[Entry into general practice training: no relation with focus on primary care in the undergraduate curriculum]. / Instroom in de huisartsenopleiding: geen verband met aandacht voor de eerste lijn in het basiscurriculum.

OBJECTIVE: To investigate differences between medical faculties in the proportion of graduates entering general practice (GP) training, and to analyse whether this is related to the degree of orientation towards general practice of Dutch medical undergraduate curricula. DESIGN: Retrospective cohort study. METHODS: Several databases were used to investigate which percentage of medical graduates per faculty entered the GP training programme between 1989 and 2001. The coordinators of general practice education in the undergraduate curriculum of the eight Dutch faculties of medicine filled in a questionnaire about the degree of orientation toward general practice of their curriculum and the extent to which medical students came into contact with primary care. RESULTS: The number of medical graduates per faculty in the period 1989-2001 varied between 1682 and 2443. On average, 23.5% of the students entered GP training. The medical faculties of Maastricht University, Radboud University Nijmegen and VU University Amsterdam showed the strongest orientation towards general practice. Leiden University, the University of Amsterdam and University of Groningen were the least oriented, and Utrecht University and Erasmus University Rotterdam were in between. There was no clear correlation between the orientation of the curriculum towards general practice and the percentage of medical graduates entering general practice training. CONCLUSION: There were small differences between faculties in the proportion of graduates entering a GP training programme during a 10-year period. Although there were differences between curricula in the degree of orientation towards general practice, this had little effect on the number of medical graduates entering general practice training. Presumably, other factors such as personal preferences and the employment situation are more important.

Early student-patient contacts in general practice: an approach based on educational principles.

BACKGROUND: Clinical teaching and learning is generally seen as an educationally sound approach, but the clinical environment does not always offer optimal conditions to facilitate students' learning processes. AIMS: To show how insights on constructing a good learning environment for student-patient contacts in real practice can be translated into an undergraduate clinical general practice programme in Year 3 and to study its feasibility. METHOD: Literature search, yielding starting points for the development of the new programme and questionnaire evaluation of the programme. RESULTS: Six starting points for a good learning environment for early student-patient contacts: continuing exposure to patients,transformation of experience into knowledge, active role of students, supervision and feedback, time and space for teaching and teacher training were translated into a the new programme. The evaluation showed that the programme was feasible and well received by students and GPs, although some improvements are possible. CONCLUSION: In a curriculum with clear goals for early student-patient contacts, it is feasible to implement an early clinical programme in general practice based on educational principles.

Vitalum study design: RCT evaluating the efficacy of tailored print communication and telephone motivational interviewing on multiple health behaviors.

BACKGROUND: A large proportion of adults fail to meet public health guidelines for physical activity as well as fruit, vegetable and fat intake. Interventions are needed to improve these health behaviors. Both computer tailoring and motivational interviewing have shown themselves to be promising techniques for health behavior change. The Vitalum project aims to compare the efficacy of these techniques in improving the health behaviors of adults aged 45-70. This paper describes the design of the Vitalum study. METHODS/DESIGN: Dutch general medical practices (N = 23) were recruited via a registration network or by personal invitation. The participants were then enrolled through these general practices using an invitational letter. They (n = 2,881) received a written baseline questionnaire to assess health behaviors, and potential psychosocial and socio-demographic behavioral determinants. A power analysis indicated that 1,600 participants who were failing to meet the guidelines for physical activity and either fruit or vegetable consumption were needed. Eligible participants were stratified based on hypertension status and randomized into one of four intervention groups: tailored print communication, telephone motivational interviewing, combined, and control. The first two groups either received four letters or took part in four interviews, whereas the combined group received two letters and took part in two interviews in turns at 5, 13, 30 and 43 weeks after returning the baseline questionnaire. Each letter and interview focused on physical activity or nutrition behavior. The participants also took part in a telephone survey 25 weeks after baseline to gather new information for tailoring. There were two follow-up questionnaires, at 47 and 73 weeks after baseline, to measure short- and long-term effects. The control group received a tailored letter after the last posttest. The process, efficacy and cost-effectiveness of the interventions will be examined by means of multilevel mixed regression, cost-effectiveness analyses and process evaluation. DISCUSSION: The Vitalum study simultaneously evaluates the efficacy of tailored print communication and telephone motivational interviewing, and their combined use for multiple behaviors and people with different motivational stages and education levels. The results can be used by policymakers to contribute to evidence-based prevention of chronic diseases. TRIAL REGISTRATION: Dutch Trial Register NTR1068.

The effect of alcohol intake on cardiovascular disease and mortality disappeared after taking lifetime drinking and covariates into account.

