Hawthorne effects and research into professional practice.

The Hawthorne studies in the 1930s demonstrated how difficult it is to understand workplace behaviour, and this includes professional performance. Studies of interventions to improve professional performance, such as audit, can provide useful information for those considering using such methods, but cannot replace judgement. In particular, there is no single phenomenon that can be labelled 'the Hawthorne effect'. The process of triangulation, considering a subject from different perspectives, might overcome the problems of Hawthorne effects better than using a single method such as controlled trials.

Audit in British general practice: domination or disillusionment?

The history of audit is traced over the past 30 years demonstrating how it has come to dominate attempts to improve the quality of patient care in British general practice. Nevertheless it is still uncertain whether audit usually or occasionally yields such improvements. There is much more to learn about audit including whether any benefits it brings are through professional education. I suggest that the use of audit as a foundation upon which clinical governance is built is not a secure one.

Auditing palliative care in one general practice over eight years.

OBJECTIVE: To document the delivery and outcome of palliative care in one practice. DESIGN: All appropriate deaths were documented over the period of the study. SETTING: One general practice of four doctors caring for 8000 patients in the North-West of England. SUBJECTS: All patients dying of malignant disease which had included a palliative phase of at least one week. MAIN OUTCOME MEASURES: Place of death; continuity of care; general practitioners' assessment of symptom relief; follow-up of bereaved relatives. RESULTS: 118 deaths from terminal malignant disease were recorded over eight years in my practice. 75% were being cared for by us (GPs) at the time of death. More detailed information was recorded on 64 of these patients showing generally "satisfactory" care. CONCLUSIONS: A simple audit can help maintain high standards of palliative care. General practitioners are encouraged to maintain registers of the care received by terminally-ill patients as an aid to quality assurance in this area.

Benzodiazepine prescribing and withdrawal for 3234 patients in 15 general practices.

Benzodiazepines are still widely prescribed in general practice, despite repeated warnings about the problems associated with their use. Other studies have shown that a variety of interventions can reduce prescribing, but these have been restricted to relatively few general practices or patients. We co-ordinated an audit of benzodiazepine prescribing and withdrawal in 15 practices caring for 87,900 patients across a district. In total 3234 patients (37 per 1000 registered patients) were discovered to be taking the drugs at the start of the programme, and 16% of these people stopped taking the drugs by the conclusion of the audit 8 months later. There was no relation between success at benzodiazepine cessation and initial levels of prescribing, nor with practice size. Younger patients were significantly more likely to stop benzodiazepines than those over the age of 65.

General practitioners and work in the Third World.

In recent years the number of general practitioners who have worked in the third world before entering general practice has fallen. The reasons for this are not clear but may include worries about future career prospects. Ninety four doctors who had entered general practice since 1984, after previously working in the third world, completed a questionnaire about their career experience and views about the value of such work. They were generally widely experienced and well-qualified and work abroad had not apparently harmed their careers, rather, many believed it had enhanced it. Work in the usually arduous conditions of poor countries was often considered by the respondents to lead to a wider perspective, increased maturity, confidence, self-reliance, adaptability and initiative. Doctors who are interested and suitable for work in the third world prior to entering general practice should be encouraged to pursue this possibility.

Benefits and risks of childhood immunisations in developing countries.

The ratio of benefit to harm from an imaginary, modest immunisation programme in a developing country and the numbers of lives likely to be saved and severe handicaps prevented have been estimated. Immunisation is much more likely to benefit children than to harm them, and health workers can be confidently encouraged not to withhold the benefits of immunisation from most children.

PIP: The ratio of benefit to harm an imaginary, modest immunization program in a developing country and the numbers of lives likely to be saved and severe handicaps prevented are estimated. Immunization is much more likely to benefit children than to harm them, and health workers can be confidently encouraged not to withhold the benefits of immunization from most children. The UN target date for immunization to be available to all the world's children is 1990. Benefits and risks of a typical program in a developing country are calculated for diphtheria, tetanus, pertussis, polio, and measles. Such a program could be expected to save about 45 lives a month and prevent about 12 children being left with a serious handicap each month. In contrast it may cause 1 death over 22 years and 1 serious handicap every 7 1/2 years.