[Recruitment for general practice - relationship between practice-based curriculum and career choice]

BACKGROUND

Demographic change and recruitment problems in general practice are increasingly threatening an adequate primary care workforce in many countries. Medical schools play an important role in attracting young physicians to this field. The influence of the general practice curriculum on the career choice of graduates has not yet been sufficiently investigated.

METHODS

The present study combines continuously collected data of medical students concerning the participation in miscellaneous general practice courses with data of a later graduate survey.

RESULTS

Response rate was 64.2%. Although only 4.7% of the participants preferred a career in general practice at study entry, this specialty was, at 12.3%, the second most frequent career choice. Among the future general practitioners, only 18.5% had initially planned this career. The future general practitioners took part significantly more frequently in all facultative general practice courses. They reported more frequently to have met role models in general practice and to have gained experience in rural areas. Future general practitioners would more often prefer to work in rural areas in the future.

CONCLUSIONS

Overall, the present results indicate that a broad and practice-oriented general practice curriculum has the potential to attract medical students to the specialty.

Do general practitioners recognize mild cognitive impairment in their patients?

OBJECTIVES

The need for recognition of mild cognitive impairment (MCI) in primary care is increasingly discussed because MCI is a risk factor for dementia. General Practitioners (GPs) could play an important role in the detection of MCI since they have regular and long-term contact with the majority of the elderly population. Thus the objective of this study is to find out how well GPs recognize persons with MCI in their practice population.

DESIGN

Cross-sectional study.

SETTING

Primary care chart registry sample.

PARTICIPANTS

3,242 non-demented GP patients aged 75-89 years.

MEASUREMENTS

GPs assessed the cognitive status of their patients on the Global Deterioration Scale (GDS). Thereafter, trained interviewers collected psychometric data by interviewing the patients at home. The interview data constitute the basis for the definition of MCI cases (gold standard).

RESULTS

The sensitivity of GPs to detect MCI was very low (11-12%) whereas their specificity amounts to 93-94%. Patients with MCI with a middle or high level of education more often got a false negative assignment than patients with a low educational level. The risk of a false positive assignment rose with the patients' degree of comorbidity. GPs were better at detecting MCI when memory or two and more MCI-domains were impaired.

CONCLUSION

The results show that GPs recognise MCI in a very limited number of cases when based on clinical impression only. A further development of the MCI concept and its operationalisation is necessary. Emphasis should be placed on validated, reliable and standardised tests for routine use in primary care encompassing other than only cognitive domains and on case finding approaches rather than on screening. Then a better attention and qualification of GPs with regard to the recognition of MCI might be achievable.

[Respiratory symptoms in the general practice. An analysis of the Leipzig SESAM Study]

The Saxon Study of General Medicine (SESAM) investigated the reasons why patients consulted the general practitioner, which diagnoses were established and how the patients were subsequently treated. In the majority of cases, the respiratory symptoms were simple infections of the upper and lower respiratory tract. Pneumonia must always be considered, while severe pulmonary diseases are of no significance in the differential diagnosis of respiratory complaints in the general practice.

[Patient care in nursing homes by the family physician]

When treating the acute and chronic diseases of nursing home residents, the family physician must consider the patient's decreased ability to make decisions and shortened life expectancy in each case. Nurses tend the elderly people, help them wherever it is necessary, have time to listen to the hardships and worries of their charges and are an irreplaceable help to the family physician for observing patients and assessing the measures taken based on these observations.

[Basic pain management care by the family physician]

After a cleardiagnosis has been made, many acute as well as chronic pain symptoms can be treated by the family physician on an outpatient basis. For the step therapy of chronic pain, particular attention must be given to the side effects. In some cases, side effects necessitate the use of comedication, such as for nausea, constipation or depression. Particularly complex pain treatments should still be treated by the specialist.

[Red, yellow, green: management of gastrointestinal complaints]

In a patient presenting with acute abdominal pain, initiation of symptomatic treatment must be preceded by the reliable exclusion of a potentially serious situation (acute abdomen = red light). Rapidly progressive or severe abdominal pain mandates an urgent diagnostic investigation on the part of the physician. No less important is the positive diagnosis of psychosomatic disorders (yellow light). If the family doctor fails to properly counsel the patient, too much diagnostic effort can lead to an iatrogenic somatic fixation. In the absence of all the above, the light shows green for causal therapy, an open mind on the diagnosis, symptomatic treatment and follow-up.

