Countries with historically unlimited patient choice of medical provider, such as Korea, have been promoting rational health care pathways. Factors related to the length of doctor-patient relationship (DPR) for enhancing primary care in those countries should be studied. Participants were patients who had visited their family practices on six or more occasions over a period of more than 6 months. Five domains (21 items) of the Korean Primary Care Assessment Tool (first contact, coordination function, comprehensiveness, family/community orientation, and personalized care) and general questions were administered in the waiting rooms. From seven practices, the response rate was 83.7% (495/591). The older the age, the lower the income, the shorter the duration of education, the more the number of diseases the patients had, and in provincial cities rather than in Seoul, the longer length of DPR ( ≥ 4 yr) was shown. The long-term DPR was associated with total primary care quality score (upper [ ≥ 71.4] vs lower [ < 71.4], OR, 1.74; 95% CI, 1.10-2.76), especially with coordination function (OR, 1.01; 95% CI, 1.00-1.02), being adjusted for confounding variables. Strengthening the coordination function may have to be the first consideration in primary care policy in countries like Korea.
Primary Health Care; Quality Assurance; Health Care Policy; Korea
Background. This qualitative study aims to gain insight into the perceptions and experiences of older patients with regard to sharing health care decisions with their general practitioners. Patients and Methods. Thirty-four general practice patients (≥70 years) were asked about their preferences and experiences concerning shared decision making with their doctors using qualitative semistructured interviews. All interviews were analysed according to principles of content analysis. The resulting categories were then arranged into a classification grid to develop a typology of preferences for participating in decision-making processes. Results. Older patients generally preferred to make decisions concerning everyday life rather than medical decisions, which they preferred to leave to their doctors. We characterised eight different patient types based on four interdependent positions (self-determination, adherence, information seeking, and trust). Experiences of a good doctor-patient relationship were associated with trust, reliance on the doctor for information and decision making, and adherence. Conclusion. Owing to the varied patient decision-making types, it is not easy for doctors to anticipate the desired level of patient involvement. However, the decision matter and the self-determination of patients provide good starting points in preparing the ground for shared decision making. A good relationship with the doctor facilitates satisfying decision-making experiences.
Anecdotes abound about doctors' personal illness experiences and the effect they have on their empathy and care of patients. We formally investigated the relationship between doctors' and medical students' personal illness experiences, their examination results, preparedness for clinical practice, learning and professional attitudes and behaviour towards patients.
Newly-qualified UK doctors in 2005 (n = 2062/4784), and two cohorts of students at one London medical school (n = 640/749) participated in the quantitative arm of the study. 37 Consultants, 1 Specialist Registrar, 2 Clinical Skills Tutors and 25 newly-qualified doctors participated in the qualitative arm. Newly-qualified doctors and medical students reported their personal illness experiences in a questionnaire. Doctors' experiences were correlated with self-reported preparedness for their new clinical jobs. Students' experiences were correlated with their examination results, and self-reported anxiety and depression. Interviews with clinical teachers, newly-qualified doctors and senior doctors qualitatively investigated how personal illness experiences affect learning, professional attitudes, and behaviour.
85.5% of newly-qualified doctors and 54.4% of medical students reported personal illness experiences. Newly-qualified doctors who had been ill felt less prepared for starting work (p < 0.001), but those who had only experienced illness in a relative or friend felt more prepared (p = 0.02). Clinical medical students who had been ill were more anxious (p = 0.01) and had lower examination scores (p = 0.006). Doctors felt their personal illness experiences helped them empathise and communicate with patients. Medical students with more life experience were perceived as more mature, empathetic, and better learners; but illness at medical school was recognised to impede learning.
The majority of the medical students and newly qualified doctors we studied reported personal illness experiences, and these experiences were associated with lower undergraduate examination results, higher anxiety, and lower preparedness. However reflection on such experiences may have improved professional attitudes such as empathy and compassion for patients. Future research is warranted in this area.
In recent years, the importance of social differences in the physician-patient relationship has frequently been the subject of research. A 2002 review synthesised the evidence on this topic. Considering the increasing importance of social inequalities in health care, an actualization of this review seemed appropriate.
A systematic search of literature published between 1965 and 2011 on the social gradient in doctor-patient communication. In this review social class was determined by patient's income, education or occupation.
