Discussing STIs: doctors are from Mars, patients from Venus.

BACKGROUND: Primary care plays an important role in promoting sexual health, but in this setting counselling regarding sexually transmitted infections (STIs) is rarely performed and often inadequate. OBJECTIVE: Our aim was to identify and quantify the barriers physicians encounter in discussing STIs with their patients. METHODS: A postal questionnaire-based survey was carried out in a random sample of 200 primary care physicians in Antwerp, Belgium. RESULTS: The response rate was 68%. Among the 122 respondents, only 44.3% provide some form of counselling (asking about sexual history, informing about safe sex or informing about STIs) regularly, at least once a week. Major barriers are language and comprehension problems (for 74.2% of respondents), ethnic differences (68.4%), insufficient training (69.4%), lack of time (60.8%), presence of the patient's partner (89.2%) or mother (94.2%), first contact with a patient (60.8%), fear of embarrassing the patient (30.6%) and a patient without genital complaints (71.4%). About half of the GPs fail to counsel an asymptomatic patient with obvious STI risk, and as many give no safe sex advice in a first contraception consultation. CONCLUSIONS: Physicians have many and various barriers to discussing STIs with their patients. Features of contemporary STI counselling and solutions to its problems are discussed. Education of health care providers should be given priority.

The impact of feminisation on general practice.

For centuries the medical world was exclusively a male domain. This is gradually changing all over the world. The first part of the article provides figures demonstrating that the number of women in general practice has significantly increased. This part also provides the most recent figures for Belgium. The feminisation has an important impact on "service volume". Female physicians will produce fewer medical services than men. Moreover, whilst many young physicians in different European countries leave the profession after some time, this phenomenon is more prevalent among female than male general practitioners. In the second part the impact of feminisation at the qualitative level is considered from three points of view: at the level of care: are women changing primary health care? at the level of attitudes: do women have different interaction styles? at the level of organisation: do women have an impact on the way medical practices/surgeries are organised? We conclude that feminisation can play an important role in the shortage of general practitioners in the future. This is a serious problem because many countries have placed responsibility for primary care with general practitioners. For the qualitative aspects women contribute to the introduction of favourable developments in medicine. Finally a number of points of attention and recommendations are given in the framework of the faculties' "emancipatory potential" and for making sound policy in the men/women power planning for health governments.

Patient adherence to treatment: three decades of research. A comprehensive review.

Low compliance to prescribed medical interventions is an ever present and complex problem, especially for patients with a chronic illness. With increasing numbers of medications shown to do more good than harm when taken as prescibed, low compliance is a major problem in health care. Relevant studies were retrieved through comprehensive searches of different database systems to enable a thorough assessment of the major issues in compliance to prescribed medical interventions. The term compliance is the main term used in this review because the majority of papers reviewed used this term. Three decades have passed since the first workshop on compliance research. It is timely to pause and to reflect on the accumulated knowledge. The enormous amount of quantitative research undertaken is of variable methodological quality, with no gold standard for the measurement of compliance and it is often not clear which type of non-compliance is being studied. Many authors do not even feel the need to define adherence. Often absent in the research on compliance is the patient, although the concordance model points at the importance of the patient's agreement and harmony in the doctor-patient relationship. The backbone of the concordance model is the patient as a decision maker and a cornerstone is professional empathy. Recently, some qualitative research has identified important issues such as the quality of the doctor-patient relationship and patient health beliefs in this context. Because non-compliance remains a major health problem, more high quality studies are needed to assess these aspects and systematic reviews/meta-analyses are required to study the effects of compliance in enhancing the effects of interventions.

Effectiveness of basic clinical skills training programmes: a cross-sectional comparison of four medical schools.

OBJECTIVE: Training in physical diagnostic skills is an important part of undergraduate medical education. The objective of this study was to study the outcome of skills training at four medical schools. CONTEXT: At the time of the study, three schools had a traditional lecture-based curriculum and one school had a problem-based learning curriculum with a longitudinal skills training programme. All schools offer extended exposure to clerkships. METHOD: A cross-sectional study in four medical schools was performed, using a written test of skills that has good correlation with actual student performance. The scores attained from four student groups were compared within and between the four medical schools. A total of 859 volunteer students from the later four years at each medical school participated in the study. RESULTS: The mean scores in the traditional medical schools increased with the start of skill training and the hands-on experience offered during the clerkships. Students from the school with the longitudinal skills training programme and the problem-based learning approach had significantly higher mean scores at the start of the clerkships, and maintained their lead in the subsequent clinical years. CONCLUSIONS: Longitudinal skills training seems to offer the students a superior preparation for clerkships as well as influencing the students' learning abilities during the clerkships. The effect of the problem-based learning approach, also related to the innovative philosophy of the curriculum, could not be accounted for.

Lower incidence of the upper respiratory tract infections among general practitioners as compared to their patients.

A retrospective cohort study suggest that general practitioners (GPs) run a significant reduced risk (more then 50%) to develop an upper respiratory tract infection (URTI) with fever compared to their patients. This difference can't be explained by variables such as gender, age, children and particularly young children, vaccination against influenza, presence of chronic illness or allergies, medication taken on a regular basis, smoking habits and regular physical exercise.