[Diagnostic work-up of abdominal pain by the family doctor: an avertable potentially threatening situation must be excluded]

When patients attend the physician's office with acute abdominal pain, the doctor must first exclude a potentially dangerous condition (acute abdomen) before initiating symptomatic treatment (e. g. painkilling drugs). The need for this is based in the first instance on the presence of severe complaints in combination with the absence of a plausible explanation for the patient's distress, as well as, secondarily, the anxiety of the patient or the person accompanying him, or even the doctor's own anxiety about possibly overlooking a serious pathology.

[Presenting problem: abdominal pain]

The Saxon Study for General Medicine (SESAM) investigated the reasons why patients consulted the general physician, what diagnoses were established, and how the patients were subsequently treated. In the majority of cases, the reason for the abdominal complaints was located in the gastrointestinal or urogenital tract, in the presence of infections or psychosomatic problems. Gynecological problems must also be considered, while diseases other than gastrointestinal are of no significance for the differential diagnosis of abdominal complaints in the general physician's office.

[Insect stings and their sequelae]

In the summer months, insect stings are a common reason for seeking help from the general physician. In the majority of cases a local reaction is seen, but, far less often, an anaphylactic reaction may also occur. Such an acute situation requires calm but decisive action, and the initiation of an evaluation by an allergy specialist. The family doctor should regularly review the facilities for treating an anaphylactic reaction in his office, and, where necessary, optimize them.

[Sports and leisure injuries in summer]

In the first days of summer, there is an increase in the number of summer-related accidents and injuries. Typical for the types of sports practiced in summer, such as ball games, cycling or skating are injuries to the wrist and ankle, knee, head and shoulder. The most frequent victims of swimming accidents are children under four years of age, and adolescents aged between 15 and 19 years. During grilling, burns often occur, most of which, however, are superficial and can be treated in the doctor's office. The incidence of dog bites also increases in summer. In such cases consideration must be given not only to tetanus boosters, but also to the possibility of an infection with rabies.

[STEP--standardized assessment of elderly people in primary care]

BACKGROUND

There is a need for a standard preventive assessment scheme, which is effective, feasible and acceptable throughout European primary care.

METHODS

A consensus based guideline including systematic reviews of the evidence was done by an expert panel of general practitioners (core group) and epidemiologists / geriatricians from seven European countries.

RESULTS

The Step group identified 8 health domains to be considered in a preventive assessment; client's perspective and attitudes. physical state, functional state, significant symptoms, mental function, social circumstances, medication and primary preventive issues. To select the health areas with a proven preventive potential the strength of scientific evidence and the relevance to primary preventive care was assessed. The final recommendations graded as the preventive primary care impact factor as follows: A1=strongly recommended were hypertension, symptomatic heart failure, urinary incontinence, hearing impairment, vision impairment, falls, breathlessness, depression, dementia, medication review, functional status, activity and physical exercise. A2=recommended: Hypertension over the age of 80, history of myocardial infarction, symptomatic coronary heart disease, atrial fibrillation, history of TIA or stroke, peripheral vascular disease, diabetes, thyroid dysfunction, osteoporosis, lipids, faecal incontinence, weight status, foot problems, oral heath, osteoarthritis, sleeplessness, pain, social circumstances, tobacco and alcohol use, psychological support for patients with chronic disease and (national) immunization & cancer programs.

CONCLUSIONS

The rising population of elderly people in Europe gives cause for health care professionals and policy makers to consider optimal ways to preserve health and function in old age. An Evidence based, proactive preventive geriatric assessment can help to promote heath and function in older people.

An evidence-based approach to assessing older people in primary care

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Psychosocial care by general practitioners--where are the problems? Results of a demonstration project on quality management in psychosocial primary care

OBJECTIVE

Since 1987, psychosocial services have been a part of the primary care setting in Germany. In the framework of an eight-center national demonstration program, problems in the diagnosis and therapy of psychosocial problems and psychosomatic disorders were assessed. Methods to improve quality were also implemented.

