Perception of the risk of venous thromboembolic disease in primary care

OBJECTIVES: To determine the prevalence in out-patients of risk factors leading to venous thromboembolic disease (VTE); and to analyse what perception primary care centre (PCC) doctors have of this risk and what attitude they adopt to therapy. DESIGN: 1) An observational, crossover study, with patients included at random. 2) A study with a teaching intervention, which was neither controlled nor randomised. PATIENTS: PCC patients over 25 seen either on demand, with appointments or at home. INTERVENTION: A clinical history was composed, using a closed questionnaire. A risk category and therapeutic attitude were then assigned. A guide on prevention and treatment of VTD was presented and discussed in clinical sessions. RESULTS: 11 PCC doctors polled 272 patients. 45 of these had moderate to high risk of VTD; and 4 had one of the criteria of the European Accord on VTD prevention for commencing prophylactic treatment. In two of these four, it was thought necessary to start prophylaxis. CONCLUSIONS: The prevalence of patients with moderate to high risk of VTD is 17% in patients over 25 who seek medical attention at PCCs. Doctors detected 50% of moderate to high risk patients. If the criteria used for in-patients were followed, prophylaxis should have been started in 1.5% of patients.     

English teaching in the Italian medical faculties: results of a survey

BACKGROUND: Although a compulsory examination in medical English has been present in the medical degree curriculum in Italy since 1990, guidelines indicating what should be learnt and suggesting some means of overcoming the various problems this entails are still lacking. OBJECTIVE: To investigate the main features of teaching English in the Medical Faculties and enquire into how the various problems are solved in the individual English teaching units. METHOD: A questionnaire addressing the above issues was sent out to all the Italian Universities with a Medical Faculty. RESULTS: The first finding of our survey was that response was very poor: less than 30% of the survey volunteered any reply. Within the very reduced sample which responded, there was a high degree of variation among the solutions adopted, although the underlying problems were perceived to be much the same throughout Italy. CONCLUSIONS: The general objective of the English course for medicine should be more precisely defined, together with a series of specific minimum skills the student should possess to pass the final examination. A closer collaboration among the English teaching units might help to standardize these requirements, improve the quality of the teaching and hence the level of proficiency in English for the specific purpose of medical practice.     

The teaching of clinical oncology in Italian medical schools. A survey among teachers and students

BACKGROUND: Oncologists, health care workers and health organizations consider well-performed teaching programs in clinical oncology a fundamental step in cancer control. The aim of our study was to assess the views of teachers and students on the present status of oncology teaching in Italian medical schools and on the most common shortcomings in cancer education. MATERIALS AND METHODS: A survey was carried out among teachers and students of 17 Italian medical schools using two different questionnaires. Six hundred forty-seven students of Northern, Central and Southern Italy in the final two years (5th and 6th) of their medical curriculum and 87 professors of pathology, surgery, internal medicine and medical oncology completed the questionnaires. RESULTS: Doctor/patient relationships and integration among disciplines were the most unsatisfactory aspects of oncology teaching, according to students. Biology, epidemiology, radiotherapy, and medical treatment were felt to be insufficiently treated, whilst diagnostic aspects, clinical management and surgery were rated sufficient. The median number of cancer patients to whom each student had access during his/her training was limited, averaging only 13 patients; however, a high degree of variability was noted. A larger number of patients was generally observed in smaller, less crowded medical schools, with notable exceptions. Although the majority of teachers had clinical practices related to their disciplines, only a small number of students underwent a period of clinical training. Traditional methods of teaching were preferred to innovative methods, while interaction among disciplines was uncommon. CONCLUSIONS: This survey emphasizes the dualism between students' expectations and teachers' ideas about cancer teaching. Doctor/patient relationships and poor attention to practical clinical problems seem the most critical issues for clinical oncology training in Italian medical schools.     

