whose fathers were manual workers generally had more unfavourable personality profiles and more negative coping styles. External locus of control, neuroticism, and the absence of active problem focused coping explained about half of the association between childhood social class and self rated poor health. The findings were independent of adult social class and height. CONCLUSIONS: A higher prevalence of negative personality profiles and adverse coping styles in subjects who grew up in lower social classes explains part of the association between social class in childhood and adult health. This finding underlines the importance of psychological mechanisms in the examination of the negative effects of adverse socioeconomic conditions in childhood.     

The cost of childhood immunisation in general practice

AIM: To estimate the cost, to general practices in the Wellington Immunisation Network, of the audit process of recalling and immunising children according to the New Zealand Immunisation Schedule. METHOD: Practices recorded all clinical and clerical time spent on immunisation as well as the materials used throughout one audit cycle. Staff time and materials were costed directly. Practice overheads were apportioned to immunisation according to the actual time spent on each of the tasks relating to immunisation relative to the total staff hours at the practice. RESULTS: The average cost of immunising a child who attended a non-capitated practice after a single reminder or recall was $15.15. The cost to the practice after taking the practice nurse subsidy and GMS into account was $8.51. The cost of immunising children who were not immunised at the first recall increased in proportion to the number of recall reminders. The annual average cost of immunisation to practices in the study exceeded the revenue obtained from the Immunisation Benefit. CONCLUSION: Overall, given the frequency of recall reminders, there was a net cost to practices for childhood immunisation after deducting the current immunisation benefit rate of $9.78 excluding GST. Thus, the practices in this study made a "loss" in carrying out childhood immunisations.     

Barriers to preventive care in general practice: the role of organizational and attitudinal factors

BACKGROUND: There are numerous barriers to preventive care. In this paper we focus on barriers related to the organization of preventive services and to the general practitioners' (GPs') attitudes and self-efficacy expectations. The prevention of cardiovascular disease was taken as a case study. AIM: To study the organization of cardiovascular services and the attitudes and self-efficacy expectations of GPs, the relationships that exist between these factors, and the influence of practice and provider characteristics. METHOD: A survey was conducted among 95 general practices with 195 GPs. RESULTS: Few practices were sufficiently well-organized to provide effective preventive services. Seventy per cent of the GPs had positive self-efficacy expectations. Thirty to fifty per cent had positive attitudes. Few relationships were found between the organization of services and positive attitudes or expectations. Moreover, few relationships were found between practice and provider characteristics and barriers studied. List size played some role in the presence of barriers. CONCLUSION: Barriers to prevention exist. Even a positive attitude or self-efficacy expectation does not automatically coincide with a practice organization equipped for prevention. Changing attitudes is probably not enough. Efforts have to be directed at the organization of services.