Increasing size of health centres may not prevent occupational isolation.

BACKGROUND: A Finnish national survey in 2002 revealed that Finnish physicians often feel that working in a primary heath care centre is isolated work. AIMS: To determine the factors related to perceived isolation in health centre work among general practitioners (GP) working in health centres. METHODS: A postal questionnaire study of physicians (N = 1829) working in primary health care centres. RESULTS: The majority of GPs (67%) agreed that 'working in a health centre is too often isolated work'. Physicians felt isolated most often when working in the largest health centres (>20 posts), whereas physicians working in health centres with 3-10 posts perceived isolation least often. Difficulty in collaboration with partners or the managerial team was associated with this feeling. CONCLUSIONS: Feelings of isolation are common among Finnish health centre physicians, but increasing the size of primary health care units may not prevent these feelings.

Occupational isolation among general practitioners in Finland.

BACKGROUND: It is proposed that isolation in general practice is one of the factors that leads to work-related stress and the low attraction of this work. In Finland, 71% of physicians who worked or had worked in a primary health care centre agreed with the statement 'working as a doctor in a health centre is too often isolated work'. AIMS: To gain a deeper understanding of this feeling and to find out which factors constitute it. METHODS: A qualitative in-depth interview study of 32 physicians working in a primary health care centre in Finland. Qualitative analysis of transcribed verbatim interviews using a constant comparison method. RESULTS: The main components of isolation were making decisions alone, lack of collaboration with other workers in the health centre and secondary care specialists, not being a part of the work community and lack of mentoring at work. CONCLUSIONS: Enabling flexible teamwork and social and professional support networks are the key issues in solving the problem of occupational isolation in general practice.

They call it stormy Monday--reasons for referral from primary to secondary care according to the days of the week.

Previous studies of specialist care have shown that the onset of acute myocardial infarction occurs most frequently on Mondays; however, the septadian pattern in the reasons for referrals from primary care to secondary care has not been examined previously. We examined daily variations in rates of referral from primary to secondary care in central and northern Finland, using International Classification of Primary Care codes, during two weeks (30 November to 6 December 1992, and 28 November to 4 December 1994) before and after the introduction of a reform in the system of financing health care. Monday peaks were observed in the occurrence of angina pectoris, fractures of the tibia/fibula, lumbar disc lesions, and infections of the eye. Tuesday peaks were found in the occurrence of headache. Two peaks (on Tuesday and Thursday) were observed for patients with suspected appendicitis. Many problems of primary health care leading to referral to secondary care are not random events but occur in a weekly pattern. Further investigation is needed within these subgroups of patients to identify the causes of this variation.

Where have all the back pains gone? Changes in the reasons for requiring out-of-hours medical care from a centralized primary care centre after changing to a list system.

OBJECTIVE: We aimed to study changes in reasons for seeking assistance during out-of-hours work in a single health centre before and after introduction of the list system. METHOD: A questionnaire concerning all out-of-hours general practice consultations for 1 week each month in two separate years (in 1990 and 1993) was completed in one health centre in central Finland (Palokka health centre) in a region with 39,465 inhabitants (37,960 inhabitants in 1990). All patients contacting the health centre to request medical help during out-of-hours work were asked to complete the questionnaire. Outcome measures were consultation rates by ICPC main codes. RESULTS: The annual out-of-hours consulting rate per 1000 inhabitants decreased from 823 to 533 (35%) (P < 0.001). The clearest decrease (57%) from 172 to 74 consultations per 1000 inhabitants occurred in patients with musculoskeletal problems. A marked reduction (75%; from 52 to 13 consultations per 1000 inhabitants) was found in male patients with back symptoms. For female patients with neck problems the reduction of out-of-hours consultations was also marked (67% reduction; from 12 to 4 consultations per 1000 inhabitants). CONCLUSION: Improvement of continuity of care for patients having musculoskeletal problems is partly a question of organization, and it is also economically justifiable.

Drinking problems load health centre hospitals in Finland.

This study examined the reasons for referral of patients from general practice to health centre hospitals in central and northern Finland during one week in 1994. Participants were 806 general practitioners (GPs) from public health centres. Outcome measures were reasons for referral by ICPC codes, with respect to characteristics of patients, GPs, and practices. A total of 723 patients (1.4%) were referred from 53,633 consultations. Most referrals (532, 74%) were from out of hours consultations. The most commonly reported reasons for referral in the age group under 65 years were alcohol abuse for males and vertigo for females. For patients aged 65 or over, angina pectoris was the most common reason for referral for both male and female patients. Our results will be useful in developing primary healthcare and the training of GPs. Future research should focus on alcohol-related diseases in those patients referred to health centre hospitals.