The educational component of senior house officer posts: differences in the perceptions of consultants and junior doctors

The aims of this study were to elicit general practitioner (GP) trainee's perceptions of the educational structure of their hospital posts, to compare them with those of consultants who had GP trainees as senior house officers (SHOs) in their departments and to examine the use of educational objectives in the hospital component of vocational training for general practice. A confidential postal questionnaire was sent to all the GP trainees (165 doctors) in the hospital component of their vocational training schemes (VTS) for general practice in Trent Region and all the consultants (161 doctors) in Trent who had GP trainees in their SHO posts on that date. Responses were received from 136 trainees (82%) and 134 consultants (83%). Educational objectives were stated as existing in the SHO post by 31 trainees (23%) and by 62 consultants (46%). Of those doctors who said that objectives existed, 19 of the trainees (61%) and 40 of the consultants (65%) said that the objectives were useful. Only nine (29%) of the trainees who stated that educational objectives existed felt that they were being put into practice by senior staff, compared with 41 (66%) of consultants who had made that statement. Of all respondents, 113 trainees (87%) and 100 consultants (77%) agreed or strongly agreed that the use of educational objectives would be beneficial to the trainees. Only 10 (7%) of trainees said that they received no teaching in their current posts. Forty trainees (32%) and 88 consultants (67%) said that teaching took place in protected time. Both groups cited consultants as the member of staff giving the most teaching. Ninety-six consultants (73%) replied that it was possible for GP trainees to obtain study leave, but 102 trainees (75%) either had experienced difficulties in obtaining study leave or had not attempted to obtain study leave. Trainees and consultants differed appreciably in their perceptions of the amount of assessment and feedback which was provided for GP trainees. The use of educational objectives in the hospital component of vocational training was felt to be beneficial by both consultants and GP trainees. Consultants were more likely than trainees to report the use of educational objectives, protected teaching time, GP-orientated teaching, ability of trainees to attend VTS half-day release and the provision of assessment and feedback to trainees.     

Understanding of informed consent by elderly patients

Fifty patients, aged 60 years or more, who had been admitted to a hematology ward for more than 1 month, were studied in regard to their understanding of informed consent. The doctors informed 74% of their patients about the disease for which they were being treated. The rate of informing patients remained low in those with advanced age or with malignant tumors. However, only 42% of the patients realized that they had been informed of their diagnosis and clinical condition. The comprehension rate remained low at 43.2% even in patients who were informed by their doctors. While 60% of patients declared that they understood what the doctors described, only 36% could write something about the name or the state of their disease. Even among the patients who could understand the doctor's explanation, the comprehension rate was 43.3%. Sixty-six percent of patients demonstrated their wish to have a correct explanation of their diagnosis, 36% of patients wanted to be treated according to their own wishes, and 48% of patients left the decisions regarding their treatment to the doctors.     

Surgery in medical education. Division of surgical oncology

Medical education is being required to make a big change over the last 10 years due to the rapidly expanding knowledge of medicine and socioeconomical demands from the public. The education system is now focusing on teaching medical students how to learn individual subjects by themselves leading to understand the concept of self learning and adult learning. It is also required for students and residents to improve clinical competence as early as possible. The purpose of this change in medical education is to produce better doctors for the future. In order to achieve our aim it is essential to have continuous education system during the pre and postgraduate periods and also to realize the importance of education. Standardized education program is also essential to be established. Evaluation system for teaching is needed to attract young doctors to teaching, otherwise enough staffs for education would not be obtained. Teaching experiences should be counted as a career pass at the time of promotion. For a surgeon clinical competence is most important task to achieve but experience of research is also important for young surgeons to become a research minded surgeon or academic surgeon who will make a breakthrough in the field of surgery in the future. It should be emphasized that dean and professors are most responsible in the development of medical education.     

