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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Increasing awareness and improving the management of heart failure in Europe: The IMPROVEMENT of HF initiative
Background: Previous reports suggest that patients with suspected heart failure are inadequately investigated and that patients who do have heart failure are sub-optimally treated. Guidelines on the diagnosis and treatment of heart failure have been published by the European SoCiety of Cardiology and provide a framework for the management of heart failure against which to judge current medical practice. Both primary care and hospital physicians are responsible for ensuring appropriate management of patients with heart failure. This programme concentrates on management of heart failure in primary care and is complementary to a similar exercise that will be conducted in 50 European regions (EUROHEART-CHF). Aims: The IMPROVEMENT of HF initiative investigates, in Europe, how primary care physicians perceive heart failure should be diagnosed and treated and whether they perceive that they are provided with adequate support to implement best medical practice. Subsequently, their perceptions are compared to their actual practice by reviewing relevant case notes. The results will be used to recommend changes in practice. A future study is planned to analyse the impact of the initiative. Methods: The initiative comprises a research phase and an educational phase. For the research phase, 10 regional centres (to include both urban and rural areas) from each of 14 participating countries have been identified and each region has randomly selected 10 primary healthcare physicians. The primary healthcare physicians are participating in two surveys: a 'perception' survey and an 'actual practice' survey. For the 'actual practice' survey, the physicians are supplying case notes of nine patients who have or are at high risk of having heart failure. The results of these surveys will be used to organise an educational programme. Conclusion: This study is expected to provide valuable data on the perceptions of primary care physicians about heart failure, possible deficiencies in the current provision of care and how any deficiencies may be corrected. (C) 1999 Published by European Society of Cardiology.
Descriptive study of cooperative language in primary care consultations by male and female doctors
Objective. To compare the use of some of the characteristics of male and female language by male and female primary care practitioners during consultations. Design. Doctors' use of the language of dominance and support was explored by using concordancing software. Three areas were examined: mean number of words per consultation; relative frequency of question tags; and use of mitigated directives. The analysis of language associated with cooperative talk examines relevant words or phrases and their immediate context. Subjects. 26 male and 14 female doctors in general practice, in a total of 373 consecutive consultations. Setting. West Midlands. Results. Doctors spoke significantly more words than patients, but the number of words spoken by male and female doctors did not differ significantly Question tags were used far more frequently by doctors (P < 0.001) than by patients or companions. Frequency of use was similar in male and female doctors, and the speech styles in consultation were similar. Conclusions. These data show that male and female doctors use a speech style which is not gender specific, contrary to findings elsewhere; doctors consulted in an overtly non-directive, negotiated style, which is realised through suggestions and affective comments. This mode of communication is the core teaching of communication skills courses. These results suggest that men have more to learn to achieve competence as professional communicators.
Concordancing: Use of language-based research in medical communication
Background. The available literature on medical communication reports almost exclusively on observational, qualitative studies. We aimed to apply a novel approach to the analysis of doctor-patient consultation by means of computer concordancing. This methodology, established in linguistic research but rarely applied to professional language, allows both the quantitative and qualitative study of language. Methods. We analysed the language of 40 doctors and their patients during 373 complete primary-care consultations. We examined the use of jargon by doctors, the language of power and absence of power, and ways in which language was used to diminish the potential threat of the presenting disorder. Findings. There was no evidence that the doctors used medical jargon. Some doctors used language associated with social power, and some patients used language associated with absence of power. There was substantial evidence that the doctors used language to express emotions (eg, anxiety), to diminish threats (eg, words such as 'little'), and to reassure patients. Interpretation. Concordancing is a valuable resource to study the consultation. The finding that doctors do not use jargon suggests that they are aware of the need to avoid it, but it does not follow that they are easily understood by patients. The use of some elements of the language of power may imply that consultations may be less democratic than is appropriate. The language of emotion and diminution is a major part of the primary-care doctor's repertoire and denotes a therapeutic use of language.
Community-based clinical education at the University of Birmingham medical school
Throughout the United Kingdom, medical schools have begun to make significant changes in the content and delivery of their undergraduate curricula in response to a number of social and educational forces. In particular, many schools have begun to focus increasingly on community-based education. This and other changes mirror developments that have taken place in other countries and in the context of other health care systems, with such forerunners as Harvard, Maastricht, and McMaster having had a fundamental influence. In this article the authors describe the forces for curricular change in the United Kingdom and the specific recommendations for change made by the General Medical Council. They then discuss in detail the new curriculum at the University of Birmingham medical school, focusing in particular on a community medicine module, where students spend ten days per academic year learning in general medical practices in and around the city of Birmingham.