Reasons for referral from general practice in Finland.

OBJECTIVE: To examine the reasons for referral from general practice in Finland. DESIGN: Survey over one week of all referrals from general practice. SETTING: Central and northern Finland, comprising 72% of the area of the country and one-third of the population. PARTICIPANTS: 851 general practitioners (GPs) from public health centres. OUTCOME MEASURES: Referrals by speciality and reasons for referrals by ICD-9 and ICPC codes in terms of characteristics of patients, GPs, and practices. RESULTS: A higher proportion of male (39%) than female (33%) patients were referred to surgical speciality (p < 0.001). Ten per cent of the patients referred by female GPs were referred to gynaecology departments, compared with 5% of those referred by male GPs (p < 0.001). Otitis media in children and abdominal pain in adults were the commonest reasons for referral of both male and female patients. CONCLUSION: Our results will be useful in developing the training of GPs with respect to those health problems that most commonly lead to a referral to hospital.

A list system can help to reduce the proportion of out of hours referrals for male patients.

OBJECTIVE: To examine differences in referral patterns by general practitioners (GPs) with and GPs without a list of patients. DESIGN: Survey of all referrals from primary to secondary care during one week. SETTING: Central and northern Finland, in a region comprising 72% of the area of the country and one-third of the population. PARTICIPANTS: 851 GPs, of whom 199 (23%) had a list system. OUTCOME MEASURES: Referrals in terms of practice characteristics. RESULTS: There were 58760 consultations during the study period, and 2921 patients were referred to secondary care. GPs with a list referred 64% of all referred male patients and 63% of all referred female patients during normal working hours. The corresponding referral figures for GPs without a list were 43% and 58%. CONCLUSION: GPs with a list of patients had a more appropriate distribution of referrals between normal and out of hours work than GPs without a list. Our results may help in developing solutions to problems of providing good primary health care.

Saturday night fever? Reasons for referral from health centres to hospitals during weekends in Finland.

OBJECTIVE: We aimed to examine the reasons for referral from health centres to hospitals during the weekend in Finland. METHOD: We conducted a survey of all referrals from general practice on two weekends (30 November to 6 December 1992 and 28 November to 4 December 1994) in central and northern Finland, which covered 72% of the area of the country and one-third of the population. The participants were 178 GPs from public health centres and who made 530 referrals during these weekends. The outcome measures were reasons for referrals by ICPC codes with respect to the characteristics of patients, GPs and practices. RESULTS: During the weekends studied, 530 patients were referred from out-of-hours work. More male (53%) than female patients (47%) were referred. Out of a total of 530 patients, 213 (40%) were referred to surgery, 139 (26%) to internal medicine, 48 (9%) paediatric medicine, 32 (6%) to neurology, 28 (5%) to both ear, nose and throat (ENT) and psychiatry, 25 (5%) to gynaecology and 18 (4%) to other specialities (ophthalmology, lung disease and cancer departments). Fractures requiring surgery, angina pectoris for which patients were sent to internal medicine and stroke for which patients were sent to other specialities were the most commonly reported reasons for referral. Male patients were referred 12 times more often than females for arrhythmia (atrial fibrillation or tachyarrhythmia); males experienced dislocations eight times more often and fractures three times more often than females. CONCLUSION: Our results point out the need to train GPs about those complaints that most often require a referral to specialist care during the weekend. Future research should focus on those patients who are responsible for the huge gender gap of reasons for referral during weekends.

Discrepancies between the assessed urgency and the actual time taken to obtain a consultation with an internist.

OBJECTIVE: To compare postreferral waiting times to hospital in internal medicine with the urgency of the cases as assessed by a panel of doctors. DESIGN: Retrospective evaluation of referrals to three hospitals during 1 week. SETTING: Referrals to internal medicine departments of Kuopio University Hospital, Kajaani central hospital and Pieksämäki regional hospital in Finland. PARTICIPANTS: Two specialists in internal medicine working in university hospital and four specialists in general practice, two of whom were private sector general practitioners (GPs), the other two being public health centre chief physicians. OUTCOME MEASURES: Postreferral waiting times, assessment of the urgency of the referral by a panel of doctors, and the reliability of this assessment. RESULTS: Mean delay to specialist consultation was 36 days. There were no significant differences between the assessors in their opinions regarding the degree of urgency of referrals. Interobserver agreement between assessors was moderate or substantial (kappa values 0.46-0.62) and intraobserver agreement varied from moderate to almost perfect (kappa values were between 0.57 and 0.88). However, of those patients who were assessed to require examination by a consultant within 1 week only 34% actually saw the specialist within that time. Of those patients who were assessed to be require the treatments within 8-30 days, 48% were examined by a specialist within that time. CONCLUSION: It is possible to reliably assess the urgency of referrals to internal medicine departments. There is a need to improve the referral process for those patients requiring consultation with a hospital specialist within 30 days.