Comparison among patients considered candidates for radical prostatectomy in academic institutes in different countries

OBJECTIVE: Radical prostatectomy is performed in potentially curable prostatic cancers, but surgical indication might somehow depend on the idiosyncrasies of a population. Herein we compare the characteristics of patients undergoing radical prostatectomy in teaching University Hospitals of different countries. METHODS: We conducted a retrospective review on 250 consecutive patients who underwent radical prostatectomy before January 1997 in five teaching University Hospitals in Europe (Spain, Sweden, Switzerland, Turkey) and the United States (Detroit, MI). Clinicopathological data were recorded and compared, and a questionnaire investigated whether patient and physician attitudes towards surgery differed. RESULTS: The number of surgeries per month at each institution ranged from 0.9 to 10 and the proportion of newly diagnosed patients that undergo surgery from 0.14 to 0.36. The Kruskal-Wallis test revealed both median age and preoperative prostate-specific antigen (PSA) levels were different between groups. Similarly, despite standardized surgery and histologic work-up, differences in the detection of extracapsular invasion and the rate of detectable PSA after surgery were observed between institutions. Diagnosis in the Swedish and Swiss groups was more often based on digital rectal examination, while the rest were more confident with transrectal ultrasound. Doctors at some institutions were more inclined to recommend radical surgery, either by not mentioning or disapproving other therapeutic strategies. The proportion of patients who said they would elect surgery again ranged from 72% to 92%, and the proportion of doctors who said they would perform surgery again ranged from 78% to 100%. Patients' and doctors' degree of satisfaction with the decision made were also different. CONCLUSIONS: (i) Candidates for radical prostatectomy in teaching hospitals of several countries are different. Might therefore have practical implications on the design of clinical trials and the interpretation of the results of treatment. (ii) Patient and physician acceptance of surgery varies according to countries and is more established firm in those countries where it is more frequently performed.     

An evaluation of the role of the night nurse practitioner

A study was carried out at a London teaching hospital to ascertain the perceived need for night nurse practitioners. The majority of nurses questioned acknowledged the benefit of night nurse practitioners' experience and believed them to be key to maintaining the optimum level of care during the night. Junior doctors also found they provided valuable clinical support and greatly reduced their workload after midnight.     

The spectrum of patients strongly influences the usefulness of diagnostic tests for pneumonia

OBJECTIVE: To study the influence of the spectrum of patients on the usefulness of five clinical cues, "very annoying dyspnoea", "strong lateral chest pain", crackles, C-reactive protein analysis, and erythrocyte sedimentation rate in the diagnosis of pneumonia. DESIGN: Evaluating the diagnostic properties of the cues against radiographic pneumonia at four steps in the diagnostic process, associated with increasing prevalence of pneumonia: 1. in all the 581 patients included, 2. in 402 of these patients who underwent physical chest examination, 3. in 188 patients classified by the doctors as having a lower respiratory tract infection, and 4. in 79 patients referred for radiography by the doctors. SETTING: The municipal emergency clinic in Troms?, Norway. PARTICIPANTS: 581 adult patients with respiratory tract infection. OUTCOME MEASURES: Sensitivity, specificity, Likelihood Ratio, and Positive predictive value. RESULTS: A tendency of decreasing specificity and Likelihood Ratio with increasing prevalence of pneumonia was demonstrated for all test, except for C-reactive protein analysis. This tendency may be explained either by the emphasis laid on the tests by the doctors when selecting patients for the diagnostic steps, or by an association between the evaluated tests and those emphasized by the doctors. CONCLUSION: As the diagnostic value of symptoms and signs are strongly influenced by selection, caution should be shown when transferring diagnostic values from one clinical setting to another.     