Twenty original research papers and meta-analyses were included. Social differences in doctor-patient communication were described according to the following classification: verbal behaviour including instrumental and affective behaviour, non-verbal behaviour and patient-centred behaviour.
This review indicates that the literature on the social gradient in doctor-patient communication that was published in the last decade, addresses new issues and themes. Firstly, most of the found studies emphasize the importance of the reciprocity of communication.
Secondly, there seems to be a growing interest in patient's perception of doctor-patient communication.
By increasing the doctors' awareness of the communicative differences and by empowering patients to express concerns and preferences, a more effective communication could be established.
Communication; Physician-patient relations; Social class
In one Inner London health district many doctors seemed reluctant to work in health centres. To investigate the reasons, 44 general practitioners in two matched groups were interviewed. Those working in health centres appreciated the advantages of pleasant premises and the presence of a primary health care team. Other doctors believed health centres were disliked by patients, were bureaucratic in organization, and involved difficult interpersonal relationships. These were confirmed as real problems by health centre doctors. Thus, reluctance to join health centre practices is based on a realistic appraisal of the drawbacks. Recommendations are made.
To examine the differences in physician satisfaction associated with open- versus closed-model practice settings and to evaluate changes in physician satisfaction between 1986 and 1997. Open-model practices refer to those in which physicians accept patients from multiple health plans and insurers (i.e., do not have an exclusive arrangement with any single health plan). Closed-model practices refer to those wherein physicians have an exclusive relationship with a single health plan (i.e., staff- or group-model HMO).
Two cross-sectional surveys of physicians; one conducted in 1986 (Medical Outcomes Study) and one conducted in 1997 (Study of Primary Care Performance in Massachusetts).
Primary care practices in Massachusetts.
General internists and family practitioners in Massachusetts.
Seven measures of physician satisfaction, including satisfaction with quality of care, the potential to achieve professional goals, time spent with individual patients, total earnings from practice, degree of personal autonomy, leisure time, and incentives for high quality.
Physicians in open- versus closed-model practices differed significantly in several aspects of their professional satisfaction. In 1997, open-model physicians were less satisfied than closed-model physicians with their total earnings, leisure time, and incentives for high quality. Open-model physicians reported significantly more difficulty with authorization procedures and reported more denials for care. Overall, physicians in 1997 were less satisfied in every aspect of their professional life than 1986 physicians. Differences were significant in three areas: time spent with individual patients, autonomy, and leisure time (P ≤ .05). Among open-model physicians, satisfaction with autonomy and time with individual patients were significantly lower in 1997 than 1986 (P ≤ .01). Among closed-model physicians, satisfaction with total earnings and with potential to achieve professional goals were significantly lower in 1997 than in 1986 (P ≤ .01).
This study finds that the state of physician satisfaction in Massachusetts is extremely low, with the majority of physicians dissatisfied with the amount of time they have with individual patients, their leisure time, and their incentives for high quality. Satisfaction with most areas of practice declined significantly between 1986 and 1997. Open-model physicians were less satisfied than closed-model physicians in most aspects of practices.
health maintenance organizations; job satisfaction; physicians' practice patterns; United States; professional autonomy
Deaf and hard-of-hearing (DHoH) individuals are underrepresented among physicians and physicians-in-training, yet this group is frequently overlooked in the diversity efforts of many medical training programs. The inclusion of DHoH individuals, with their diverse backgrounds, experiences, and struggles contributes to medical education and health care systems in a variety of ways, including: (1) a richer medical education experience for students and faculty resulting in greater disability awareness and knowledge about how to interact with and care for DHoH individuals and their families; (2) the provision of empathetic care desired by many patients and their families, including individuals who have a disability or chronic condition; and (3) the promotion of a more supportive and accessible professional environment for physicians, including older physicians in practice and as educators, who are experiencing age-associated decreased hearing acuity or other acquired disabilities.
To determine if fourth-year medical students are as effective as faculty in teaching the physical examination to first-year medical students.
Stratified randomization of the first-year students.
A public medical school.
All 100 first-year medical students in one medical school class were randomly assigned (controlling for gender) to either a faculty or a fourth-year student preceptor for the Physical Examination Module.
The first-year students of faculty preceptors scored no differently on the written examination than the students of the fourth-year medical student preceptors (82.8% vs 80.3%, p = .09) and no differently on a standardized patient practical examination (95.5% vs 95.4%, p = .92). Also, the first-year students rated the two groups of preceptors similarly on an evaluation form, with faculty rated higher on six items and the student preceptors rated higher on six items (all p > .10). The fourth-year student preceptors rated the experience favorably.