General practice consultations in central and northern Finland.

OBJECTIVE: To examine general practice consultations in health centres in central and northern parts of Finland. DESIGN: A questionnaire concerning all general practice consultations during one week. SETTING: Central and northern parts of Finland in a region comprising 72% of the area of the country and one-third of its population. PARTICIPANTS: 851 health centre doctors. OUTCOME MEASURES: Consultation rates by age and sex of the patients and by characteristics of doctors and their practices. RESULTS: The average consultation rate per 1,000 female inhabitants was 43 and per 1,000 male inhabitants 34 per week. For total contacts, a J-shaped association with increasing age was demonstrated for both sexes. The average number of consultations per doctor in a week was 72. Consultation rates were lowest among physicians over 45 years of age. A low consultation rate was also found among general practitioners not participating in the personal doctor programme and among those who worked in municipalities with over 30,000 inhabitants. CONCLUSION: In Finland, consultation rates per 1,000 inhabitants, as well as per general practitioner, are remarkably lower than in most European countries. The personal doctor programme with defined lists of patients seems to be associated with high consultation rates.

The list system can reduce the waiting time and number of consultations in a centralized primary care centre that provides out of hours medical care.

OBJECTIVE: To study the waiting time and number of consultations of the patients who required out of hours medical care from a centralized primary care centre before and after the introduction of a list system. DESIGN: Non-controlled intervention study. A questionnaire, completed by receptionists, concerning all out of hours general practice consultations for one week each month during two separate years (in 1990 with no list system and in 1993 with list system in operation). SETTING: One health centre in central Finland in a region with 39495 inhabitants. SUBJECTS: All patients contacting the health centre to request medical help during out of hours work. OUTCOME MEASURES: Consultation rates by age and sex of the patients and their waiting time before seeing the GP. RESULTS: In 1990, the average out of hours consultation rate per 1000 inhabitants per year was 826 for women and 819 for men. These figures were reduced by 271 for women (95% CI 262-280) and 305 for men (95% CI 297-314) in 1993. The mean waiting time was 55 min in 1990 and 32 min in 1993 (p < 0.001). CONCLUSION: The introduction of a list system leads to more effective primary care services.

Exposure to airborne microbes during the repair of moldy buildings.

Concentrations of airborne microbes, studied during the repair of seven moldy buildings, showed that concentrations of airborne fungi increased during the repair work. This was especially true during the demolition of moldy building materials, even though the total dust levels remained low. Concentrations of viable fungi sampled with a six-stage cascade impactor were 10(3) - > 1.9 x 10(5) cfu/m3, and the total concentrations of fungal propagules, as determined by the Camnea method (i.e., air filtration method with epifluorescence microscopic counting of acridine-stained organisms) showed 10(5)-10(6) counts/m3 during the demolition. Penicillium was the main genus throughout. Concentrations of viable total bacteria also increased, but this change proved less noticeable than that of the fungi. However, rather high concentrations of viable actinomycetes up to 10(4) cfu/m3 were detected during the demolition. Results show that construction workers are exposed to high concentrations of microbes, perhaps causing health problems. Thus, personal protection of both the respiratory system and eyes is strongly recommended for workers as they repair moldy buildings. In addition, the repair room should be isolated from other areas to protect occupants or any other people present.

Does the doctors' professional experience reduce referral rates? Evidence from the Finnish referral study.

OBJECTIVE: To examine hospital referral rates in Finnish health centres according to doctors' and health centres characteristics. DESIGN: Survey of all general practice hospital referrals over one week. SETTING: Central and northern part of Finland, in a region comprising 72% of the area of the country and one-third of the population. PARTICIPANTS: 851 health centre doctors. OUTCOME MEASURES: Referral rates in terms of characteristics of doctors and health centres. RESULTS: During the study period, the 851 health centre doctors had 58 760 consultations (mean 69 patients/week), and 2 921 (5%) patients were referred to secondary care. The variation between the highest and lowest referral quintile of the doctors was almost 17-fold, and of the health centres 2.4-fold. Relatively more referrals were made by locums, young, not yet graduated and female doctors than by specialized, more experienced and male doctors. CONCLUSION: A low referral rate is closely connetected with the extent of the general practitioners' professional experience and specialist training. Investing in specialist training and continuing medical education seems to be the best way to reduce high referral rates.