Comparison of prescribing habits of general practitioners in The Netherlands versus England and Wales.

The alleged prescribing habits of 44 randomly chosen Dutch family doctors were compared with those of 59 family doctors from England and Wales by inference from their prescribing responses to 10 hypothetical patients presented in a mail survey. The response options were: (a) neither prescribing nor advising over-the-counter (OTC) medication; (b) advising OTC medication; or (c) prescribing medication. Although sample numbers were small, the sample appeared to be broadly representative of GPs in each country. There were significant differences in stated treatment habits between doctors of the 2 countries, especially with regard to treatment of sore throat, temporal arteritis, epigastric pain, travellers' diarrhoea and polyarthralgia. The results suggest substantial differences in management of common general practice problems exist between England/Wales and The Netherlands, despite their similar healthcare systems. These differences point to the need for rationalisation of management through improved education and audit.

Death, dying and the medical student.

The objective of this study was to determine the extent of medical students' experience of death and dying. A questionnaire was given to two groups of Birmingham medical students at the beginning of clinical studies (third year) and in the final year which was designed to estimate their experience of death and of dying people. The questionnaire also explored the students' attitudes to their own future deaths. Questionnaires were returned by 119 third-year and 143 final-year students. Students had little experience of death and what they did have was largely acquired before entry to medical school or in their social rather than medical lives. Where they did have experience of death this was often traumatic and there was little chance for them to have counselling about it. There is need for increased teaching about death and dying particularly before clinical training and at the time of graduation. Another time may be at the beginning of human dissection.

A study of communication between general practitioners and specialists.

A random sample of referral letters from general practitioners to outpatient departments of general medicine, dermatology, neurology, and gastroenterology at an Amsterdam teaching hospital were analysed together with the specialists' replies for 144 referrals. The pairs of letters were judged by a panel of four general practitioners and four specialists. Letters were assessed according to quality and content, clarity, request for return to general practitioner care, time intervals between referral and consultation and between consultation and the specialist's reply. The judges were also asked to assess whether in their opinion the letters were of value in teaching or were discourteous. Though in general intraobserver agreement on what constitutes a good letter was low, deficiencies were revealed in the quality of letters and there were delays in transmission and missed educational opportunities.

Morbidity at an Amsterdam inner city clinic in relation to drug use.

In a small clinic in a deprived area of Amsterdam, a city with a high incidence of recreational drug use, sexually transmitted diseases and social problems, the association between drug use and disease was notable. Frequent presentation with sexually transmitted diseases, repeated trauma, unexplained recurrence of infections of the skin and respiratory tract, or severe dental caries may alert the physician to the possibility of recreational drug use and with it an increased possibility of HIV related illness. The group of drug users staying permanently in the city appeared to be ageing, without being replenished by youngsters. Very young drug users were mainly 'drug tourists' from neighbouring countries who were without medical insurance or money.

A nurse practitioner in general practice: patient perceptions and expectations.

A study exploring the acceptability of a nurse practitioner to a random sample of 126 patients is reported. Sixty per cent of patients either approved of the concept and expressed willingness to consult the nurse or held no strong views. Fifty three per cent of the 61 patients who had seen her already were prepared to see her again. Fifty four per cent of patients had difficulty in differentiating between the role of the nurse practitioner and the doctor and the perceived differences included qualifications, ability to prescribe drugs and the severity of the condition dealt with. Women were nearly three times more likely than men to consult a nurse practitioner. Good communication skills were reported to be among the most sought after qualities of those whom patients consult about their health problems.

Sources of information about new drugs and attitudes towards drug prescribing: an international study of differences between primary care physicians.

Doctors in different countries completed a questionnaire relating to the importance they attributed to eight possible sources of information about a new drug, their estimation of patients' expectations of the doctor prescribing drugs under specific circumstances and their therapeutic response to common clinical general practice situations. There were major differences between the stated behaviour of doctors in different countries with regard to the importance they attached to the eight sources of information on drugs. While doctors agreed on the importance of books and journals and on the unimportance of patients, nurses and other paramedicals, there was a major disagreement about the importance of drug company representatives: this source of information about new drugs was rated high in Sweden and Yugoslavia and low in Britain and Belgium. Doctors also differed in their estimation of patients' expectations of how they would prescribe and how they responded to the clinical problems. The differences, which might be due to differences in education about therapeutics or to cultural differences between countries, are important because of the high cost of drugs bills in all countries.

A nurse practitioner in general practice: working style and pattern of consultations.

The work of a specially trained nurse practitioner, to whom patients had open access, was studied in an inner city general practice over a period of six months in 1983. A total of 858 patients of all ages and ethnic origins sought consultations for 979 problems. Morbidity from every diagnostic group was presented but the majority of the problems (60.4%) fell into the 'Supplementary' group: preventive medicine; health instruction and education; social, marital and family problems; administrative procedures. The consultation room setting and the long appointment times available (20 minutes) may partly account for this. Additional problems, mostly concerning health education, were raised in 46.0% of consultations. Most patients chose a consultation with the nurse practitioner appropriately and in more than one-third of all consultations the nurse managed the presenting problem without further referral for investigation, prescription or other medical advice. It is concluded that nurses have a much larger and more autonomous part to play in the care of patients than hitherto.

The role of socio-behavioural scientists in health care practice.

This paper attempts to analyse some of the complex problems that face primary health care practice in the developed world today. These are shown to be a degree of depersonalisation, that has come with greater efficiency, and a reduction in the quality of the doctor-patient relationship, which has accompanied increased medical effectiveness. These changes are in turn related to changes in diagnostic methods in primary care, to changes in the organisation of primary care and to change in the stress laid on interventive, preventive and rehabilitative care. All these inter-related problems have to be viewed against a background of shortage of resource which demand a far more stringent system of accountability than has been common until now. A possible solution lies in redefining the traditional medical role and the philosophical basis which underlies that role at a time when primary health care is confronted by the special problems of the AIDS pandemic. This would require major alterations in medical attitudes and in established medical education which may be impossible for the doctors to achieve by themselves. It is suggested that a most important role of socio-behavioural scientists lies in helping the medical profession to remove the attitudinal and educational barriers which prevent the realisation of the concept of a new sort of doctor who may cope with the demands of primary health care as we approach 2000.