Antibody landscape of C57BL/6 mice cured of B78 melanoma via immunotherapy.

Hoefges et al. utilized a whole-proteome peptide array approach to show that C57BL/6 mice develop a large repertoire of antibodies against linear peptide sequences of their melanoma after receiving a curative immunotherapy regimen consisting of radiation and an immunocytokine. Antibodies can play an important role in innate and adaptive immune responses against cancer, and in preventing infectious disease. Flow cytometry analysis of sera of immune mice that were previously cured of their melanoma through a combined immunotherapy regimen with long-term memory showed strong antibody-binding against melanoma tumor cell lines. Using a high-density whole-proteome peptide array, we assessed potential protein-targets for antibodies found in immune sera. Sera from 6 of these cured mice were analyzed with this high-density, whole-proteome peptide array to determine specific antibody-binding sites and their linear peptide sequence. We identified thousands of peptides that were targeted by 2 or more of these 6 mice and exhibited strong antibody binding only by immune, not naive sera. Confirmatory studies were done to validate these results using 2 separate ELISA-based systems. To the best of our knowledge, this is the first study of the "immunome" of protein-based epitopes that are recognized by immune sera from mice cured of cancer via immunotherapy.

Somatisation disorder and its associated factors in multiethnic primary care clinic attenders.

BACKGROUND: Somatisation disorder (SD) has been reported as common in all ethnic groups, but the estimates of its prevalence have varied and the evidence for its associated factors has been inconsistent. PURPOSE: This study seeks to determine the prevalence of SD and its associated factors in multiethnic primary care clinic attenders. METHODS: This cross-sectional study was on clinic attenders aged 18 years and above at three urban primary care clinics in Malaysia. The operational definition of SD was based on ICD-10 criteria for SD for research, frequent attendance, and excluded moderate to severe anxiety and depression. The instruments used were the ICD-10 symptom list, the Hospital Anxiety and Depression Scale, a semi-structured questionnaire, and SF-36. RESULTS: We recruited 1,763 patients (response rate 63.8%). The mean age of respondents was 44.7 ± 15.8 years, 807 (45.8%) were male; there were 35.3% Malay, 30.1% Chinese and 34.6% Indian. SD prevalence was 3.7%; the prevalence in Malay was 5.8%, Indian 3.0% and Chinese 2.1%. Significant associations were found between SD prevalence and ethnicity, family history of alcoholism, blue-collar workers and the physical component summary (PCS) score of SF-36. Multivariate analysis showed that SD predictors were Malay ethnicity (OR 2.7, 95% CI 1.6, 4.6), blue-collar worker (OR 2.0, 95% CI 1.2, 3.5) and impaired PCS score of SF-36 (OR 0.92, 95% CI 0.90, 0.95). CONCLUSION: The prevalence of SD was relatively uncommon with the stringent operational criteria used. SD preponderance in blue-collar workers may be attributable to secondary gain from getting sickness certificates and being paid for time off work.

Perceptions of the causes of childhood disability among Pakistani families living in the UK.

It has been well documented that South Asian families caring for a child with a disability experience discrimination and disadvantage in accessing health and social care services. This gives increasing cause for concern as the number of South Asian people with severe learning impairments in the UK continues to rise. Mainstream services are ill-equipped to provide individual services to parents who choose to define and address disability differently, and whose concerns and solutions may differ from the majority population, despite the fact that these parents possess many strengths and may present alternative ways of addressing their needs. This study aimed to provide a detailed account of the ways that Pakistani parents living in a northern city in the UK and caring for a child with a disability, account for and understand their child's disability. Sixteen in-depth interviews were carried out between October 2002 and July 2003, with Pakistani parents and one grandparent of children with a disability. All final transcripts were in English, and a thematic analysis was undertaken. Results include a detailed account of parents' understanding of the causes of their child's disability. All parents made reference to theological explanations as to why they had a child with a disability; however, most parents also gave biomedical or other explanations. The relationship between theological and biomedical explanations was explored along with the consequences of the different beliefs for individuals and families. Parents also spoke vividly about the impact of negative and stigmatizing beliefs about causes of disability which they felt were prevalent in the Pakistani community, and they used a biomedical discourse to refute these ideas. The authors suggest that knowledge of individual and family beliefs, and awareness of the impact of these beliefs, can provide a valuable conceptual lens for health and social care practitioners to use when working in family-centred, culturally congruent ways with parents.

A comparison of sexual satisfaction and post-natal depression in the UK and Taiwan.

AIM: To compare the sexual expression and sexual satisfaction of women in the UK and Taiwan before and after childbirth, to determine if there is an association between self reported sexual satisfaction and postnatal depression (PND) and the main sources of sexual information for women during this period. METHOD: A comparative survey of postnatal women in the UK and Taiwan using a selfadministered questionnaire, a semi structured interview and the Edinburgh Postnatal Depression Scale (EPDS) to investigate sexual satisfaction, sexual expression and main sources of information as well the prevalence of postnatal depression. RESULTS: Seventy per cent of the UK women and 89% of the Taiwanese women were generally satisfied with their sex life during the postnatal period although in both countries women thought that sexual expression was not as important to themselves as to their partner. There were differences in ranking criteria for physical and emotional sexual satisfaction in the two countries. Eighty-three per cent of UK women had sufficient information about sex during the postnatal period compared to 60% of Taiwanese women. There was no significant difference in the prevalence of PND (18% UK, 19% Taiwan p < 0.01 ANOVA) but significant negative associations (correlation coefficient) between 'sexual self-confidence' and PND in the UK (p < 0.01) and Taiwan (p < 0.05). UK Women with an unsatisfactory sex life (p < 0.05), insufficient sexual information (p < 0.05) and sexual worries after birth (p < 0.05) were more likely to have symptoms of PND. There was a strong association between a poor relationship with her partner and PND (p < 0.001). CONCLUSIONS: These associations may be either a consequence of or a contributing factor to PND. The observed differences between the two countries may be attributed to cross cultural factors and differences in health care systems although further investigation is required.