Fourth-year medical students were as successful as faculty in teaching first-year medical students the physical examination as measured by first-year student’s performances on objective measures and ratings of teaching effectiveness.
education; teaching; physical examination; small-group teaching; preceptors
Many physicians have medical experience in developing countries early in their career, but its association with their medical performance later is not known. To explore possible associations we compared primary care physicians (GPs) with and without professional experience in a developing country in performance both clinical and organisational.
A retrospective survey using two databases to analyse clinical and organisational performance respectively. Analysis was done at the GP level and practice level.
517 GPs received a questionnaire regarding relevant working experience in a developing country. Indicators for clinical performance were: prescription, referral, external diagnostic procedures and minor procedures. We used the district health insurance data base covering 570.000 patients. Explorative secondary analysis of practice visits of 1004 GPs in 566 practices in the Netherlands from 1999 till 2001. We used a validated practice visit method (VIP; 385 indicators in 51 dimensions of practice management) to compare having experience in a developing country or not.
Almost 8% of the GPs had experience in a developing country of at least two years.
These GPs referred 9,5% less than their colleagues and did more surgical procedures. However, in the multivariate analysis 'experience in a developing country' was not significantly associated with clinical performance or with other GP- and practice characteristics. 16% of the practices a GP or GPs with at least two years experience in a developing country. They worked more often in group and rural practices with less patients per fte GP and more often part-time. These practices are more hygienic, collaborate more with the hospital and score better on organisation of the practice. These practices score less on service and availability, spend less time on patients in the consultation and the quality of recording in the EMD is lower.
We found interesting differences in clinical and organisational performance between GPs with and without medical experience in developing countries and between their practices. It is not possible to attribute these differences to this experience, because the choice for medical experience in a tropical country probably reflects individual differences in professional motivation and personality. Experience in a developing country may be just as valuable for later performance in general practice as experience at home.
Primary Health Care (PHC) is increasingly being introduced into undergraduate medical education. In Greece, the Faculty of Medicine of the University of Crete was the first to introduce a 4-week long training in primary health care. This paper presents the experiences gained from the initial implementation of the teaching of practice-based primary care in rural Crete and reports on the assessment scale that was developed.
284 students' case write-ups from the 6 primary care units (PCUs) where they were allocated for the period 1990 to 1994 were analysed. The demographic data of the students and patients and the number of home visits were studied. Content analysis of the students' write-ups was carried out, using an assessment scale consisting of 10 dichotomous variables, in order to quantify eight (8) primary qualitative criteria.
Internal reliability was estimated by the index KR20 = 0.67. Face and content validity was found to conform to the standards set for the course, while logistic linear regression analysis showed that the quality criteria could be used as an assessment scale.
The number of home visits carried out varied between the various different PCUs (p < 0.001) and more were reported in the write-ups that fulfilled criteria related to the biopsychosocial approach (p < 0.05). Nine quantitative criteria were fulfilled in more than 90% of case reports, but laboratory investigations were reported only in 69.0% of case reports. Statistically significant differences between the PCUs were observed in the fulfilment of criteria related to the community approach, patient assessment and information related to the patient's perception of the illness, but not to those related to aspects of clinical patient management. Differences in reporting laboratory investigations (p < 0.001) are explained by the lack of such facilities in some PCUs. Demographic characteristics of the patients or the students' do not affect the criteria.
The primary health care course achieved the objectives of introducing students to comprehensive, community oriented care, although there was variation between the PCUs. The assessment scale that was developed to analyse the case-write ups of the students provided data that can be used to evaluate the course.
Specialist mental health care is out of reach for most Indians. The World Health Organisation has called for the integration of mental health into primary health care as a key strategy in closing the treatment gap. However, few studies in India have examined medical practitioners’ mental health-related knowledge and attitudes. This study examined these facets of service provision amongst doctors providing primary health care in a rural area of Karnataka is Southern India.
A mental health knowledge and attitudes questionnaire was self- administered by participants. The questionnaire consisted of four sections; 1) basic demographics and practice information, 2) training in mental health, 3) knowledge of mental health, and self-perceived competence in providing mental health care, and 4) attitudes towards mental health. Data was analysed quantitatively, primarily using descriptive statistics.