METHOD

General practitioners (n = 191) from six regions participated in the study. One thousand three hundred and forty-one treatment episodes of patients with predominantly psychosocial symptoms were documented. Differences between psychosocial strain, treatment, and outcome were determined by analyses of variance.

RESULTS

Anxiety (62%), depression (51%), and marital/family conflicts (44%) were the most frequent symptoms. Psychosocial treatment was offered more often to those patients who had the highest level of anxiety and depression. Patients with pain and without a psychological attribution to their illnesses were offered less psychosocial treatment and suffered worse results. Partners and family members were rarely integrated into therapy. The procedures employed to improve outcome were quality circles, family-oriented case conferences, consultation services, and collaborative groups.

CONCLUSIONS

These initial results are promising. A process of internal quality management has been initiated. Some of the physicians still resist documenting the data. Patients with somatic symptoms without psychological attribution may need special psychosocial interventions to improve their outcomes.

[Psychotherapeutic and psychosocial therapy in general practice. Results of demonstration project on quality management in psychosocial primary care]

Since 1987, psychosocial primary care (PPC) provided by General Practitioners, are reimbursed by German health insurances. The aim of the psychosocial primary care is to improve recognition and treatment of mental disorders in the primary care sector. As a part of a eight-center national demonstration program on quality management in the outpatient services, General Practitioners (n = 191) from 5 regions participated in the study. 1341 treatment episodes of patients with predominately psychosocial strain were documented. Differences between psychosocial strain, treatment and outcome were determined by analyses of variance. Men and patients beyond the age of 65 were underrepresented. Psychosocial treatments were offered more often to those patients, who had the highest level of anxiety and depression. Patients with physical illness, with pain and without psychological attribution to the illness belief were offered less psychosocial interventions and reached a worse outcome. The study outcome helps to improve training programs as to recognition and treatment of psychosocial problems in primary care. Male and generally elderly patients with somatic symptoms and lack of psychological attribution need a special psychosocial intervention to improve the outcome.

[Primary psychosomatic management in general practice. Results of a German nationwide demonstration project of quality assurance]

In the frame of a national demonstration program, psychosocial care of patients with psychological and psychosomatic problems were assessed. General practitioners (n = 191) from six regions participated in the study. 1341 treatment episodes of patients with predominately psychosocial symptoms were documented. Anxiety (62%), depression (51%) and marital/family conflicts (44%) were the most frequent symptoms. Somatic treatment and psychosocial intervention were offered equally. Patients with psychosocial treatment achieved better results. Partners and family members were rarely integrated into therapy. The procedures employed to improve outcome were quality circles, family-orientated case conferences, consultation services and collaborative groups.

[Gerontopsychiatric treatment in comparison between integrated management at a university and separated management at a district hospital. 1: Patient characteristics]

OBJECTIVE

We wanted to study differences between geriatric psychiatric patients and their management in an integrated (with other adult age groups) care in the University Psychiatric Hospital (PUK) compared to those in a separated (only according to age) care in the Psychiatric State Hospital (LKH), which together treat all psychiatric inpatients in Goettingen, Germany.

METHOD

We performed standardized chart reviews of randomly selected groups of patients, who had been treated in the PUK (n = 151) and the LKH (n = 145) in the years 1991 and 1992.

RESULTS

The LKH patients were significantly older (74.8 +/- 8.7 y versus 70.3 +/- 8.3 y), more often living alone and/or without children. 31.9% of them were living in a nursing home compared to 6.5% of the PUK patients. Psychic disorders had not shown up before old age in 55.7% of all cases. 50.4% of the patients were in a psychiatric hospital for the first time. The majority of the patients (65.6%) had not been investigated by a psychiatrist before admission.

CONCLUSIONS

More socially handicapped patients were treated in the LKH. For most cases, the hospital treatment had been the first psychiatric treatment at all.

[Gerontopsychiatric treatment in comparison between integrated management at a university and separated management at a district hospital. 2: Diagnoses and treatment]

OBJECTIVE

We wanted to study differences between geriatric psychiatric patients and their management in an integrated (with other adult age groups) care in the University Psychiatric Hospital (PUK) compared to those in a separated (only according to age) care in the Psychiatric State Hospital (LKH), which together treat all psychiatric inpatients in Goettingen, Germany.

METHOD

We performed standardized chart reviews of randomly selected groups of patients, who had been treated in the PUK (n = 151) and the LKH (n = 145) in the years 1991 and 1992.

