[Complementary and Alternative Medicine Offers of Teaching Practices for General Medicine]. / Komplementär- und alternativmedizinische Angebote von Lehrpraxen für Allgemeinmedizin.

OBJECTIVE: Germany's new medical licensure act has increased the importance of general practice in academic medical education. This study gives an overview of complementary and alternative medicine in general teaching practices in Germany and their adherence to evidence-based criteria which is required in order to qualify as a teaching practice. METHODS: After a systematic search for German teaching practices, we assessed their diagnostic and therapeutic offers via their websites. We calculated the various frequencies of treatments and differentiated between evidence-based complementary medicine and alternative medicine with little to no evidence. RESULTS: Of 4102 practices, more than half offered complementary and/or alternative treatment. Most of those were treatments approved of by the German medical association. Alternative medicine was offered by 18.2% of the practices. CONCLUSION: Collective terms and conflicting evidence complicate the classification of treatments. Teaching practices offering non-evidence-based treatment raise the question whether recruitment of additional teaching practices stands at odds with the quality of medical education. Explicit offers of alternative treatment should disqualify a teaching practice as such. Controversial treatment may be taught academically and during residency with a focus on evidence-based guidelines and communication skills in order to prepare young medical practitioners for talks with their patients about the subject.

General practice location and malpractice litigation.

INTRODUCTION: Healthcare systems in many countries struggle to recruit general practitioners (GPs) for clinics in rural areas leading to less GPs for an increasing number of patients. As a result, fewer resources are available for individual patients, potentially influencing patient satisfaction and the likelihood of malpractice litigation. The aim of this study was to investigate the association between malpractice litigation and local setting characteristics in a Danish national sample of GPs considering rurality, number of patients listed with the GP, as well as levels of local unemployment, education, income and healthcare expenditure. METHOD: This is a register study on Danish complaint files and administrative register data using multivariate logistic regression. RESULTS: No statistical significant association could be established between litigation figures and rurality, occupation with respect to education, and municipality level of healthcare expenditures. However, larger patient list size was associated with higher rates of malpractice litigation (odds ratio (OR) 1.05 per 100 patients). Litigation was less frequent in settings with higher income patient populations (OR 0.65), although where it did occur the criticism seemed much more likely to be justified (OR 6.03). CONCLUSION: Many GPs face an increasing workload in terms of patient lists. This can cause drawbacks in terms of patient dissatisfaction and malpractice litigation even though local factors such as economic wealth apparently interfere. Further research is needed about the role of geographic variations, workload and socioeconomic inequality in malpractice litigation.

Reconfiguring diagnostic work in Danish general practice; regulation, triage and the secretaries as diagnostician.

Health care systems as well as bodies of medical knowledge are dynamic and change as the result of political and social transformations. In recent decades, health care systems have been subjected to a whole assemblage of regulatory practices. The local changes undertaken in Denmark that are being explored here are indicative of a long-term shift that has occurred in many welfare states intended to make public services in the Global North more efficient and transparent. Departing in prolonged field work in Danish general practice and the anthropological literature on audit culture, this paper suggests that the introduction of regulatory practices has enhanced the need for triage as a key organising principle. The term triage literally means separating out and refers to the process of sorting and placing patients in time and space. The paper suggests that an increasing introduction of triage feeds into a reconfiguration of diagnostic work, where the clinical setting is gradually becoming more intertwined with the governing domains of policy, and the work of the secretary is gradually becoming more intertwined with that of the doctor. Finally, the paper argues that an increasing regulation of general practice poses an ethically charged challenge to existing welfare politics of responsibility between the state and the public, as it makes it increasingly difficult to negotiate access to care.

At the dawn of delegation? Experiences and attitudes of general practitioners in Germany - a questionnaire survey.