Is the international normalised ratio (INR) reliable? A trial of comparative measurements in hospital laboratory and primary care settings
Aims - To determine the reliability of international normalised ratio (INR) measurement in primary care by practice nurses using near patient testing (NPT), in comparison with results obtained within hospital laboratories by varied methods. Methods - As part of an MRC funded study into primary care oral anticoagulation management, INR measurements obtained in general practice were validated against values on the same samples obtained in hospital laboratories. A prospective comparative trial was undertaken between three hospital laboratories and nine general practices. All patients attending general practice based anticoagulant clinics had parallel INR estimations performed in general practice and in a hospital laboratory. Results - 405 tests were performed. Comparison between results obtained in the practices and those in the reference hospital laboratory (gold standard), which used the same method of testing for INR, showed a correlation coefficient of 0.96. Correlation coefficients comparing the results with the various standard laboratory techniques ranged from 0.86 to 0.92. It was estimated thai up to 53% of tests would have resulted in clinically significant differences (change in warfarin dose) depending upon the site and method of testing. The practice derived results showed a positive bias ranging from 0.28 to 1.55, depending upon the site and method of testing. Conclusions - No technical problems associated with INR testing within primary care were uncovered. Discrepant INR results are as problematic in hospital settings as they are in primary care. These data highlight the fallings of the INR to standardise when different techniques and reagents are used, an issue which needs to be resolved. For primary care to become more involved in therapeutic oral anticoagulation monitoring, close links are needed between hospital laboratories and practices, particularly with regard to training and quality assurance.
A primary care evaluation of three near patient coagulometers
Aim - To compare the reliability and relative costs of three international normalised ratio (INR) near patient tests. Materials - Protime (ITC Technidyne), Coaguchek (Boehringer Mannheim), and TAS (Diagnostic Testing). Methods - All patients attending one inner city general practice anticoagulation clinic were asked to participate, with two samples provided by patients not taking warfarin. A 5 ml sample of venous whole blood was taken from each patient and a drop immediately added to the prepared Coaguchek test strip followed by the Protime cuvette. The remainder was added to a citrated bottle. A drop of citrated blood was then placed on the TAS test card and the remainder sent to the reference laboratory for analysis. Parallel INR estimation was performed on the different near patient tests at each weekly anticoagulation clinic from July to December 1997. Results - 19 patients receiving long term warfarin treatment provided 62 INR results. INR results ranged from 0.8-8.2 overall and 1.0-5.7 based on the laboratory method. Taking the laboratory method as the gold standard, 12/62 results were < 2.0 and 2/62 were > 4.5. There were no statistical or clinically significant differences between results from the three systems, although all near patient tests showed slightly higher mean readings than the laboratory, and 19-24% of tests would have resulted in different management decisions based on the machine used in comparison with the laboratory INR value. The cost of the near patient test systems varied substantially. Conclusions - All three near patient test systems are safe and efficient for producing acceptable and reproducible INR results within the therapeutic range in a primary care setting. All the systems were, however, subject to operator dependent variables at the time of blood letting. Adequate training in capillary blood sampling, specific use of the machines, and quality assurance procedures is therefore essential.
Imprecision in medical communication: Study of a doctor talking to patients with serious illness
Uncertainty is believed to be a central feature in illness experiences. Conversations between a consultant haematologist and 61 seriously ill patients were transcribed, entered on a database and scrutinized for patterns of language uncertainty by linguistic concordancing analysis. Transcripts were then discussed in detail with the haematologist, and techniques of protocol analysis were used to gain insight into his thought processes during consultations. The main findings were that the doctor used many more expressions of uncertainty than did patients: that evaluative terms were widely used to reassure rather than to worry patients; and that patients and doctor together used certain key terms ambiguously, in a manner which allowed the doctor to feel that facts were not misrepresented while perhaps permitting the patient to feel reassured.
Putting evidence into practice
Heart failure is a common condition associated with substantial mortality, morbidity and impairment of quality of life. However, despite the proven efficacy of angiotensin-converting enzyme (ACE) inhibitors, heart failure is often under-diagnosed and under-treated, particularly in primary care. In some studies, for example, only about one-third of patients received ACE inhibitors, and at doses substantially lower than those shown to be effective in clinical trials. The major reason for under-prescribing ACE inhibitors appears to be that concerns over adverse effects dominate perceptions of treatment benefits. The recent Assessment of Treatment with Lisinopril And Survival (ATLAS) Study, however, has shown that treatment with high doses of lisinopril is associated with a significant reduction in deaths and hospitalizations, without a concomitant increase in the risk of serious adverse events. There is, therefore, evidence for the routine use of maximum-tolerated doses of ACE inhibitors in patients with heart failure treated in primary care. Guidelines for the initiation of such treatment are presented.