Defensive dental behaviour: illusion or reality?

Defensive medicine or defensive behaviour of physicians is considered a major problem in contemporary health care. It seems reasonable to assume that defensive behaviour also occurs in dental practice, although so far very little has been published in the dental literature on this subject. The main objective of this study was to investigate whether defensive behaviour occurs in dentistry. As a survey study 38 dentists were interviewed: 30 men and 8 women, mainly general dental practitioners with an average of 20.9 years in practice. The results of this pilot-study indicate that it is very likely that defensive behaviour occurs in dental practice, despite the fact that there is hardly any evidence of fear for malpractice claims and lawsuits among the respondents. The majority of the dentists interviewed stated that they carried out some treatments at their patient's request although they did not believe the treatment to be necessary from a professional point of view. A motive for deliberately refraining from treatment is lack of dental motivation by the patient and poor oral hygiene. According to some respondents patients are sometimes referred unnecessarily to specialists. Also 'difficult' patients run the risk of unwarranted referral to specialists, and, moreover referrals because of insurance reasons are mentioned. The financial situation of the patient and the defensive behaviour of dental practitioners seem to be closely connected.

[Perspective of a patient in the general practitioners office and in the dental office]. / Het perspectief van de patiënt in de huisarts- en tandartspraktijk.

Both general practitioners and dentists acknowledge the importance of the patient's perspective and the demand for care, and, consequently, of good communication with their patients. In general practice, the concept of reason for encounter has proved to be very useful for gaining more insight in the nature and the importance of the patient's perspective. Data from the Amsterdam Transition project show that the general practitioner understands the patient's reasons for encounters very well, and that the nature of the patient's reasons for encounter clearly affect the subsequent interventions. In this article, 260 letters concerning people's experiences with their dentist are used in order to provide an impression of communication problems in dentist practice in the Netherlands. Three major problem areas are identified, with a total of ten subcategories. Several of these are well known to the general practitioner as well. In addition, some problems are characteristic for the dentist practice. It is suggested to incorporate the concept of reason for encounter in dental care as an essential part of the description and analysis of the communication between dentists and their patients.

The core of computer based patient records in family practice: episodes of care classified with ICPC.

A central element in the definition of primary care is that primary care clinicians address the large majority of personal health care needs of their patients. As a consequence, they should document data on these health care needs reliably and continuously. To establish whether this occurs, the episode of care is the most appropriate unit of assessment: a health problem from its first encounter with a health care provider until the completion of the last encounter for it. An episode of care is distinguished from episodes of disease and of illness. The episode of care as an epidemiological concept for the calculation of rates has evolved into a central element of a computer based record. Episode oriented data classified with the International Classification of Primary Care (ICPC), and specified with ICD-10 as a nomenclature are especially suitable as the core of a generic patient record in family practice. ICPC has been available to the family medicine community for well over a decade as the main ordering principle of its domain. The basic structure of an encounter (within the string of encounters which together form an episode of care) distinguishes reasons for encounter, diagnoses and diagnostic and therapeutic interventions. In this article, a more refined structure of encounters is proposed for a more precise documentation of episodes of care in a computer based patient record. The conversion structure between ICPC and ICD-10 allows both a high level of specificity in the patient's problem list and optimal communication with specialists who contribute to the episodes of care for which the documentation is the primary care provider's responsibility.

The International Classification of Primary Care (ICPC): new applications in research and computer-based patient records in family practice.

The international Classification of Primary Care (ICPC) has now been available to the family medicine community for a decade as the main ordering principle of its domain. Research data and practical experiences with ICPC, as well as the development of new concepts in family medicine, have resulted in new applications. The structure of episodes of care to be included in a computer-based patient record has been further developed and refined. ICPC as the ordering principle of patient data is now available in 19 languages. Its conversion structure with the International Classification of Diseases (ICD-10) allows the highest possible level of specificity in a patient's problem list necessary in patient care, while the compatibility of the ICPC drug codes with the Anatomic Therapeutic Chemical Classification Index allows the systematic inclusion of data on prescription.

Classification of severity of health problems in family/general practice: an international field trial.