RESULTS

Most patients of the LKH suffered from organic brain diseases/dementia (63.4%; PUK: 29.1%). In the PUK, depression was the most frequent diagnosis (57.6%; LKH: 21.1%). A part of about 25% of the patients showed neurological deficits. Specialised diagnostics were performed mostly in the PUK. Both institutions treated the wide majority of patients with CNS drugs. Antidementia drugs were given significantly more often in the LKH. About one third of the patients were released into changed living environments.

CONCLUSIONS

Patients with further progressed dementias were treated mainly in the LKH. This has consequences for diagnostics, treatment duration and side effect rate.

Gender differences in the recognition of depression in old age

OBJECTIVE

The study should answer the question of whether identical symptom presentations of depression in male and female patients leads to similar recognition rates in primary care.

METHOD

We performed a survey in primary care. Two written case vignettes were presented to 170 family physicians in a face-to-face interview which took place in their practices. The case vignettes described either a mildly depressed otherwise healthy old patient (case 1) or a severely depressed patient with somatic comorbidity (case 2). For each case different versions with regard to patients' gender were used: in case 1 only the gender of the patient varied; in case 2 both the gender and the anamnesis (stroke/hypothyroidism) varied. Afterwards the interviewers asked standardised open questions. The physicians were not aware of the mental health focus and the gender focus of the study.

RESULTS

The study is representative with a response rate of 77.6%. For primary diagnosis, the female versions were given the diagnosis of depression more often. There was a non-significant trend that female physicians considered depression more often.

CONCLUSION

The results show that gender-related experience and stereotypes on the physicians' side influence the diagnosis of (old age) depression in primary care. Further studies should elucidate the influence of the physicians' gender on the management of psychiatric disorders.

Family physicians and the risk of suicide in the depressed elderly

BACKGROUND

Depression is the most frequent psychiatric disorder in the elderly. It is the reason for most suicides in this age group.

METHOD

We performed a representative survey in primary care. Two written case vignettes were presented to 170 family physicians in face-to-face interviews which took place in their practices. The case vignettes described either (Case 1) a mildly depressed otherwise healthy old patient or a severely depressed patient (Case 2) with somatic comorbidity. Afterwards the interviewers asked standardized open questions. The physicians were not let into the mental health focus of the study.

RESULTS

The response rate was 77.6%. Depression was considered for primary or differential diagnosis by 91.2% of the physicians in Case 1 and by 70% in Case 2 (chi2-test; p < 0.01). For further anamnesis, only 2.4% of the physicians were interested in suicidal ideation of the patient. When directly asked at the end of the interview, 76.9% of the physicians said they would talk about suicide. Those who would not, thought that the patient would communicate suicidal intent himself/herself, or they feared to induce suicide by asking directly.

CONCLUSION

Thinking of suicidality and its prevention is not uppermost in the physicians' mind. Therefore, and also with regard to the relatively high rate of depression recognition, we conclude that educational means should not only focus on the recognition and screening of depression, but also on the management--'how to talk about...'--of complex problems like suicide in the elderly, in order to change suicide rates.

[Early diagnosis and early treatment of cognitive disorders: a study of geriatric screening of an unselected patient population in general practice]

To investigate the feasibility of early assessment of preventable disabilities in primary care, we developed a geriatric preventive screening examination with various indicators of physical, emotional, and social functions as well as laboratory exams. Cognitive impairment was measured by the modified MMSE. Severe cases of dementia, who would deserve home visits were excluded. Results of the assessment procedure in 446 patients aged 70 and over (71.5% females) were compared to ratings of general practitioners (n = 67). In these patients we found 4250 medical, 374 psychiatric, and 528 social problems. 45.4% of medical, 61.8% of psychiatric, and 56.8% of social problems where hitherto unknown to the GPs. The prevalence of cognitive impairment was 4.6% according to GPs diagnosis and 21% according to the MMSE. The sensitivity of GPs diagnosis was 14%, the specificity 98%, and the overall agreement measured by kappa was 0.17. There were significant (p < 0.05) associations of cognitive impairment with poor health, vascular disease, syncope, weight loss, previous hospitalization, depression, and ADL and IADL-items. Hypertension, or pathological thyroid function, occurred more frequently in the cognitively impaired (p > 0.05). Only 19.5% of dementia cases had severe functional loss, which substantiates our hypothesis that mild dementia was studied. Of all cases with newly identified cognitive impairment (n = 83 of 446 patients), three (3.6%) had reversible disorder such as depression (n = 1), drug toxicity (n = 2) 3 (3.6%) received counseling, and 5 (6%) further diagnostic assessment or treatment. One (1.2%) patient did not accept any treatment. In the remainder of 71 patients (85.5%), the GPs adopted a wait and see strategy with no intervention. In conclusion, memory deficits seem to be underdiagnosed in general practice despite much treatable comorbidity or social problems, and some reversible conditions such as depression and drug adverse effects.

