Consent obtained by the junior house officer--is it informed?
Of 30 junior house officers questioned, 21 had obtained patients' consent for colonoscopy. Of these 21, about one-third did not routinely discuss with patients the risks of perforation and haemorrhage. Ideally, consent should be obtained by a person capable of performing the procedure. If it is to be obtained by junior house officers, they need to know exactly what must be disclosed about each procedure. This could easily be done as part of the induction package. (+info)
Computers in ophthalmology practice.
Computers are already in widespread use in medical practice throughout the world and their utility and popularity is increasing day by day. While future generations of medical professionals will be computer literate with a corresponding increase in use of computers in medical practice, the current generation finds itself in a dilemma of how best to adapt to the fast-evolving world of information technology. In addition to practice management, information technology has already had a substantial impact on diagnostic medicine, especially in imaging techniques and maintenance of medical records. This information technology is now poised to make a big impact on the way we deliver medical care in India. Ophthalmology is no exception to this, but at present very few practices are either fully or partially computerized. This article provides a practical account of the uses and advantages of computers in ophthalmic practice, as well as a step-by-step approach to the optimal utilization of available computer technology. (+info)
The implementation of evidence-based medicine in general practice prescribing.
BACKGROUND: Research on the implementation of evidence-based medicine has focused on how best to influence doctors through information and education strategies. In order to understand the barriers and facilitators to implementation, it may also be important to study the characteristics of those doctors and practices that successfully implement evidence-based changes. AIM: To determine the relationship between practice and doctor characteristics and the implementation of recommended evidence-based changes in the area of prescribing. METHOD: Visits were made to 39 practices in southern England. Audits of three key prescribing changes were carried out and amalgamated to produce an 'implementation score' for each practice. These scores were related to a wide range of practice and doctor variables obtained from a questionnaire survey of doctors and practice managers. RESULTS: There was wide variation between the practices' implementation scores (mean 67%, range 45% to 88%). The only factors that had a significant relationship with implementation of these important prescribing changes were an innovative approach among the doctors (most practitioners were cautious of change), and fundholding status. Use of clinical protocols, disease registers, or computers was not associated with overall implementation score, nor was the doctor's age. Doctors complained of information overload. CONCLUSIONS: The emphasis on the need for evidence in medicine, and better transmission of information, needs to be balanced by a recognition that most general practitioners are pragmatic, averse to innovation, and already feel overwhelmed with information. Important advances in therapy may be crowded out. More attention should be given to the facilitation of priority changes in practices. (+info)
Repeat dispensing by community pharmacists: advantages for patients and practitioners.
Repeat prescribing is an appreciable chore for general practitioners (GPs), and often lacks rigorous clinical control. This paper reports on a pilot repeat dispensing system, which employed community pharmacists to streamline the process and provide clinical supervision. The system described operated within the current regulations, was popular, and worked well for patients on stable treatment regimes. (+info)
Audiotapes and letters to patients: the practice and views of oncologists, surgeons and general practitioners.
A range of measures have been proposed to enhance the provision of information to cancer patients and randomized controlled trials have demonstrated their impact on patient satisfaction and recall. The current study explored the practice and views of oncologists, surgeons and general practitioners (GPs) with regards to providing patients with consultation audiotapes and summary letters. In stage 1, 28 semi-structured interviews with doctors were conducted to provide qualitative data on which to base a questionnaire. In stage 2, 113 medical oncologists, 43 radiation oncologists, 55 surgeons and 108 GPs completed questionnaires. Only one-third of doctors had ever provided patients with a copy of the letter written to the oncologist or referring doctor, and one-quarter had provided a summary letter or tape. The majority of doctors were opposed to such measures; however, a substantial minority were in favour of providing a letter or tape under certain conditions. More surgeons and GPs (> two-thirds) were opposed to specialists providing a consultation audiotape than oncologists (one-third). Gender, years of experience and attitude to patient involvement in decision-making were predictive of doctors' attitudes. The majority of doctors remain opposed to offering patients personalized information aids. However, practice and perspectives appear to be changing. (+info)
How should we pay doctors? A systematic review of salary payments and their effect on doctor behaviour.
We reviewed the published and unpublished international literature to determine the influence of salaried payment on doctor behaviour. We systematically searched Medline, BIDS Embase, Econlit and BIDS ISI and the reference lists of located papers to identify relevant empirical studies comparing salaried doctors with those paid by alternative methods. Only studies which reported objective outcomes and measures of the behaviour of doctors paid by salary compared to an alternative method were included in the review. Twenty-three papers were identified as meeting the selection criteria. Only one of the studies in this review reported a proxy for health status, but none examined whether salaried doctors differentiated between patients on the basis of health needs. Therefore, we were unable to draw conclusions on the likely impact of salaried payment on efficiency and equity. However, the limited evidence in our review does suggest that payment by salaries is associated with the lowest use of tests, and referrals compared with FFS and capitation. Salary payment is also associated with lower numbers of procedures per patient, lower throughput of patients per doctor, longer consultations, more preventive care and different patterns of consultation compared with FFS payment. (+info)
Primary inguinal hernia repair: how audit changed a surgeon's practice.
Over 10 years one senior consultant surgeon performed 114 standard plication darn herniorraphies on 92 patients with primary inguinal hernias. These patients were contacted and were reviewed if there was any suspicion of recurrence. Four recurrences were detected, giving an overall recurrence rate of about 3.5%. According to actuarial life-table analysis the risks of recurrence at 1 year, 5 years and 10 years were 0.94%, 3.02% and 9%. This level of recurrence is unacceptable in modern practice and, as a result of the audit, the surgeon changed his technique of primary inguinal hernia repair. (+info)
Primary care units in A&E departments in North Thames in the 1990s: initial experience and future implications.
BACKGROUND: In 1992, the Tomlinson Report recommended a shift from secondary to primary care, including specific primary care provision in accident and emergency (A&E) departments. Availability of short-term so-called Tomlinson moneys allowed a number of experimental services. A study of the experience of A&E-based staff is reported to assist general practitioners (GPs) and purchasers and identify areas for further research. AIMS: To find the number and scope of primary care facilities in A&E services in North Thames; to find factors encouraging or inhibiting the setting-up of a successful service; to examine the views of a range of A&E staff including GPs, consultants, and nurses; and to suggest directions for more specific research. METHOD: A postal questionnaire was sent to all North Thames A&E departments, and an interview study of staff in one unit was arranged, leading to a questionnaire study of all GPs employed in North Thames primary care services in A&E. This was followed by interviews of staff members in five contrasting primary care units in A&E. RESULTS: By mid-1995, at least 16 of the 33 North Thames A&E departments ran a primary care service. Seven mainly employed GPs, the others employed nurse practitioners (NPs). Problems for GPs included unclear role definition and their non-availability at times of highest patient demand. GPs' reasons for working in A&E sometimes differed from the aims of primary care in an A&E service. Staff interviews revealed differing views about their role and about use of triage protocols. Ethnicity data were being collected, but not yet being used, to improve service to patients. CONCLUSIONS: A number of benefits follow the introduction of primary care practitioners into A&E. Different models have evolved, with a variety of GP and NP staffing arrangements according to local ideas and priorities. There is some confusion over whether these services aim to improve A&E-based care or to divert it to general practice. Cost information is inadequate so far, though the use of GPs has shown the possibility of economy. Appropriate location of services requires clearer identification of costs. This may be possible for the proposed primary care groups. (+info)