BACKGROUND: In the future, 'delegation' as task shifting from general practitioners (GPs) to non-physicians will be important in primary care. Therefore, the aim of this study was to evaluate the attitudes towards the concept of task shifting and to identify predictors of a positive attitude towards task shifting from the perspective of GPs. METHODS: This cross-sectional questionnaire study analysed attitudes towards the concept of task shifting and delegated tasks from the perspective of GPs who were recruited in the German federal state of Schleswig-Holstein. Descriptive statistics and binary regression analyses were computed to identify potential predictors of a positive attitude towards task shifting. RESULTS: Out of 1538 questionnaires distributed, 577 GP questionnaires were returned (response rate: 37.5%). A total of 53.2% of the respondents were male, and 37.3% were female. A positive attitude regarding task shifting was shown by 49% of the participating GPs. The highest level of agreement (95.2%) was found for time savings with task shifting, and a lower agreement (39%) was found regarding the lack of clarity concerning the responsibilities and legal aspects with regards to task shifting. The most frequently delegated tasks were recording electrocardiograms and measuring blood glucose levels. A positive attitude towards task shifting was positively associated with higher job satisfaction and a need for qualified staff. CONCLUSION: Our sample of GPs for this study was very open-minded towards the concept of task shifting. Germany is just beginning this delegation, but the implementation of task shifting depends on different aspects, such as legal requirements, adequate payment and qualified staff. Finally, there is a need for continuing professional development in primary care teams, especially for non-clinical practice staff.

Occupational violence and staff safety in general practice.

BACKGROUND: The recent death of a Victorian surgeon who was assaulted by a member of the public when leaving work has re-highlighted the risk and potential cost of violence experienced by healthcare workers. OBJECTIVE: The aim of this article is to outline the risk of occupational violence experienced by doctors, and general practitioners in particular, and to discuss practical measures that can be taken to manage this risk. DISCUSSION: The majority of doctors have experienced aggression or violence in their workplaces in the past 12 months. Risks for violence include elements of workplace design, policy and procedures, and client factors. A series of practical tools designed to assist the assessment and management of risk of occupational violence are discussed.

Fatal visit to the general practitioner.

A 31-year-old female asthmatic patient received an infusion of metamizole and tramadol for chronic pain at a GP surgery. After a few minutes, the patient developed breaing difficulties and died in spite of resuscitation measures. The general practitioner was suspected of medical malpractice. Medico-legal investigations confirmed the assumption that death was caused by anaphylacitic shock. In spite of temporary intubation into the oesophagus no evidence of medical malpractice was found, however.

How to write a medico-legal report.

BACKGROUND: The preparation and provision of medico-legal reports by the treating doctor is an inevitable but sometimes unwelcome part of general practice. OBJECTIVE: This article outlines the steps involved in preparing a 'good' medico-legal report, including some of the common pitfalls to avoid. DISCUSSION: General practitioners play an important role in providing medico-legal reports about their patients for a wide variety of purposes. A medico-legal report may be seen by a diverse, non-medical audience. Once prepared, the report may be used as evidence in court proceedings and subjected to close scrutiny. A structured and comprehensive medico-legal report may minimise the chances of having to give evidence in court.

[End of life care in general practice: results of an observational survey with general practitioners]. / Hausärztliche Versorgung am Lebensende (HAVEL): Ergebnisse einer retrospektiven Beobachtungsstudie.

BACKGROUND: Little is known about the amount of end of life care provided by general practitioners (GPs) in Germany. Therefore the aim of the HAVEL study is to describe the involvement of GPs in end of life care in more detail. METHODS: Data from all patients who died from natural causes within a period of 12 months (n = 452) were collected from 30 general practices with a self-developed questionnaire and compared to data from patients who died in hospice or palliative care units. RESULTS: Contact rates with GPs increased at the end of life and approximately half of the patients (48 %) were seen within 48 h prior to death. A different spectrum of diseases and symptoms were observed compared to hospice and palliative care units with predominantly chronic diseases (e.g. cardiovascular and mental diseases). DISCUSSION AND CONCLUSIONS: General practitioners are highly involved in palliative health care, even for patients who eventually die in hospitals. Differences in patient characteristics and circumstances compared to specialized palliative care should be reflected in curricula for training in palliative care and the definition of a palliative situation.