[Cerebral cognitive deficits in the aged. Diagnostic and therapeutic standards: organization of strategies for problem detection and solution]

This paper reports the results of a representative survey which was performed in cooperation with 145 family physicians and 14 primary care neuropsychiatrists (response rate 83.2%) in the area of Göttingen, Germany. With the use of a standardised interview referring to written sample case histories, we investigated the diagnostic and therapeutic management of memory disturbances in old age. The results showed, that dementia and depression are underdiagnosed in primary care, and that memory disturbances are mainly regarded as consequences of disturbed cerebrovascular perfusion. About 70% of all physicians would prescribe a cognition enhancer, however about a third of them would do it in spite of major doubts about their efficacy. The results underline the necessity of continuing education especially with regard to early diagnosis of dementive and affective disorders in later life. The development of therapeutic standards in this area should take "irrational" motives into account. Appropriate exemplary case histories seem to be a potentially useful tool for the measurement of physicians' competence and its changes.

[Quality assurance in basic psychosomatic care. Report of an expert survey within the scope of the Federal Public Health Administration instigated pilot project]

This article outlines a nationwide quality improvement project in counselling funded by the German Ministry of Health. To develop the project, expert surveys and consensus conferences are currently organized by the coordination center. A questionnaire with mainly open questions was sent to 32 teachers in general practice. Counselling for psychiatric, psychosomatic and psychosocial problems in primary care was regarded as an important field for quality assurance. The experts believed short psychotherapy to be an integral part of family medicine as some 30% of our patients present with complaints caused by psychosocial or psychological reasons. However, only some 70% of patients receive a specific treatment. The experts rated better recognition of psychosomatic problems as the most important area for quality improvement. Suitable interventions to improve the physicians' ability in the area mentioned were continuing medical education, balint groups, quality circles and flexible guidelines. The experts made invaluable contributions to the development of a practice documentation for psychosocial problems.

Prescribing practice with cognition enhancers in outpatient care: are there differences regarding type of dementia?--Results of a representative survey in lower Saxony, Germany

Previous studies of cognition enhancers have mainly focused on insufficiently defined groups of cognition disorders, e.g., "cerebral insufficiency". With regard to the various biological changes in senile dementia of Alzheimer's type (SDAT) and in vascular dementia (VD), which together make up the great majority of senile dementias, many authors have encouraged different studies of these types of dementias, especially since both can be diagnosed clinically with satisfying certainty. Since primary care physicians treat the majority of elderly and demented patients, they have their own experience with cognition enhancers. We were therefore interested to know, how far these physicians differ in their treatment of SDAT and VD. We performed a representative survey (response rate 83.2%; 145 family physicians and 14 neuropsychiatrists) in the Goettingen area. A written case vignette described a 70-year-old widow with moderate dementia and vascular risk factors which are easily treated with drugs. Two versions were randomly assigned, in which (version A) either a "typical" VD history or a typical SDAT history (version B) were described. After perusal, the physician was asked whether and which drugs he would choose to treat the cognitive disorders in this patient. Most frequently, piracetam (A/B: 25.6%/30.9%), ginkgo biloba (24.4%/28.4%), and nimodipine (14.1%/25.9%) were considered. Aspirin was cited by 29.5%(A) and 17.3%(B) of the physicians respectively. As far as the type of dementia was concerned, significant differences were found only for co-dergocrine, which was preferred in SDAT. The following inter-group trends were observed: family physicians considered ginkgo biloba more often than nimodipine or co-dergocrine. The results show the apparent importance of cost-and safety aspects, while the type of dementia has hardly any impact. The latter impression corresponds to the results of drug trials demonstrating no different efficacy. In our opinion, aspirin was not sufficiently taken into consideration.