This study recruited 46 participants. The majority of participants (69.6%) felt competent in providing mental health services to their patients. However, there was a substantial level of endorsement for several statements that reflected negative attitudes. Almost one third of participants (28.0%) had not received any training in providing mental health care. Whilst three-quarters of participants correctly identified depression (76.1%) and psychosis (76.1%) in a vignette, fewer were able to name three common signs and symptoms of depression (50.0%) and psychosis (28.3%).
Integrating mental health into primary health care requires evidence-based up-skilling programs. Doctors in this study desired such training and would benefit from it, with a focus on both depth of knowledge and uncovering stigmatising attitudes towards people with mental health problems.
New values and practices associated with medical professionalism have created an increased interest in the concept. In the United Kingdom, it is a current concern in medical education and in the development of doctor appraisal and revalidation.
To investigate how final year medical students experience and interpret new values of professionalism as they emerge in relation to confronting dying patients and as they potentially conflict with older values that emerge through hidden dimensions of the curriculum.
Qualitative study using interpretative discourse analysis of anonymized student reflective portfolios. One hundred twenty-three final year undergraduate medical students (64 male and 59 female) from the University of Cambridge School of Clinical Medicine supplied 116 portfolios from general practice and 118 from hospital settings about patients receiving palliative or end of life care.
Professional values were prevalent in all the portfolios. Students emphasised patient-centered, holistic care, synonymous with a more contemporary idea of professionalism, in conjunction with values associated with the ‘old’ model of professionalism that had not be directly taught to them. Integrating ‘new’ professional values was at times problematic. Three main areas of potential conflict were identified: ethical considerations, doctor-patient interaction and subjective boundaries. Students explicitly and implicitly discussed several tensions and described strategies to resolve them.
The conflicts outlined arise from the mix of values associated with different models of professionalism. Analysis indicates that ‘new’ models are not simply replacing existing elements. Whilst this analysis is of accounts from students within one UK medical school, the experience of conflict between different notions of professionalism and the three broad domains in which this conflict arises are relevant in other areas of medicine and in different national contexts.
medical professionalism; medical education; qualitative research; students’ reflections
To implement a Spanish language and culture initiative in a doctor of pharmacy (PharmD) curriculum that would improve students' Spanish language skills and cultural competence so that graduates could provide competent pharmaceutical care to Spanish-speaking patients.
Five elective courses were created and introduced to the curriculum including 2 medical Spanish courses; a medical Spanish service-learning course; a 2-week Spanish language and cultural immersion trip to Mexico; and an advanced practice pharmacy experience (APPE) at a medical care clinic serving a high percentage of Spanish-speaking patients. Advisors placed increased emphasis on encouraging pharmacy students to complete a major or minor in Spanish.
Enrollment in the Spanish language courses and the cultural immersion trip has been strong. Twenty-three students have completed the APPE at a Spanish-speaking clinic. Eleven percent of 2010 Butler University pharmacy graduates completed a major or minor in Spanish compared to approximately 1% in 2004 when the initiative began.
A Spanish language and culture initiative started in 2004 has resulted in increased Spanish language and cultural competence among pharmacy students and recent graduates.
Hispanic; Latino; Spanish; curriculum; cultural competence
The aim of this study was to examine the reasons why primary care doctors undertake postgraduate diploma studies in a mixed private/public Asian setting.
Twenty four past or current postgraduate diploma students of the family medicine unit (FMU) of the University of Hong Kong participated in three focus group interviews. A structured questionnaire was constructed based on the qualitative data collected and was sent to 328 former applicants of postgraduate diploma studies at FMU.
“Upgrading medical knowledge and skills” and “improving quality of practice” were two of the factors that most of the respondents considered to be significant in motivating them to undertake postgraduate diploma studies. “Time constraint” and “workload in practice” were however the most significant demotivating factors. Financial issues were more seriously considered by the junior than the senior doctors. To be able to “expand patient base and/or number” was considered to be a significant factor by the private doctors who were also keen to “improve communication and relationship with patients”.
These findings suggest that there are mixed reasons for primary care doctors to undertake postgraduate diploma studies. Course organisers should take into consideration these various reasons in planning their programmes.
Asia; general practitioners; postgraduate studies; primary care doctors
To assess the extent to which perceptions of specific aspects of the doctor–patient relationship are related to overall satisfaction with primary care physicians among HIV-infected patients.