Access to physical health care for people with serious mental illness: a nursing perspective and a human rights perspective-common ground?

Relative to the general population, people with serious mental illness (SMI) experience elevated risks of physical disease and illness and live shorter lives. A human rights perspective argues that people with serious mental illness have a right to equal access to physical health care. Nurses in mental health services can contribute to improving the availability and accessibility of physical health care. This study, involving focus group interviews with nurses in a large regional and rural mental health care district of Queensland, Australia, revealed significant problems in access to physical health care for service users. The current article reports on our exploratory analysis of nurses' views and perceptions to identify (1) orientation of nurses to human rights, and (2) access of consumers with SMI to general practitioner services. It was rare for nurses to raise the topic of human rights, and when raised, it was not as a strategy for improving access to physical health care services that they felt consumers with SMI greatly needed. Two main themes were identified as causes of poor access: clinical barriers to physical care and attitudinal barriers to physical care. In light of these results, the authors explore a human rights perspective on access and how this provides an inclusive lobbying umbrella under which nurses and other groups can pursue access to physical health services that are adequate, accessible, and non-discriminatory. The article then discusses the implications for these findings for the value of human rights as a perspective and means of increasing physical health of people with SMI.

Between the idea and the reality: GP liaison in a rural setting.

OBJECTIVES: To describe the organisational, clinical and pragmatic features of a GP liaison service established by the Division of Mental Health in the Darling Downs Hospital and Health Service catchment to facilitate the care of rural patients and improve communication between primary and specialist care. CONCLUSIONS: The GP liaison service was created using funding from the Commonwealth STP initiative to provide weekly registrar clinics to primary care providers in the Darling Downs. The service was eagerly accepted by providers who saw patient benefits outweighing financial considerations. Expectations of a greater level of care than the assessment and advice provided reflects the large unmet need for mental health services in rural areas. GPs expressed enthusiasm for true collaborative care, such as case management overseen by the public mental health service but based at GP offices.

[A special facet of testing the ability to stand trial: home visits by forensic physicians]. / Eine besondere Facette der Prüfung auf Verhandlungsfähigkeit: gerichtsärztliche Hausbesuche.

Home visits by physicians are generally regarded as a characteristic task of general practitioners. However, this form of external medical practice is also performed in the field of forensic assessments. The article presents the data material of the "Gerichtsärztlicher Dienst" (Medico-Legal Service) of the Free and Hanseatic City of Hamburg collected from 1975 to 2012 and analyses the numerical development and contents of external medico-legal examinations. Statistical records and evaluations of medico-legal examinations are a rarity in Germany. The study presented here is the first investigating external examinations of subjects. It focuses mainly on home visits related to criminal proceedings where it is not clear whether the person concerned is able to stand trial. This special type of medico-legal assessment is an essential part of the administration of justice today. As the article shows, there are parallels with the work of the general practitioner not only with regard to the general aspects of home visits, but also concerning their content. A general medical knowledge is indispensible for experts working in the field of clinical forensic medicine.

Implications of the law on video recording in clinical practice.

BACKGROUND: Technological developments allow for a variety of applications of video recording in health care, including endoscopic procedures. Although the value of video registration is recognized, medicolegal concerns regarding the privacy of patients and professionals are growing. A clear understanding of the legal framework is lacking. Therefore, this research aims to provide insight into the juridical position of patients and professionals regarding video recording in health care practice. METHODS: Jurisprudence was searched to exemplify legislation on video recording in health care. In addition, legislation was translated for different applications of video in health care found in the literature. RESULTS: Three principles in Western law are relevant for video recording in health care practice: (1) regulations on privacy regarding personal data, which apply to the gathering and processing of video data in health care settings; (2) the patient record, in which video data can be stored; and (3) professional secrecy, which protects the privacy of patients including video data. Practical implementation of these principles in video recording in health care does not exist. CONCLUSION: Practical regulations on video recording in health care for different specifically defined purposes are needed. Innovations in video capture technology that enable video data to be made anonymous automatically can contribute to protection for the privacy of all the people involved.