Diagnosis and treatment of type 2 diabetes in three Belgian regions. Registration via a network of sentinel general practices.

BACKGROUND: The objective of this descriptive study is to investigate the incidence of type 2 diabetes in sentinel general practices in three regions in Belgium and to describe the patient characteristics and the start of the medical management after diagnosis. METHODS: For two successive years all patients who were newly diagnosed with type 2 diabetes were registered. Two weeks after inclusion, the registering physician completed an extensive questionnaire. This questionnaire dealt with risk factors, biochemical parameters, existing complications and treatment. RESULTS: According to this study, the yearly incidence of type 2 diabetes in Belgium is 231 per 100,000 inhabitants. Though the biochemical parameters (BMI, HbA1c, serum cholesterol and triglycerides) do not differ in the three regions of the country being investigated, there are considerable differences in the treatment prescribed for diabetes and its co-morbidity. In Flanders, treatment is usually started with sulphonylurea, in the Walloon provinces with biguanides. Hypolipaemic treatment is also started more frequently in the latter region. In Flanders, hypertension is registered in 51.4% of the newly diagnosed patients with diabetes, which is higher than in the other regions. However, no difference is noted between the different regions in the number of patients with diabetes who are treated for hypertension. CONCLUSION: A network of sentinel physicians, taking part in voluntary registration, can be helpful in calculating the incidence of a health problem, in particular type 2 diabetes in general practice. The sentinel net can also serve as an instrument for describing patient characteristics and showing how physicians deal with health problems. The regional differences in medical approach that are described require further investigation, mainly with respect to their impact on the patients' outcome.

Antibiotics for coughing in general practice: a qualitative decision analysis.

BACKGROUND: In family practice, medical decisions are prompted most often by complaints about coughing. There is no single yardstick for the differential diagnosis of respiratory tract infections (RTIs). In 80% of cases, the excessive use of antibiotics in the treatment of RTIs is caused by the prescription behaviour of GPs. OBJECTIVE: Our aim was to explicate GPs' diagnostic (and therapeutic) decisions regarding adult patients who consult them with complaints about coughing, and to investigate what determines decision making. METHODS: Exploratory, descriptive focus groups were held with GPs. Hypotheses were generated on the basis of 'qualitative content analysis'. Results. Twenty-four GPs participated in four semi-structured group discussions. In order to differentiate RTIs from other possible diagnoses, less likely diagnoses were not ruled out explicitly. In the case of suspected RTI, there was a low degree of certainty in the differentiation between RTIs (e.g. between bronchitis and pneumonia). Clinical signs and symptoms, which determine the probability of disease, often left GPs with reasonable diagnostic doubt. In the end, the decision whether or not to prescribe antibiotics was taken. GPs' prescription behaviour was also determined by doctor- and patient-related factors (e.g. having missed pneumonia once, patient expectations). The 'chagrin factor' explains why these factors lead to a shift in the action threshold, in favour of antibiotics. CONCLUSION: This inductive research method enabled the generation of meaningful hypotheses regarding the complex decision processes pursued by GPs. The authors are developing an educational intervention that builds on these findings, focusing on the prescribing decision.

An evaluation study of the didactic quality of clerkships.

CONTEXT: Previous qualitative research at the University of Antwerp revealed dissatisfaction amongst medical students about clinical clerkships. OBJECTIVE: To use quantitative methods to further explore student perceptions of their clinical teaching. METHOD, SAMPLE AND SETTING: Monthly questionnaire administered to final-year medical students at the University of Antwerp, Belgium. RESULTS: The response rate was 83.9%. Many of the qualitative findings were reproduced. Educational resources were not optimally used. The junior doctor was the most important clinical teacher. Many activities were passive experiences. Coaching, feedback and supervision associated most with general satisfaction of the clerkship, however, these dimensions were often considered suboptimal. CONCLUSIONS: Clinical clerkships do not automatically provide an ideal learning environment for medical students.

Contraceptive knowledge and expectations by adolescents: an explanation by focus groups.

To determine the needs and expectations of adolescent girls concerning contraceptive use as well as their attitude to health care providers, a qualitative research was performed with four focus groups of 17-year-old girls of different education levels. All 26 girls except one were of Belgian origin. There was a fixed scenario for each group. The discussions were tape-recorded, transcribed and analysed via content analysis. Knowledge concerning the daily use and side-effects of contraceptives was insufficient. A school physician is not the person they want to talk to. The influence of the peer in the group is very important. The general practitioner is the most frequently consulted health care provider for the first pill prescription, but for a gynaecological examination they thought they had to visit a gynaecologist. The girls expected confidentiality from their general practitioner and wanted sufficient consultation time. Factors inhibiting the visits for obtaining contraceptives were the cost, waiting time and fear of the gynaecological examination. Adolescents intended to visit their general practitioner for contraceptives, but the family practice had to be easily accessible. It is a challenge for general practitioners to provide good contraceptives to adolescents and to promote compliance.