Longitudinal, observational study of HIV-infected persons new to primary HIV care. Data were collected at enrollment and approximately 6 months later by in-person interview.
Two urban medical centers in the northeastern United States.
Patients seeking primary HIV care for the first time.
MEASUREMENTS AND MAIN RESULTS
The primary outcome measure was patient-reported satisfaction with a primary care physician measured 6 months after initiating primary HIV care. Patients who were more comfortable discussing personal issues with their physicians (P = .021), who perceived their primary care physicians as more empathetic (P = .001), and who perceived their primary care physicians as more knowledgeable with respect to HIV (P = .002) were significantly more satisfied with their primary care physicians, adjusted for characteristics of the patient and characteristics of primary care. Collectively, specific aspects of the doctor–patient relationship explained 56% of the variation in overall satisfaction with the primary care physician.
Patients' perceptions of their primary care physician's HIV knowledge and empathy were highly related to their satisfaction with this physician. Satisfaction among HIV-infected patients was not associated with patients' sociodemographic characteristics, HIV risk characteristics, alcohol and drug use, health status, quality of life, or concordant patient-physician gender and racial matching.
HIV; satisfaction; doctor–patient relationship
Faculty of Medicine University of Gezira, utilized a community based educational strategy. In the module primary health care centre practice and family medicine (PHCCP & FM), each student is assigned a family for whom priority health problems are identified and education given accordingly.
To provide, through medical students, health education to diabetics in the assigned families and to assess the impact of the students’ intervention.
This is longitudinal interventional study which was conducted in three stages: training of medical students, education to diabetic patients and evaluation of the intervention.
There was a highly significant difference in the students’ knowledge and skills including communication skills on the home management of diabetes mellitus.
Diabetics in the families were 80(3.3%), 42 (52.5%) females, 38 (47.5%) males. Their ages ranged between 22-78 years. Illiteracy rate was 9 (11.2%), most of the families’ incomes ranged from low to middle, only 25% were of the high income bracket.
More than half 47(58.7%) of the diabetics reported complications of diabetes. Eye complications 6 (7.5%), peripheral neuropathy 15 (18.7%), foot sepsis 4 (4.5%), urinary tract infection 11 (13.7%), renal failure 2 (2.5%), others 9 (11.2%).
There was a highly significant improvement in the knowledge, attitudes and practices of the diabetics, as a result of the student intervention. These included compliance to treatment, adherence to diabetic diet, regular care of the feet, knowledge of major diabetic complications, knowledge of signs of hypoglycaemia, and home management of hypoglycemia. Ten cases with serious complications were referred to Wad Medani teaching hospital.
Patient education; community based education; home management of diabetes
Objectives: To discover the perceived size of pool of doctors considered to be underperforming in general practice in the Northern Deanery and to discover whether these perceptions are based on formal assessments.
Design: Postal questionnaire.
Setting: Area covered by the Northern Deanery.
Subjects: Seven health authority directors of primary care, seven secretaries of local medical committees, and 14 chief officers of community health councils.
Results: The response rate was 100% for directors of primary care and secretaries of local medical committees and, after one reminder, 92% for chief officers of community health councils. Numbers of doctors perceived to be underperforming ranged from none to over 15 in different health authority areas. Main areas for concern were communication skills, clinical skills, and management skills. Patients’ representatives were concerned about lack of power of patients and health authorities and doctors’ lack of accountability. Health authorities were concerned about lack of power, identification of underperforming doctors, and doctors’ professional loyalty. Local medical committees were concerned about the problem of identifying underperformance. A number of methods were used for identification, and there was no common method applied.
Conclusions: The number of doctors thought to be underperforming was small. Work still needs to be done on developing tools that can be used in everyday practice to enable doctors to confirm for themselves, their colleagues, and their patients that they are providing an adequate level of care.
