Practice tip. Which cerumenolytic?

AIM

To test the in vitro dispersion of ear wax by four commonly used cerumenolytics.

METHOD

Equal parts of the same piece of ear wax were covered with 10 mL of each preparation and observed for up to 30 days.

RESULTS

Sodium bicarbonate and Waxsol dispersed wax within 2 hours, Cerumol was much slower and olive oil had no effect.

CONCLUSIONS

The cheapest and most effective cerumenolytic is a solution of sodium bicarbonate.

Doctors badmouthing each other. Does it affect medical students' career choices?

OBJECTIVES

To study the frequency of negative comments (badmouthing) made by teaching hospital specialists about metropolitan and rural general practitioners (GPs) and by GPs about hospital specialists and the impact of these comments on medical students' intended career choice. In this study badmouthing is defined as unwarranted, negative, denigrating, even sarcastic comments made by doctors about other doctors.

METHODS

A retrospective questionnaire survey of 170 5th and 6th year medical students from The University of Western Australia conducted in 1997. The questionnaire was a modified version of one developed by medical educators at the University of Washington School of Medicine, using both ranked and open questions.

RESULTS

Overall students reported either no comments or hearing balanced comment from both teaching hospital specialists and GPs. Seventy-eight percent of all students reported at least one negative comment per year about urban GPs, 50% reported a negative comment on rural GPs and 59% a negative comment by GPs about specialists in teaching hospitals. The reported impact on students, intentions to pursue any of these three disciplines was inversely proportional to the frequency of negative comments heard. Twelve percent of students reported being influenced against pursuing a future career in urban general practice, 7% against becoming a rural GP and 8% against becoming a specialist. Widespread badmouthing of rural GPs, reported in 1987, has apparently diminished with students reporting balanced and positive comment on rural GPs to be five times more common than negative comment.

CONCLUSION

A low level of badmouthing by all medical disciplines is an unattractive part of the learning milieu of medical students. In this study it had an influence on the current career choices of 21% of participating students.

Staying in or leaving rural practice: 1996 outcomes of rural doctors' 1986 intentions

OBJECTIVE

To examine the 1996 outcomes of a sample of Western Australian rural doctors who in 1986 had indicated their intentions to stay in or leave rural practice.

DESIGN

Postal questionnaire survey in December 1996, semi-structured interview and feedback by doctors on a draft of this article.

PARTICIPANTS

91 respondents from the 101 doctors who in 1986 had filled in a questionnaire on their intentions to stay in or leave rural practice.

MAIN OUTCOME MEASURES

Proportion of doctors whose actions by 1996 were at variance with their intentions in 1986, and the reasons for their change of direction.

RESULTS

49% (22/45) of doctors who intended to leave had stayed ("stayers") and 24% (11/46) who intended to stay had left ("leavers"). Doctors' main concerns in 1986 were overwork, lack of locum relief, professional contact with colleagues, specialist backup in emergencies, downsizing of hospital facilities, continuing medical education, and income. By 1996 stayers had solved most of these professional problems and felt they were doing a special job which made a difference to their community. Conversely, more than half the leavers were unable to solve these problems and felt disempowered and dispirited. Their most potentially solvable problems were overwork, forced deskilling and conflict with other healthcare professionals.

CONCLUSION

Professional satisfaction was the main reason for doctors staying in or leaving rural practice. Professionally dissatisfied rural doctors reach a critical phase which they have to surmount if they are going to stay. An examination of the positive experiences of the stayers points the way to retaining at least half the potential future leavers.

The use of an N-of-1 randomised clinical trial in resolving therapeutic doubt. The case of a patient with an 'attention disorder'

OBJECTIVE

To describe the use of an N-of-1 randomised clinical trial (N-of-1 RCT) in general practice as illustrated by the case of a 16 year old boy with a learning and attention problem whose parents were convinced that amphetamines were necessary.

DESIGN

The N-of-1 RCT with a double blind technique was used in which a single patient served as his own control in testing whether amphetamine had any advantage over placebo.

RESULTS

No difference was noted in the boy's teachers' behavioural assessment scores nor in his own self reported ability to concentrate when taking either amphetamine or placebo.

CONCLUSION

This study showed that this patient obtained no objective improvement from amphetamine and the result was well accepted by his parents. N-of-1 RCTs are a relatively easy technique for tackling any area of therapeutic doubt. They can help the thoughtful GP to feel 'more like a scientist and less like a quack'.

Declare the past, diagnose the present, foretell the future: rural health for all Australians by 2000?

The health status of rural people still lags behind that of urban dwellers, and Aboriginal children have an equivalent health status to that of non-Aborigines 40 years ago. Yet, the shortage of country doctors is nearly as acute today as it was 100 years ago. Past 'solutions' to these problems are replete with mistakes, misjudgements, false messiahs and transient fashions. The failure to know about the rural past and to learn from it has resulted in a 20-year cycle of rediscovery. The most efficient way to solve future rural health problems is to have a scholarly appreciation of rural history and build on what we already know but haven't worked out how to apply.

Academic general practice comes of age?