The place of information and communication technology-mediated consultations in primary care: GPs' perspectives.

BACKGROUND: New information and communication technologies such as email and text messaging have been shown to be useful in some aspects of primary care service delivery. Little is known about Scottish GPs' attitudes towards the adoption of these technologies as routine consultation tools. OBJECTIVES: To explore GPs' perceptions of the potential place of new non-face-to-face consultation technologies in the routine delivery of primary care; to explore GPs' perceived barriers to the introduction of these technologies and to identify the processes by which GPs feel that new consultation technologies could be incorporated into routine primary care. METHODS: Qualitative interview study: 20 in-depth semi-structured interviews carried out with maximum variation sample of GPs across Scotland. RESULTS: Whilst the face-to-face consultation was seen as central to much of the clinical and diagnostic work of primary care, many GPs were conditionally willing to consider using new technologies in the future, particularly to carry out administrative or less complex tasks and therefore maximize practice efficiency and patient convenience. Key considerations were access to appropriate training, IT support and medico-legal guidance. CONCLUSIONS: GPs are conditionally willing to use new consultation media if clinically appropriate and if medico-legal and technical support is available.

Self-perceived need for interpreter among immigrants in Denmark.

AIM: Starting in June 2011, immigrants who have lived for more than 7 years in Denmark have to pay a user-fee for interpreters in GP consultations and when hospitalised. We do not know yet how many immigrants will be affected by this amendment to the Danish Health Act and which socioeconomic factors characterise the immigrants who might be affected. To shed light on this, we investigated self-perceived need for interpreter (SNI) in GP consultations among participants from the largest non-Western immigrant groups in Denmark, the association between socioeconomic factors and SNI, and the characteristics of the immigrants potentially affected by the act amendment. METHODS: Survey data on 2866 immigrants from former Yugoslavia, Iraq, Iran, Lebanon, Pakistan, Somalia, and Turkey, linked to registry information on socioeconomic factors were examined. We compared unadjusted proportions of SNI by country of birth. Logistic regression analyses were performed to investigate associations between SNI and socioeconomic factors. RESULTS: Overall, 20% of immigrants living longer than 3 years in Denmark and 15% after 7 years reported a need for interpretation in their encounters with GPs. Of the latter group, the majority were outside the labour force (72.3%) and reported poor health (56%). Sex, age, length of stay, education, employment and household income were important factors for SNI. CONCLUSIONS: The amendment to the Health Act will primarily affect immigrants with modest household income, poor health and who are outside the labour force, thereby contributing and creating ethnic and social inequalities in access to health care in Denmark.

What do general practitioners think of the new professional competence scheme?

The Irish Medical Practitioners Act 2007 places a statutory obligation on all registered Medical Practitioners to maintain their professional competence by participating in a recognised Professional Competence Scheme. A questionnaire survey was conducted among 48 GPs attending educational meetings to see if doctors had concerns about the Professional Competence Scheme and to ask if they felt they had the necessary time, skills and knowledge to carry out an audit. Twenty-eight GPs (58%) had concerns regarding their participation in the Professional Competence Scheme; 75% were concerned about the time required, and 67% felt they needed further education about the scheme. Although 73% of doctors reported that they understand how to undertake a clinical audit and 50% reported they have carried out an audit in practice, 60% have never had any teaching on audit and 85% would like teaching in this area. Only 48% of the group surveyed felt that audit was practical in their current practice. Doctors have some concerns about the new Professional Competence Scheme, including the audit component. In particular, they report a requirement for more teaching in this area, and are concerned about the time involved.

[Advance directives in general practice]. / Patientenverfügung in der Hausarztpraxis.

View the fact of a doubling percentage of people aged 80 and over in the coming 20 years the topic of advance directives (AD) will play a more important role in general practice. It is the task of the GP as the integrating professional in any palliative care network to provide discussion and advice and to collaborate with the patient for a reliable version. Formulating AD's in principal means a life long process respectfully accompanied by the GP. By this approach AD's facilitate the discussion about taboos and serve as a valuable instrument for decision making, both for the patient and the GP. There are many reasons to address AD's in our daily clinical practice and to document it routinely in our medical charts as systematic as "allergies" or "vaccinations". From a recent study we learn that the most simple version of AD's is preferred by patients with 77 % of pre-existing and 81 % of newly written AD's consisting of one page only. Longer and more complex versions may produce fears.