BACKGROUND: A methodology is needed for classification of health problems by severity. OBJECTIVES: We aimed to test the Duke Severity of Illness Checklist (DUSOI) for feasibility and usefulness. METHOD: The DUSOI was field tested internationally by 22 family/general practitioners in 9 countries. RESULTS: The DUSOI was found to be feasible for rating severity of illness of health problems in family/general practice. The measure was shown to be clinically useful in older patients and those with chronic and more severe health problems. Variability of severity ratings was less within the same rater than between different raters (i.e. higher intrarater than interrater reliability). Clinical face validity was supported by the finding that DUSOI ratings classified patients with the same diagnosis and those with different diagnoses according to the severity differences that would be expected clinically. CONCLUSIONS: Although research is needed to improve reliability and to test validity further, the DUSOI was shown in the present study to be a methodology that is reasonable for consideration as an international classification of health problems by their severity in primary care patients.

Episode of care: a core concept in family practice.

The new Institute of Medicine definition of primary care requires that primary care clinicians address the large majority of personal health care needs of their patients. The unit of assessment for this is the episode of care, defined as a health problem from its first encounter with a health care provider through the completion of the last encounter. An episode of care is distinct from an episode of disease or illness. In this article, episode-of-care date from Dutch family practice, classified with the International Classification of Primary Care, illustrate this approach. Data on women 25 to 44 years of age are presented. The top 20 new reasons for encounter and new episodes of care as well as the relations between a reason for encounter (headache) and disease (sinusitis) support the potential of episode-oriented epidemiology and some important clinical considerations in family practice.

Values and roles in primary care.

Discussions about research priorities and criteria for quality assessment in primary care are confusing when the differences in the underlying models and value systems are unclear. This article presents a simple grid that can facilitate discussions involving the roles of primary care physicians. One axis of the grid includes three value systems that are important to the understanding of different goals in primary care. The second axis includes three practice roles that are important to the evaluation of the actual delivery of primary care. Examples are used to illustrate how the grid can be used in discussion about the mission of primary care.

International primary care classifications: the effect of fifteen years of evolution.

To better understand the development of primary care classifications over the past 15 years, 10 primary care databases have been retrospectively analysed using the structure of the International Classification of Primary Care (ICPC) as the basis. All datasets were based on routine data collection using different classification systems by several family physicians during all encounters with their patients over considerable periods of time, in most cases one year. The prevalences or the rates of the available diagnostic--and reason for encounter--classes were distributed over four frequencies. With a few exceptions the distribution of diagnostic labels referring to common diseases is surprisingly similar. The use of ICPC however results in a quantum leap in the use of symptom and complaint diagnoses. Because of this shift primary care physicians now have available a classification with 400 diagnostic classes used with a prevalence of > or = 1/1000 patient-years or per 1000 visiting patients per year. The classification of reasons for encounter allows the physician to identify over 300 reasons for encounter used > or = 1/1000 patient years or per 1000 visiting patients per year. Family physicians have been successful in the development of new primary care classifications. Rag bag rubrics which are the result of the structure of ICPC are used relatively often and deserve more attention from primary care taxonomers.

The conversion between ICPC and ICD-10. Requirements for a family of classification systems in the next decade.

The International Classification of Primary Care (ICPC) was developed to order medical concepts into classes that have been chosen for their relevance for family medicine. Family physicians use this to label the most prevalent conditions in their practice as well as their patients' symptoms and complaints. At the same time they do not want to be divorced from the needs of the medical community at large as these are reflected in the most recent medical nomenclature: the Tenth Revision of the International Classification of Diseases (ICD-10). A full conversion between all classes in the first and seventh component of ICPC (n = 646) with those of ICD-10 (n = 1983), with the exception of the chapter on external causes, has been prepared. It was concluded that ICD-10 at the three-digit level cannot function as a core classification for an international primary care system. Of the three-digit ICD-10 rubrics only 120 are compatible on a one to one basis with an ICPC rubric. A total of 114 three-digit ICD-10 rubrics have to be broken open into four-digit rubrics to allow at least one compatible conversion to one or more ICPC rubrics. On this basis only 25% of the diagnostic classes in ICPC can be converted to a single three- or four-digit ICD-10 rubric without lumping. The rest of ICD-10, either on the three- or on the four-digit level, has to be grouped into combinations of classes (lumping) to allow compatible conversion to the remaining rubrics of ICPC. Even though ICD-10 cannot serve as a core classification for primary care, a technical conversion between ICPC and ICD-10 is practically always possible which allows primary care physicians to implement ICD-10 as a contemporary nomenclature within the classification structure of ICPC.