Academic general practice in Australia is 21 years old. In coming of age it has had to endure a very obstructed labour into Australian medical schools. Departments of General Practice have changed for the better and are being staffed by a new generation of academics, many of whom may lack historical perspective of the development of academic general practice. This article provides this historical perspective.

Rural student clubs and the social responsibility of medical schools

All faculty members agree that their medical school has an academic purpose and a research purpose, but few medical faculty members agree that a medical education has a social purpose. This is one of the main reasons why there is a serious disjunction between rural societal needs and doctors' education. Rural student clubs are part of a rural counterculture within the orthodoxy of the medical school. Members of these clubs are thus potential agents of curricular change in the field of rural medicine. They are also one of the most potentially influential forces in reminding and helping medical schools to fulfil their social responsibility to the populations of rural Australia. Most rural student clubs are multidisciplinary, and the principles underlying their role in changing the direction and ethos of medical schools also apply to schools of nursing and health sciences.

From novice to proficient general practitioner: a critical incident study

OBJECTIVE

To obtain information about any change in the performance or perceptions of doctors undertaking the Royal Australian College of General Practitioners (RACGP) Training Program, with advancing general practice experience.

DESIGN

The critical incident technique' was used, which is a comparative qualitative analysis. It involved interviews at 12 to 18 months after the basic term interview.

SUBJECTS

Eighteen Western Australian doctors, who had been interviewed in 1992, at the end of their first 6 months of general practice training and were now completing their advanced or mentor terms in the RACGP Training Program took part in the study.

RESULTS

Doctors reported an average of 4.4 critical incidents in their first interview and 5.0 in their second interview. The major areas of positive change included relationships with patients and other health care professionals, including supervisors; paediatrics and orthopaedics skills; the skills of developing a therapeutic relationship to enhance patient compliance and the ability to manage complex cardiovascular and psychiatric problems without reliance on specialist referral; attitudes of responsibility for and enjoyment of long term care of patients and families; and reduced levels of anxiety over difficult problems. New or continuing areas of difficulty were found in gynaecology; pharmacotherapy and dermatology; the diagnosis of common complaints with uncommon presentations; the skill of managing difficult or angry patients; the organisation for the follow-up of patients with potentially severe disorders; and in managing feelings of guilt over missed diagnoses or poor management.

CONCLUSION

An analysis of commonly occurring positive and negative critical incidents shows that RACGP Training Program doctors develop competence, confidence and reduced levels of performance anxiety with advancing experience. All but one doctor found the Training Program helpful in achieving these proficiencies. However, many ongoing areas of difficulty remain. The Critical Incident method is a useful tool for learning and assessment in a vocational training program.

A comparison of medical student experiences in rural specialty and metropolitan teaching hospital practice

One factor in solving the rural medical workforce shortage is to foster student interest by greater exposure to rural medicine. However, many medical school teachers are concerned that this may cause students to be disadvantaged by missing core lectures, tutorials and ward rounds in the setting of the high quality of teaching hospital medicine. This paper compares the rural specialty experience of 28 fifth-year volunteers with 28 'pairs' who remained in the city teaching hospitals. Rural students saw double the number of medical conditions, assisted in or performed six times as many procedures, and all but three students were sure that they had a better educational experience than their city counterparts. This is a strong academic argument for greater medical student exposure to rural specialty practice.

Consumer satisfaction in two small rural communities: a quick methodology to empower rural communities to assess their own healthcare needs

This study was designed to develop a quick methodology to assess the healthcare needs of a rural community and to determine what factors make these communities 'happy' or 'unhappy' with respect to medical service provision. Two rural shires of approximately 4000 people each were chosen from different health regions of Western Australia. The methodology consisted of interviews with healthcare providers and key community informants as well as a community questionnaire. The interviewing process showed that key community informants offered no new information in addition to that already provided by the healthcare providers. Furthermore, all key points would have been covered by interviewing approximately 60% of all healthcare providers in each community. Hand delivery of the community questionnaire yielded the highest response rate. The level of community satisfaction with general practitioner (GP) and hospital services determines whether a community is medically 'happy' or 'unhappy'.

Lifestyle and health habits of fourth year medical students at the University of Western Australia

OBJECTIVE

To examine the lifestyle and health habits of two classes of fourth year medical students at the University of Western Australia.

DESIGN

Anonymous completion of the Fantastic Lifestyle Assessment Inventory (FLAI) by 173 medical students in 1987 and 1992.

RESULTS

Seventy-seven per cent of students had good health habits, but 23% did not. The most common areas of negative health habits were; lack of exercise, frequent consumption of junk food and skipping breakfast. Twenty per cent of students were almost always impatient, 13% always anxious, and 30% reported more than three stressful events in the first year.

CONCLUSION

Medical students are taught and examined about healthy lifestyle and health promotion. Those who personally ignore what they know may also be predisposed to ignore health promotion opportunities with their patients. The FLAI can be a useful instrument in raising students' consciousness about these two issues.

Selection and prediction of performance of entrants to GP training

There are currently more applicants than available positions in The Royal Australian College of General Practitioners Vocational Training Program. This already entails a process to select entrants into the Program. Furthermore, any vocational program should be interested in attracting entrants who will complete their training and be successful practitioners. This paper aims to contribute to the debate on methods of selection and prediction in vocational programs for general practice.