Improvement of exercise capacity with treatment of Cheyne-Stokes respiration in patients with congestive heart failure

OBJECTIVES

The aim of this study was to determine the impact of nasal nocturnal oxygen therapy on respiration, sleep, exercise capacity, cognitive function and daytime symptoms in patients with congestive heart failure and Cheyne-Stokes respiration.

BACKGROUND

Cheyne-Stokes respiration is common in patients with congestive heart failure and is associated with significant nocturnal oxygen desaturation and sleep disruption with arousals. Oxygen desaturations and arousals cause an increase in pulmonary artery pressure and sympathoneural activity and therefore may reduce exercise capacity. Oxygen is an effective treatment of Cheyne-Stokes respiration and should improve exercise capacity in these patients.

METHODS

The study was designed as a randomized crossover, double-blind, placebo-controlled trial: 22 patients were assigned to 1 week each of nocturnal oxygen and room air. After each week, polysomnography, maximal bicycle exercise with expiratory gas analysis and trail-making test were performed, and a health assessment chart was completed.

RESULTS

Nocturnal oxygen significantly reduced the duration of Cheyne-Stokes respiration (162 +/- 142 vs. 88 +/- 105 min [mean +/- SD]; p < 0.005). Sleep improved as evidenced by less stage 1 sleep and fewer arousals (20 +/- 13 vs. 15 +/- 9/h total sleep time; p < 0.05) as well as more stage 2 and slow-wave sleep; nocturnal oxygen saturation also improved. Peak oxygen consumption during exercise testing increased after oxygen treatment (835 +/- 395 vs. 960 +/- 389 ml/min; p < 0.05). Cognitive function evaluated by the trail-making test improved, but daytime symptoms in the health assessment chart did not improve significantly.

CONCLUSIONS

Successful treatment of Cheyne-Stokes respiration with nocturnal nasal oxygen improves not only sleep, but also exercise tolerance and cognitive function in patients with congestive heart failure.

COOP-WONCA charts: a suitable functional status screening instrument in acute low back pain?

BACKGROUND

Functional status is considered an important measure of health status in primary care. The COOP-WONCA charts, which comprise six single-item scales, have mainly been used to determine functional ability in chronically ill patients.

AIM

A study was carried out to determine whether the charts are able to measure the degree of functional impairment associated with acute illness and the improvement in functional ability accompanying the process of recovery.

METHOD

A total of 95 patients presenting with acute low back pain were recruited from 15 single-handed general practices in northern Germany. At presentation and at two-week follow up, these patients completed self-administered questionnaires which included the COOP-WONCA charts. The charts ask patients to use the timescale of the past two weeks when rating their condition. Baseline and follow-up measurements of the charts were compared and correlations of chart scores with patients' measurements of pain intensity on a visual analogue scale, general practitioners' ratings of impairment and patients' measurements of recovery were analysed.

RESULTS

Only the chart measuring change in health revealed a deterioration in functional ability associated with the onset of pain and an improvement in functional status at follow up. Two of the other charts indicated a deterioration at follow up. Only the chart measuring change in health was correlated with ratings of pain and impairment at baseline. At follow up, strong correlations were found between general practitioners' assessments of impairment, patients' ratings of pain and patients' ratings of recovery for all scales except for those measuring social activities and daily activities. The patients interpreted the instructions for using the COOP-WONCA charts differently; some included the period of acute back pain while others did not.

CONCLUSION

Of the six charts only the change in health chart proved to be a suitable scale for measuring short-term changes in functional ability among general practice patients with acute low back pain. This may partly be a result of patients misunderstanding the instructions. If the COOP-WONCA charts are used with acutely ill patients, the fixed two-weeks timescale is not appropriate. It is suggested that patients consider their present complaints when rating their condition.