Key messages To quantify the problem of underperforming general practitioners in the Northern Deanery, a postal survey was carried out among representatives of healthcare commissioners, doctors, and patients A small but not insignificant number of doctors were identified as providing a poor level of performance Main areas for concern were communication skills, clinical skills, and management skills. Various methods were used for identifying underperforming doctors, but there was no common method applied Perceived problems with the present system of dealing with underperforming doctors included identification, lack of power of patients and health authorities, and doctors’ professional loyalty and lack of accountability
While much has been written about the benefits of personal continuity of care there has been little research about the views of patients. In this cross sectional study 111 patients from three group practices (one of which ran a personal list system) were interviewed at home within a week of consulting a general practitioner. Patients were selected randomly from a systematic series of consulting sessions and a semi-structured interview was administered. Patients receiving more personal continuity of care were likely to be older, to have booked their most recent appointment further in advance, to desire personal continuity of care, to have an external health locus of control and to have a lower extroversion score. In the practice with a personal list, patients had a high level of continuity of care, were satisfied and showed little interest in having a choice of doctor. In the combined list practices patients valued their choice of doctor but often could not exercise it enough and they were more critical. They made more suggestions for change than those in the practice with a personal list system, mostly about receptionists and appointments. It is concluded that most patients like to see the same doctor, but they may not be willing to wait two days for this if there is a quicker option. It may be difficult to deliver both personal continuity of care and choice in group practice.
The transition from medical student to junior doctor in postgraduate training is a critical stage in career progression. We report junior doctors' views about the extent to which their medical school prepared them for their work in clinical practice.
Postal questionnaires were used to survey the medical graduates of 1999, 2000, 2002 and 2005, from all UK medical schools, one year after graduation, and graduates of 2000, 2002 and 2005 three years after graduation. Summary statistics, chi-squared tests, and binary logistic regression were used to analyse the results. The main outcome measure was the level of agreement that medical school had prepared the responder well for work.
Response rate was 63.7% (11610/18216) in year one and 60.2% (8427/13997) in year three. One year after graduation, 36.3% (95% CI: 34.6, 38.0) of 1999/2000 graduates, 50.3% (48.5, 52.2) of 2002 graduates, and 58.2% (56.5, 59.9) of 2005 graduates agreed their medical school had prepared them well. Conversely, in year three agreement fell from 48.9% (47.1, 50.7) to 38.0% (36.0, 40.0) to 28.0% (26.2, 29.7). Combining cohorts at year one, percentages who agreed that they had been well prepared ranged from 82% (95% CI: 79-87) at the medical school with the highest level of agreement to 30% (25-35) at the lowest. At year three the range was 70% to 27%. Ethnicity and sex were partial predictors of doctors' level of agreement; following adjustment for them, substantial differences between schools remained. In years one and three, 30% and 34% of doctors specified that feeling unprepared had been a serious or medium-sized problem for them (only 3% in each year regarded it as serious).
The vast knowledge base of clinical practice makes full preparation impossible. Our statement about feeling prepared is simple yet discriminating and identified some substantial differences between medical schools. Medical schools need feedback from graduates about elements of training that could be improved.
Medically unexplained symptoms in young people can present a challenge for primary care physicians to manage. Despite the prevalence of this clinical problem, physicians feel ill-equipped to deal with it. Families may attribute symptoms to an organic cause, despite the absence of identified pathology, and often resist considering psychosocial contributing factors. The present article outlines the key principles in the management of medically unexplained symptoms. Treatment focuses on building a therapeutic alliance with the patient and the family, the use of psychotherapeutic interventions and the role of psychopharmacology. A family-oriented rehabilitative approach to care, with a focus on functional improvement rather than symptom reduction, is emphasized.
Medically unexplained; Paediatric management; Symptoms
Doctor-patient communication is a skill essential for the satisfaction of the patients’ needs and expectations. It involves an art that every practicing physician should have. The situations in health care delivery that demands good doctor-patient communication are many. Diabetes care, the management of hypertension, explaining serious disease diagnoses, prognosis, and investigative procedures are some of the common situations where good doctor-patient communication is very essential. Doctor-patient communication assumes a special status in Saudi Arabia where as a result of mixed ethnicity of the manpower in the health service and the expatriate community, there is a vast diversity of languages, health traditions and beliefs. The skill of doctor-patient communication can be developed and improved by the application of the principles of the patient-centered approach, the utilization of patient-oriented evidence that matters, and its inclusion in the undergraduate curriculum in the first few years of medical school. There should be continuous medical education programs for practicing doctors on the skills of doctor-patient communication through seminars and workshops. This would be a further step towards the improvement of the consumer's well-being.
Doctor-patient communication; Saudi Arabia
Design: A cohort study of students entering Glasgow University's new learner centred, integrated medical curriculum in October 1996.