Type 2 diabetes. Patient practices, and satisfaction with GP care

OBJECTIVE

To document patients' practices and management of DM2, their satisfaction with diabetes care and their quality of life and functional status.

DESIGN

Anonymous questionnaire completed by 467 patients recruited by 204 GPs in 124 practices in the Perth metropolitan area.

RESULTS

Patients reported an adequate amount of monitoring for stable DM2. However, they lacked awareness of diabetes risk factors and complications from which they already suffered. Some 90% of patients reported a high level of satisfaction with GP care and only 2.4% of patients had more than a moderate degree of functional disability.

CONCLUSION

Patients have a high level of satisfaction about the diabetes care received from their general practitioner. However, they lack awareness of their risk factors and complications of diabetes. A simple strategy is proposed to improve these deficits and to share the responsibility for diabetes care between patient and doctor.

A critical incident study of general practice trainees in their basic general practice term

OBJECTIVE

To obtain information on the experiences of general practice (GP) trainees during their first general practice (GP) attachment.

DESIGN

Critical incident technique--a qualitative analysis of open-ended interviews about incidents which describe competent or poor professional practice.

SUBJECTS

Thirty-nine Western Australian doctors from the Royal Australian College of General Practitioners' (RACGP) Family Medicine Program who were completing their first six months of general practice in 1992.

RESULTS

Doctors reported 180 critical incidents, of which just over 50% involved problems (and sometimes successes) with: difficult patients; paediatrics; the doctor-patient relationship; counselling skills; obstetrics and gynaecology; relationships with other health professionals and practice staff; and cardiovascular disorders. The major skills associated with both positive and negative critical incidents were: the interpersonal skills of rapport and listening; the diagnostic skills of thorough clinical assessment and the appropriate use of investigations; and the management skills of knowing when and how to obtain help from supervisors, hospitals and specialists. Doctors reported high levels of anxiety over difficult management decisions and feelings of guilt over missed diagnoses and inadequate management.

CONCLUSION

The initial GP term is a crucial transition period in the development of the future general practitioner. An analysis of commonly recurring positive and negative critical incidents can be used by the RACGP Training Program to accelerate the learning process of doctors in vocational training and has implications for the planning of undergraduate curricula.

Management of type 2 diabetes in Western Australian metropolitan general practice

The purpose of this study was: (1) to record GP opinions, practices and outcomes for the care of Type 2 Diabetes Mellitus (DM2), (2) compare practice facilities and process of care with a criterion of recommended competent care and (3) determine if there were any differences between vocationally registered and non-vocationally registered GPs. A random sample of 204 metropolitan doctors from 124 practices was selected and an audit performed on 467 of their patient records. GPs pursued good blood sugar control and advocated lifestyle changes before hypoglycaemic drugs. Over 80% regard uncomplicated DM2 as a condition for general practice management. However, only 15% conducted an annual diabetes check, 9% had a diabetic register, 6% a diabetic recall system and 8% used a diabetic health care checklist for monitoring their patients. The most commonly recorded processes of medical audit in the previous 12 months were: blood pressure (94%), duration of diabetes (72%), blood glucose (70%), diet (66%), body weight (56%), HBA1c (52%) and ophthalmoscopy (50%). The least commonly recorded processes of care were body mass index (5%), inspection of the feet (18%), enquiries about vaginitis or impotence (23%). The amount of exercise, alcohol and tobacco was recorded in only 34% of records. Hypoglycaemic drugs were used appropriately but the most commonly used drugs for treating hypertension in DM2 patients were thiazide diuretics and beta-blockers. Vocationally registered (VR) doctors had better records, higher process of care scores and more were willing to participate in the study than non-vocationally registered (NVR) doctors. However, there was no difference in metabolic control between patients from either group. The use of a Diabetic Health Care Checklist would improve diabetes care especially in the search for early complications and in the recording of HBA1c and other metabolic parameters. The drugs commonly used to control hypertension can have adverse effects on glucose and lipid metabolism and should be replaced with glucose and lipid neutral drugs.

The reading habits of RACGP Training Program doctors

AIM

To describe the reading habits of a cohort of Western Australian RACGP Training Program doctors undertaking general practice terms in 1992.

METHOD

A questionnaire that included a list of journals and books relevant to general practice was distributed to trainees. Information obtained included demographic data, the frequency of journal reading and the number of books read.

RESULTS

There were 68 respondents from a total of 100. Time spent in medical reading ranged from one to 12 hours per week, with a mean of 3.3. The number of journal titles read in the past six months ranged from three to 16. The number of books actually read (from the 39 titles presented) ranged from zero to 17. The most frequently read were the reference type books. Very few of the 'core' books about the nature, scope and philosophy of general practice had been read.

CONCLUSIONS

RACGPTP doctors read mainly for information. To produce educated doctors knowledgeable about their chosen discipline, the Training Program will need to place greater emphasis on introducing their vocational trainees to the writings of the thinkers and philosophers of general practice and family medicine.