Anticoagulation clinics: the Italian experience

BACKGROUND AND OBJECTIVE: The clinical quality of oral anticoagulant therapy (OAT) depends on how successful physicians and patients are in achieving and maintaining levels of anticoagulation capable of preventing thromboembolic events without increasing the risk of hemorrhagic complications. Concerning the patient, education and compliance are the major problems. As for the physician, on the other hand, the management of patients receiving OAT is a complex task that requires frequent laboratory testing, dosage regulation, prompt diagnosis and treatment of thromboembolic and hemorrhagic events. It requires educated and skilled personnel and a well-organized framework of services. Anticoagulation clinics, which provide patient education, close monitoring of prothrombin time and continuous clinical surveillance, may help in improving the overall quality of OAT. INFORMATION SOURCES: The authors have been working in this field contributing, original papers. In addition, the material examined in this article includes articles published in the journals covered by the Science Citation Index and Medline. STATE OF ART AND PERSPECTIVES: The concept of a coordinated network of medical services specifically devoted to the control of OAT was developed in the Netherlands following the model created by the late Professor Jordan, who in 1949 founded the first thrombosis center at the University of Utrecht. Many other anticoagulant clinics were organized on, a voluntary basis in the following decades in the Netherlands. The Dutch Federation of Thrombosis Centers was founded in 1971 and each affiliated Center is formally recognized and supported by the central Government. Today, there is a nation-wide system of regionally centralized anticoagulant control for outpatients and home patients that counts approximately 70 anticoagulant clinics (thrombosis centers), covering more than 90% of the country. Similar global approaches to the management of patients receiving OAT were proposed in other countries. In the 1950's, a group of internists and surgeons at the University of Michigan, USA, developed a unit specifically devoted to the diagnosis and treatment of thromboembolic disease, and proposed common strategies, teaching and research programs. In 1959, Sevitt and Gallagher were the first to propose a formal recognition of an anticoagulant unit in Great Britain. Finally, the Italian Federation of Centers for the Surveillance of Anticoagulant (FCSA) therapies was founded in 1989. Nowadays, Italian anticoagulation clinics operating in the framework of the FCSA are still voluntary organizations which provide a specific medical service by continuously reorganizing the personnel, structures and resources available to meet increasing demands. Since OAT has a profound social impact, its control should not be left to the good will of dedicated people, but should instead represent a specific task of the public health system. The achievement of a formal recognition of federated centers is essential for their growth, but the unavoidable increase of the expenses needed to support anticoagulation clinics is difficult to bear in a public care system which is currently facing a substantial reduction of financial resources. In a fixed health care budget, a redistribution of existing resources is the only possible solution, but to achieve this goal, public authorities have to be convinced that the management of OAT in specific anticoagulation clinics is cost-effective. A more accurate estimate of costs is needed and should be performed by the FCSA. Finally, the FCSA should strengthen its contacts with patient organizations and other scientific associations in order to develop common action strategies for improving the quality of OAT.     

A case of hepatocellular carcinoma with reduction of primary tumor and disappearance of multiple lung metastasis

For a number of years not enough attention has been paid to training in practical skills, neither in pre- nor postgraduate medical education. Lack of training and experience poses particular problems for the general practitioner, who often works alone with little opportunity for assessment by and feedback from colleagues. The Clinical Skills Training Centre was established to develop and implement methods for training general practitioners in clinical skills. Its main objective is to develop teaching methods that will encourage doctors to adapt their professional behaviour as and when necessary. The centre has developed a series of short, 2-day courses for small groups of 10-12 participants where focus is on selected clinical topics. The courses are continuously evaluated including assessment by the participants themselves of their procedural proficiency. Results are encouraging, with the majority of doctors reporting implementation of one or more of the relevant procedures at the final evaluation. An interesting new concept is a programme of reciprocal visits among groups of 10 to 12 general practitioners. The intention of the programme is to break the isolation of the consultation and utilize the potential for learning that exists when colleagues are able to observe each other at work and draw on each other's experiences.     