Methods: Students' pre year 1 and post year 1, post year 3, and post year 5 responses to the "attractive patient" vignette of the Ethics in Health Care Survey instrument were examined quantitatively and qualitatively. Analysis of students' multi-choice answers enabled measurement of the movement towards professional consensus opinion. Analysis of written justifications helped determine whether their reasoning was consistent with professional consensus and enabled measurement of change in knowledge content and recognition of the values inherent in the vignette. Themes on students' reasoning behind their decision to enter a relationship or not were also identified.
Results: No significant movement towards consensus was found at any point in the curriculum. There was little improvement in students' performance in terms of knowledge content and their abilities to recognise the values inherent in the vignette. In deciding to enter a relationship with the patient the most frequently used reasoning was that it could be justified if the patient changed their doctor.
Conclusions: Teaching on the subject of sexual or improper relationships between doctors and patients, including relationships with former patients requires to be made explicit. Case based teaching would fit in with the ethos of the problem based, integrated medical curriculum.
Continuity of patient care is one of the cornerstones of primary care.
To examine publicly available, Internet-based reviews of adult primary care physicians, specifically written by patients who report long-term relationships with their physicians.
This substudy was nested within a larger qualitative content analysis of online physician ratings. We focused on reviews reflecting an established patient-physician relationship, that is, those seeing their physicians for at least 1 year.
Of the 712 Internet reviews of primary care physicians, 93 reviews (13.1%) were from patients that self-identified as having a long-term relationship with their physician, 11 reviews (1.5%) commented on a first-time visit to a physician, and the remainder of reviews (85.4%) did not specify the amount of time with their physician. Analysis revealed six overarching domains: (1) personality traits or descriptors of the physician, (2) technical competence, (3) communication, (4) access to physician, (5) office staff/environment, and (6) coordination of care.
Our analysis shows that patients who have been with their physician for at least 1 year write positive reviews on public websites and focus on physician attributes.
social media; qualitative; primary care
To determine whether nurse practitioners can provide care at first point of contact equivalent to doctors in a primary care setting.
Systematic review of randomised controlled trials and prospective observational studies.
Cochrane controlled trials register, specialist register of trials maintained by Cochrane Effective Practice and Organisation of Care Group, Medline, Embase, CINAHL, science citation index, database of abstracts of reviews of effectiveness, national research register, hand searches, and published bibliographies.
Randomised controlled trials and prospective observational studies comparing nurse practitioners and doctors providing care at first point of contact for patients with undifferentiated health problems in a primary care setting and providing data on one or more of the following outcomes: patient satisfaction, health status, costs, and process of care.
11 trials and 23 observational studies met all the inclusion criteria. Patients were more satisfied with care by a nurse practitioner (standardised mean difference 0.27, 95% confidence interval 0.07 to 0.47). No differences in health status were found. Nurse practitioners had longer consultations (weighted mean difference 3.67 minutes, 2.05 to 5.29) and made more investigations (odds ratio 1.22, 1.02 to 1.46) than did doctors. No differences were found in prescriptions, return consultations, or referrals. Quality of care was in some ways better for nurse practitioner consultations.
Increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care.
What is already known on this topicNurse practitioners have existed in North America for many yearsAn increasing number of such nurses are being employed in the United Kingdom in general practice, emergency departments, and other primary care settingsReviews suggest that nurse practitioners are equivalent to doctors on most variables studied, but the relevance of this in the context of the NHS is unclearWhat this study addsPatients are more satisfied with care from a nurse practitioner than from a doctor, with no difference in health outcomesNurse practitioners provide longer consultations and carry out more investigations than doctorsMost recent research has related to patients requesting same day appointments for minor illness, which is only a limited part of a doctor's role
Against a background of government calls for a radical change in the way the medical workforce is planned and trained, the concept of skill mix seeks to match clinical presentation to an intervention based on an appropriate level of skill and training. Health economics is not the only framework within which these changes can be analysed. However unless the economic issues are thought through clearly there is a danger that resources may be used inefficiently. The aims of this paper are to outline the economic issues in the area of doctor/nurse skill mix and the problems of obtaining correct solutions from the perspective of efficiency. It concludes by offering a pragmatic framework which can facilitate decisions in this area. Although this paper is written from the perspective of primary care, it is equally relevant to skill mix in the secondary care sector.