Sleep disturbances in the demented elderly: treatment in ambulatory care

We report the results of a representative survey in Lower Saxony, Germany, that focused on the treatment of sleep disturbances in the moderately demented elderly. Two written sample case histories (vignettes) described either a vascular demented patient suffering from nocturnal wandering or an Alzheimer's-type demented patient without apparent psychotic or behavioral (sleep) disorder. These were randomly assigned and presented to 145 family physicians and 14 neuropsychiatrists working in private practice by a trained investigator, who then conducted a standardized interview with the physicians. The study was representative of physicians (response rate: 83.2%). In response to the question concerning how they would treat the patient's sleep disturbances, about 20% of the physicians (with respect to both versions) answered that they would not choose drugs. More than 40% considered neuroleptics to be the drugs of choice. Benzodiazepines, antidepressants and other substances were seldom considered. No significant difference was noted in the response to the two different case histories. The results allow for the conclusion that non-drug treatments, which (at least initially) should be the treatment of choice, are mainly disregarded by the majority of the ambulatory care physicians. The reason for this seems to be a lack of education in sleep medicine and also in geriatric medicine.

[Factors influencing the prescribing of nootropic drugs. Results of a representative inquiry in Lower Saxony]

AIM OF INVESTIGATION

To discover (1) to what extent patients' wishes and the extent of any abnormality of brain performance influence the frequency with which "nootropic" drugs (those thought to affect brain activity, e.g. piracetam, pyritinol, or improve cerebral circulation, e.g. xanthine derivatives, Ginkgo biloba, secale alkaloids, calcium antagonists) are prescribed; (2) the medical practitioner's expectations of the effectiveness of such medications.

METHOD

In a personal interview, 145 family doctors and 14 neurologists in private practice in the Göttingen area of Germany (participation rate: 83.2% of those asked to participate) were questioned about fictitious cases (case 1: mild memory problem with or without expressed wish for medication; case 2: moderate dementia, of Alzheimer or multi-infarct type). The previously arranged interviews, which took place in the doctors' practice rooms, consisted of standardized open questions to the written case reports.

RESULTS

Regardless of the wish of the patient and the extent and type of the abnormal brain function about 70% of all participating doctors would prescribe those drugs, even though about 56% had doubts about their effectiveness. About 28% expected a positive effect on brain performance. A nearly equal proportion of doctors would continue an existing drug regimen as would prescribe one.

CONCLUSION

The prescription of the named group of drugs is influenced less by medical criteria than by factors which concern doctor-patient relationship.

Reasons for prescribing cognition enhancers in primary care. Results of a representative survey in Lower Saxony, Germany

With regard either to the controversial debate about the efficacy of cognition enhancers (CEs) or to the high costs which the frequent prescription of these drugs causes the German health system's economy, we wanted to know what physicians expect from a therapy with these drugs. We performed a representative survey (response rate 83.2%) in Lower Saxony, Germany from February to July 1993. We designed two written case vignettes which described either a patient with slight memory problems or a moderately demented patient who also suffers from common systemic disorders. In a face-to-face interview 145 general practitioners and primary care internists (family physicians) and 14 community neuropsychiatrists answered the question, whether they would prescribe CEs to each of the patients described and what they would expect from this therapy. 70.4% of all physicians would prescribe a cognition enhancer to the slightly impaired patient and 63.5% to the multimorbid moderately demented patient, respectively. More than 50% of the family physicians would not expect any positive therapeutic effect in both patients, while the neuropsychiatrists did so in 57.1% in the patient with slight memory disturbances and in 35.7% in the moderately demented patient. A positive effect on cognition was expected by 28.2% of all physicians in the slight and by 18.3% in the moderately impaired patient, respectively. Other reasons mentioned were amelioration of cerebral perfusion and drive, as well as effects on disease progression. In conclusion, the results of this study clearly demonstrate that cognition enhancers are prescribed in spite of major doubts in their efficacy.

[Problem-oriented learning at the Göttingen University. Report of a 1 week introductory conference ("sample course")]

In Germany, a reform of the medical academic training is hotly discussed. However, only a few teachers and students can base their arguments on practical experience with new learning methods. Therefore, a one-week-try-out course ("Schnupperkurs Reformstudiengang") was organised at the university of Göttingen to gain experience in the problem-based learning. Tutorials took place according to the principle of the "seven steps" as practised in Maastricht. The students developed their own learning goals guided by a tutor. The acquiring of the subject was achieved by private studies, accompanying seminars, and practical training. An evaluation of the student's opinions on problem based learning and their satisfaction with the course was carried out by a questionnaire and group discussions. Our experiences show an open-mindedness of the academic staff and real enthusiasm on the part of the 21 participating students. Substantial for this success are--according to the results of the survey--the following items: The problem-orientated practical and interdisciplinary approach and teaching in small groups, which enabled a very close relationship between academic staff and students. A try-out-course might be a welcome entry to new forms of learning, because it offers practical experiences in new learning and teaching methods to open-minded lecturers and students. Therefore, such courses can contribute to an evolution at universities as they slowly but smoothly generate the essential competence needed to reform the medical education.