The impact of language as a barrier to effective health care in an underserved urban Hispanic community

BACKGROUND: Language barriers between patient and physician impact upon effective health care. This phenomenon is not well studied in the literature. METHODS: A survey was created in English and Spanish, and administered at the ambulatory site for medical housestaff and faculty at a teaching hospital. "Cases" were defined as patients who reported using a translator or as having poor English skills. Patients who reported not using a translator and having good English skills served as controls. Both groups were predominantly of Hispanic origin. RESULTS: Analysis revealed 68 cases and 193 controls. The survey completion rate was 96%. The data were predominantly categorical. Chi-square analysis was utilized. Both groups responded that understanding medication side effects corresponds to compliance (87% cases vs 93% controls, p = 0.18). More cases responded that side effects were not explained (47% vs 16%, p < 0.001). More controls reported satisfaction with medical care (93% vs 84%, p < 0.05). More controls agreed that their doctors understood how they were feeling, with statistical significance in Hispanic subset analysis (87% vs 72%, p < 0.05). Both groups felt they had enough time to communicate with their doctors (89% vs 88%, p = 0.86). More cases than controls reported having had a mammogram within the last 2 years (78% vs 60%, p < 0.05). CONCLUSIONS: Lack of explanation of side effects to medication appeared to correlate negatively with compliance with medication. The language barrier correlated negatively with patient satisfaction. Cases reported more preventive testing; test ordering may replace dialogue.     

Measuring quality in general practice. Pilot study of a needs, process and outcome measure

1. As part of the Scottish Shadow Fundholding Evaluation (1990-92), quality of care was assessed in 6 practices with 49 general practitioners using a pre-consultation health needs questionnaire, consultation length as a process measure (previously shown to be a proxy measure for quality) and a post-consultation satisfaction/outcome measure which contained a subset of six questions assessing whether patients felt enabled by their consultation. This report describes secondary analysis of the available dataset undertaken to explore whether the approach used to evaluate quality of care for patients with specific clinical problems could be extended to the generality of general practice consultations. 2. Chapters 1 and 2 of the report describe earlier work developing both the concepts and instruments used in the Shadow Evaluation, and general findings already reported. The reliability and the construct validity of the measure of enablement are examined and found to be satisfactory. 3. Strong correlations between more time at consultations and more enablement for more patients are found at population level for patients with psychological problems, with social problems and with physical problems. More complex problems require more time to achieve equal benefit. 4. Mean consultation length and mean enablement score correlate well with each other and can be used as summary statistics of quality. Where trends require explanation or exploration, other measures of the use of time and the level of benefit gained are more helpful; both sets of analyses can be derived from the same datasets (Chapter 3). 5. Analyses at practice level show that practices which spend more time at consultations enable patients more whatever the nature of problems presented. The rank orders of time spent at consultation and of enablement are highly correlated (Chapter 4). 6. Analyses at doctor level show that doctors who spend more time at consultations enable patients more and that those who spend less time enable patients less. The numbers of patients available for study were not sufficient to explore this association within subgroups of clinical presentations. As in previous studies, we found that doctors who take longer time are likely to be more patient centred, and those who take less time are likely to be less patient centred. Case-mix varies between doctors, but seems to be independent of whether a doctor is more or less patient centred (Chapter 5). 7. The methods developed in this study give useful insights into the definition and delivery of quality of care in general practice (Chapter 6). The measures now need to be tested in different clinical, cultural and organizational settings and results compared with those found using routinely available NHS data on prescribing and achievement of other clinical and management targets (Chapter 7).     

Junior doctors and clinical audit

OBJECTIVES: To assess the extent of junior doctor involvement in clinical audit, the degree of support from audit staff, and the perceived value of the resulting audits. DESIGN: Postal survey of National Health Service (NHS) junior doctors. SUBJECTS AND SETTINGS: 704 junior doctors in central Leeds hospitals, June 1996. RESULTS: Questionnaires were returned by 232 respondents (33%), 211 (31%) were completed; 157 respondents (74%) had personally performed audit. Mean (+/- SD) duration since last audit project was 14.9 (14.1) (range 0-84) months. Of the respondents who had personally performed audit, 88 (56%) did not use the hospital audit department, 60 (38%) received no guidance and only 19 (12%) were involved in re-auditing the same project. Mean (+/- SD) time spent per audit project was 27.8 (37.7), (range 2-212) hours. Seventy-five junior doctors (48%) were aware of subsequent change in clinical practice, 41 (26%) perceived a negative personal benefit from audit, 33 (21%) perceived a negative departmental benefit, and 42 (27%) felt that audit was a waste of time. CONCLUSIONS: A large proportion of junior doctors are involved in audit projects that do not conform to established good practice and which have a low impact on clinical behaviour. Although junior doctors feel that there is inadequate assistance and poor supervision whilst performing audit, they still support the principle of audit. There is a need to improve the quality and supervision of audit projects performed by junior doctors.     