[The dilemma of discharge medication. A multicentre cohort study on distribution of discharge medication and counseling by the hospital pharmacist in comparison to current practice]. / Das Dilemma der Entlassungsmedikation. Eine multizentrische Kohortenstudie zur Mitgabe und Beratung durch den Krankenhausapotheker im Vergleich zur aktuellen Praxis.

BACKGROUND: Today medication gaps are inevitable at discharge from the hospital and patients are insufficiently educated about their medication. METHODS: The rate of medication gaps and extent and quality of medication counseling were investigated in a prospective comparative study at five different hospitals. In a consecutive manner 847 patients were observed using current practice and 618 patients with a hospital pharmacist involved. Perception of patients, their general practitioners (GP) and community pharmacists with the different discharge procedures was analyzed by meansof questionnaires. RESULTS: Using current practice 24% of patients missed newly prescribed drugs at discharge. Medication gaps occurred according to patients'or GPs'reports in 10% or 22% of patients, respectively. 12% of patients were neither educated in the hospital nor in private setting about their medication. 22% of patients were not or only partially satisfied with the information received. Patient education, supported by a medication schedule and distribution of discharge medication by hospital pharmacists proved to be feasible and beneficial for patients and GPs. Medication gaps were significantly reduced to 4%. All patients received medication counseling at discharge and quality of education significantlyimproved. CONCLUSION: Distribution of discharge medication and counseling of patients bya hospital pharmacist are suitable measures in order to bridge medication and information gaps. Changes in healthcare legislation are necessary in order to implement the hospital pharmacy service.

[Physician prescription behaviour using the example of general practitioners and their prescriptions of pharmaceuticals in Austria]. / Das Verschreibeverhalten von Allgemeinmedizinern am Beispiel der Arzneimittelverordnungen in Österreich.

BACKGROUND: In extramural setting, general practitioners serve as gatekeepers and therefore control the demand for medical treatment and pharmaceuticals. As a result prescription habits are of major interest. AIM: The aim of the present study is to identify sample characteristics in the prescription behaviour of the general practitioners that allow one to differentiate between the individual and the basic population. METHODS: The prescription behaviour of 4 231 general practitioners was operationalised by means of the two variables "quantity" and "price". Outliers in those categories, that indicate a doctor prescribing too many or too expensive drugs, were identified using Chebyshev's inequality. RESULTS: We found a statistically significant linear relationship between the individual characteristics of the medical doctors and their prescription behaviour (0.54≤ r ≤0.89) as well as between the variables "quantity" and "price" (r=0.86). Particularly notable seems to be the correlation between the number of the consultations and the quantity of the prescribed drugs. The average prescription amounts to approximately 1.8 pharmaceuticals per consultation. The quantity of drugs prescribed correlates with the demand for the physician's service. Only a few general practitioners deviate from this coherence. The tendency to prescribe disproportionately expensive drugs (average costs amount to € 18.4 per drug) especially applies to those general practitioners who, in addition to their occupation as a physician, are allowed to dispense the pharmaceuticals directly to the patient within their privately owned pharmacies ("Hausapotheke"). In addition to this attribute, the variables "number of patients" and "number of consultations" intensify the effect. The risk to be identified as an outlier is 7 times higher within the group of general practitioners who own a "Hausapotheke" and account for an above average number of consultations as within the group that does not incorporate those characteristics. CONCLUSION: The strong coherence between the quantity and the demand is inherent to the health-care system and explains 79% of the variance of the prescribed quantities. Only 21% of the variance is determined by outside influences such as state of health of the patients. Physicians who have a monetary benefit from also distributing the drugs, however, enhance the prescription of high priced pharmaceuticals.