BACKGROUND: Current alcohol intake has been associated with cardiovascular morbidity and mortality. The effect of past and lifetime drinking has received less attention. In the present study, the impact of current, past and lifetime drinking on cardiovascular events and all-cause mortality has been assessed. Secondly, the effect of accounting for covariates within these relationships has been studied. METHODS: The Lifestyle and Health study is a prospective cohort study in 2 regions of the Netherlands. Men and women aged 45 to 70 years registered in 34 general practices were followed over the period July 1996 to June 2001. At baseline, an extensive questionnaire had to be filled in. It included 3 questionnaires about alcohol intake: a Weekly Recall, a Quantity-Frequency about last year, and the Lifetime Drinking History questionnaire. Health problems were registered by the general practitioners. RESULTS: During follow-up, 679 men and 397 women had a cardiovascular event and 330 men and 204 women died. Current drinking was associated with lower risks of cardiovascular events (women) and all-cause mortality (men and women) compared with never drinkers. The relationships were strongest for alcohol intake measured with the Weekly Recall. Lifetime alcohol intake and alcohol intake in the distant past did not seem to be related to all-cause mortality or cardiovascular events. Adjustments for covariates weakened the relationships. CONCLUSIONS: Potential positive effects of drinking seem to be of a transient nature, as lifetime drinking and drinking in the past could not be related to all-cause mortality or cardiovascular events. The alleged benefits of current drinking at baseline diminished with increasing methodological quality and rigor.

Coping style mediates impact of stress on alcohol use: a prospective population-based study.

AIMS: This study examines the relationship between stressful life-events and alcohol use in a longitudinal cohort study, and investigates whether gender, coping style and social support modify this relationship. DESIGN, SETTING AND PARTICIPANTS: Data analysed in this paper come from a sample of 1608 men and 1645 women drawn randomly from the cohort known as the Dutch Lifestyle and Health Study, consisting of 16,210 men and women aged 45-70 years, who were followed-up for 4 years (1996-2000). MEASUREMENT: Alcohol use (recent and in the more distant past), occurrence of threatening life-events, coping style (action, cognitive and emotion coping), social support (perceived, actual support and social contacts) and other potential confounding factors were assessed with five annual self-administered questionnaires. The data were analysed with a mixed-effects modelling technique, controlling for interactions with time and gender. FINDINGS AND CONCLUSION: An interaction effect was found between experiencing a negative life-event and emotion coping on alcohol use. A positive relationship was found between the occurrence of negative life-events and alcohol use in subjects scoring high on emotion coping, and a negative one among subjects scoring low on emotion coping. Cognitive coping, action coping, actual support, social contacts and gender did not modify the relationship between life-events and alcohol use. However, having a more cognitive coping style or more social contacts was associated with a lower level of alcohol use, whereas having an action coping style and receiving more actual social support was associated with a higher drinking level. It seems plausible that people scoring high on emotion coping, characterized by a passive, resigned, indulgent and self-accusatory coping style, increase their alcohol use after experiencing a negative life-event.

A literature overview of the relationship between life-events and alcohol use in the general population.

AIMS: A critical review of the evidence of effects of stressful life-events on alcohol use in the general population, with a particular focus on study design. METHODS: A literature search in Medline was conducted, covering the period from 1990 to 2005, to identify articles in which the relationship between life-events and alcohol use in the general population (i.e. non-problem drinking population) was investigated. Samples with a limited age range (e.g. college students) were excluded. Twelve studies with a cross-sectional design, and four articles with a longitudinal design were included in this review. RESULTS: Four cross-sectional studies found evidence that experiencing life-events is related to higher alcohol use, three other studies, however, found no such association. The relationship between specific life-events and alcohol use in the five remaining cross-sectional studies is less clear-cut. Being a victim of crime was associated with higher alcohol use, but divorce and financial problems were related to both higher and lower alcohol use. Health-related life-events were found to be associated with lower alcohol use. In studies with a longitudinal design, it was found that health-related life-events and financial problems caused a decrease in alcohol use, and life-events related to spouse, friends and relatives, and retiring led to an increase in alcohol use. CONCLUSIONS: Evidence points towards a relationship between the occurrence of life-events and alcohol use in the general population. The direction of the effect is, however, not unequivocal. When life-events are operationalized or categorized separately they are not only related to an increased alcohol use but also to a decreased alcohol use. Specification of the model to be tested, including buffering factors such as gender, social support, coping resources, as well as baseline consumption, is important for a correct estimation of the effect of negative life-events.

Follow-up care by patient's own general practitioner after contact with out-of-hours care. A descriptive study.

BACKGROUND: Little is known about the care process after patients have contacted a GP cooperative for out-of-hours care. The objective of this study was to determine the proportion of patients who seek follow-up care after contact with a GP cooperative for out-of-hours care, and to gain insight into factors that are related to this follow-up care. METHODS: A total of 2805 patients who contacted a GP cooperative for out-of-hours care were sent a questionnaire. They were asked whether they had attended their own GP within a week after their contact with the cooperative, and for what reason. To investigate whether other variables are related to follow-up care, a logistic regression analysis was applied. Variables that entered in this analysis were patient characteristics (age, gender, etc.) and patient opinion on correctness of diagnosis, urgency and severity of the medical complaint. RESULTS: The response rate was 42%. In total, 48% of the patients received follow-up care from their own GP. Only 20% were referred or advised to attend their own GP. Others attended because their medical condition worsened or because they were concerned about their complaint. Variables that predicted follow-up care were the patient's opinion on the correctness of the diagnosis, patient's health insurance, and severity of the medical problem. CONCLUSION: Almost half of all patients in this study who contacted the GP cooperative for out-of-hours care attended their own GP during office hours within a week, for the same medical complaint. The most important factor that predicted follow-up care from the patient's own GP after an out-of-hours contact was the patient's degree of confidence in the diagnosis established at the GP cooperative. Despite the limited generalisability, this study is a first step in providing insight into the dimension of follow-up care after a patient has contacted the GP cooperative for out-of-hours primary care.