How common is medical training in palliative care? A postal survey of general practitioners

BACKGROUND: General practitioners (GPs) have a central role in palliative care, yet research continues to reveal room for improvement in symptom control at home. There is a need to evaluate how well-prepared GPs are for this task of caring for the dying at home. AIM: To evaluate the training in palliative care GPs have received throughout their careers. METHOD: Postal survey of 450 randomly selected East Anglian GP principals, investigating training in five areas of palliative care (pain control, control of other symptoms, communication skills, bereavement care, use of syringe driver), as clinical students, junior hospital doctors, GP trainees (registrars), and GP principals. RESULTS: A response rate of 86.7% was obtained. While GPs were clinical students, training was uncommon, (32% reported no training in pain control, and 58% no training in bereavement care), although there has been a significant increase in more recent years. Training as junior doctors was particularly uncommon (over 70% report no training in communication skills or bereavement care); there was some evidence of an increase in more recent years. During the GP trainee year, training was much more common. For GP principals, most areas had been covered, although over 20% reported no training in communication skills and bereavement care. During the community-based years as trainee and principal, training was significantly more common than during the hospital-based years of training as clinical student and junior doctor. CONCLUSIONS: There is a continuing need for medical education in palliative care. Particular attention should be paid to the basic medical education of clinical students and the training of junior doctors, especially regarding communication skills and bereavement care.     

Professional and social responsibilities of clinical pharmacology

According to the decision of the Scientific and educational board of the Medical Faculty in Novi Sad the Institute for pharmacology toxicology and clinical pharmacology introduced the clinical pharmacology in 1975. Postgraduate studies were organized for those wishing to specialize, i.e. to get their M.Sc. degree in clinical pharmacology. Besides the youngest members of the Institute (now they are all associate professors) these studies were successfully completed by many doctors from other clinics or those employed in pharmaceutical industry. The publications which the Institute published from the field of pediatric clinical pharmacology were the very first ones not only in our country but also in world proportions. International methods for the evaluation (DDD, ATC code) of the scope and structure of drugs usage were introduced and modified according to our conditions and requirements. The studies on the usage of drugs were among the first pharmacoepidemiological studies in country and abroad. On the basis of these activities the Institute was two times the organizer of the scientific meeting sponsored by WHO. As a response to a sudden increase of the need for information on drugs due to disturbed supply and distribution of drugs from abroad (through humanitarian aid) a telephone and modem information service has been organized within the Institute. The printing of the book titled Drugs in Use was initiated (five editions since 1992) together with the issues on computer discs. The publishing of the journal Pharmaca Iugoslavica was also started under the auspices of the Association of Health Care Organizations. The service for adverse events registration was also organized. Through its activities in planning and organization of pharmacokinetic and clinical investigations, development of new analytic methods and performance of pharmacokinetic studies the Institute contributed to the development of new drugs and gave new theoretical solutions in pharmacokinetics. The Institute also initiated the establishment of the Committee for drugs of the Medical Faculty. Its professors are members of the Commission for Social Insurance, Federal Commission for Drugs and Federal Commission for Poisons. Through all mentioned activities the Institute has greatly influenced not only our but also general medical community.     

A controlled evaluation of small-group education of general practitioners in the management of drug users

We evaluated the effectiveness of small-group education of general practitioners (GPs) in the management of drug users. A total of 40 doctors were trained. Some 28 doctors who were unable to attend and 30 who did not want training participated as comparison groups. Sixteen months after the education, trained doctors notified significantly more drug users to the British Home Office database and more often prescribed methadone at first consultation with a drug user.