[Ambulatory treatment of sleep disorders in the aged]

An enquiry into the handling by medical practitioners of sleeping problems among elderly patients was conducted in southern Lower Saxony by personal interview, combined with a standard questionnaire. A typical case report had been drafted concerning a 70-year-old, previously healthy widow: her complaints were "nonspecific" and could be classified as an example of either depression, of the onset of senile dementia or as within normal limits for age. This case report was presented by two interviewers to 145 general practitioners (GPs) and 14 neurologists in private practice (response rate of 83.2%) who were asked how they would have treated the patient's sleeping disorder. 30.3% of the GPs and 14.3% of the neurologists would initially not have prescribed medication. Only GPs (19.5%) mentioned possible herbal medication. Sedative neuroleptics were preferred by 57.1% of neurologists and 26.2% of GPs, while benzodiazepines would have been given by 14% of both groups. Antidepressive drugs and chloral hydrate were chosen less often (5.7% and 2.5%, respectively). These data support the finding of a high frequency of neuroleptic prescriptions given to the elderly. They also make clear that the possibility of treatment without drugs is usually not sufficiently explored.

Attitudes of primary care physicians towards the use of a drug formulary--preliminary results of a study in Germany

Although the concept of a drug formulary in primary health care is known for more than 10 years it was only recently that the drug budget of the new German Health Legislation has drawn doctors' attention to the use of such formularies. The loose-leaf form "Göttingen formulary" has been specifically compiled for the need of primary care doctors. It contains less than 300 drugs and drug combinations (including pseudo-placebos). This formulary was ordered by 830 colleagues from November 1992 until the end of May. In June 1993 we sent a semi-structured questionnaire to the users to learn about their experience with and attitude towards the formulary and about changes in their prescribing habits. Until the end of August 223 questionnaires have been returned. Seventy-four % of the respondents were general practitioners with considerable experience (more than 10 years in practice: 77%). The majority were satisfied or very satisfied with the drugs selected for the formulary and found the list helpful or very helpful (68%). Sixty-seven % indicated that the use of the formulary changed their prescribing habits; 70% appreciated an official (governmental) positive list. Although this study did not use a representative sample and the response rate was rather low until the cut-off point, it is noteworthy that the overall appreciation of a drug formulary for primary health care was very positive. The great majority of the respondents were convinced that an individual drug formulary does not render an official positive list superfluous.

Diagnosis of dementia in primary care: results of a representative survey in lower Saxony, Germany

To investigate whether an early diagnosis of dementia is established, whether a differentiation is made between vascular and primary degenerative etiology, and whether treatable causes of dementia are considered in primary care, we performed a survey using three written sample case histories describing slight memory impairment (case 1) or moderate dementia (case 2a: vascular dementia; case 2: degenerative dementia of Alzheimer type). The combinations 1 and 2a or 1 and 2b were randomly assigned and presented to ambulatory-care physicians (145 general practitioners and primary care internists and 14 neuropsychiatrists in private practice) in Göttingen and rural surroundings by a trained investigator who then performed a standardized interview. The study was representative (response rate 83.2%). For the sample case with slight memory complaints 13.8% of all physicians arrived at a primary diagnosis of depression and 44.0% considered depression for differential diagnosis. Senile dementia of Alzheimer type was considered less often. In the sample cases with moderate dementia according to established scientific criteria, there was a striking under-diagnosis of dementia, and in both cases an over-diagnosis of underlying vascular etiology. Treatable causes of dementia, such as possible drug interactions and substance abuse, were considered only by a minority of physicians. In conclusion, memory deficits seem to be regarded mainly as consequences of disturbed cerebral perfusion, and dementia as well as depression and drug adverse effects seem to be under-diagnosed in primary care.