Young people of minority ethnic origin in England and early parenthood: views from young parents and service providers.

The paper explores the phenomenon of early parenthood in minority ethnic communities in England. The data were collected using focus group interviews, in-depth semi-structured interviews and a telephone survey. The sample consisted of 139 participants (41 service providers, 10 grandmothers, 88 young parents). The findings map out the complexity and diversity of experience of early parenthood amongst young people of minority ethnic origin, not least the multiple attachments many experience in relation to their social groups, religious affiliations and the traditional patterns of parenting within their immediate and extended family. Both the young parents and professionals in this study constructed early parenthood in more positive terms than is currently portrayed in the contemporary policy. The findings are analysed and discussed in relation to ethnic identity, social inclusion and exclusion. We explore participants' attempts to counter negative 'deficit' models of early parenthood with reference to perspectives on youth, parenthood and contemporary strategic policy. In conclusion, we suggest an unambiguous focus on the reduction of pregnancy is not a credible message when teenage pregnancy is a social norm for a particular ethnic or cultural group. For young parents of Muslim faith in particular, teenage parenting within marriage is not necessarily considered a 'problem' or seen as a distinctive event. Most participants did not view early parenthood as a barrier to re-establishing career and educational aspirations. A wide diversity of experience amongst young parents is evidenced in the communities studied; this needs to be reflected more comprehensively both in UK policy and in support services.

Computer interviewing in urogynaecology: concept, development and psychometric testing of an electronic pelvic floor assessment questionnaire in primary and secondary care.

OBJECTIVE: To develop and evaluate a Web-based, electronic pelvic floor symptoms assessment questionnaire (e-PAQ)1 for women. DESIGN: A cross-sectional study in primary and secondary care. SETTING: Two general practices, two community health clinics and a secondary care urogynaecology clinic. SAMPLE: A total of 432 women (204 in primary care and 228 in secondary care) were recruited between June 2003 and January 2004. METHODS: The e-PAQ was located on a workstation (computer, touchscreen and printer). Women completed the e-PAQ prior to their appointment. Untreated women in primary care were asked to return seven days later to complete the e-PAQ a second time (test-retest). MAIN OUTCOME MEASURES: Factor analysis, reliability, validity, patient satisfaction, completion times and system costs. RESULTS: In secondary care, factor analysis identified 14 domains within the four dimensions (urinary, bowel, vaginal and sexual symptoms) with internal consistency (Cronbach's alpha)>or=0.7 in 11 of these. In primary care, alpha values were all>or=0.7 and test-retest analysis found acceptable intraclass correlations of 0.50-0.95 (P<0.001) for all domains. A measure of face validity and utility was gained using a nine-item questionnaire, which yielded strongly positive patient views on relevance and acceptability. CONCLUSIONS: The e-PAQ offers a user-friendly clinical tool, which provides valid and reliable data. The system offers comprehensive symptoms and quality of life evaluation and may enhance the clinical episode as well as the quality of care for women with pelvic floor disorders.

Psychological treatment for insomnia in the regulation of long-term hypnotic drug use.

OBJECTIVES: To evaluate the clinical and cost impact of providing, in routine general practice settings, a cognitive-behaviour therapy (CBT) package for insomnia to long-term hypnotic drug users with chronic sleep difficulties; and to identify factors associated with variations in clinical outcomes. DESIGN: A pragmatic cluster randomised controlled trial with two treatment arms (a CBT-treated 'sleep clinic' group, and a 'no additional treatment' control group), with post-treatment assessments starting at 3, 6 and 12 months. SETTING: Twenty-three general practices in Sheffield, UK. PARTICIPANTS: In total, 209 patients (aged 31-92 years) with chronic sleep problems who had been receiving repeat hypnotic drug prescriptions for at least 1 month (mean = 13.4 years) were recruited into the trial. INTERVENTIONS: The intervention consisted of six 50-minute sessions as follows: introduction and sleep assessment, basic sleep hygiene, stimulus control and sleep restriction procedures, progressive relaxation, cognitive treatments, and review and discharge. MAIN OUTCOME MEASURES: These included: global sleep quality [as measured by the Pittsburgh Sleep Quality Index (PSQI)], frequency of hypnotic drug use, mean dose of hypnotics consumed, health-related quality of life [as measured by the Short-Form 36 (SF-36)], NHS service costs and overall cost utility. RESULTS: At 3- and 6-month follow-ups, patients treated with CBT showed improved global PSQI scores as well as improvements in the SF-36 dimensions of vitality at 3 months and physical functioning and mental health at 6 months. CBT-treated patients also reported reductions in the frequency of hypnotic drug use compared with the control group, with many CBT-treated patients reporting zero drug use at the follow-up assessments. Clinical improvements were maintained within the CBT group at the 12-month follow-up, with PSQI scores and the frequency of hypnotic drug use continuing to show significant reductions relative to the control group. Multiple regression analyses of PSQI scores within the sleep clinic group alone indicated that the magnitude of pre- to post-treatment change in overall sleep quality was closely related to Hospital Anxiety and Depression Scale depression scores at 3-, 6-and 12-month follow-ups. In each model higher depression scores at baseline were associated with poorer treatment outcomes. No significant relationship was found between the patient's age and PSQI outcomes in any of these analyses. Within the sleep clinic group, reductions in drug use showed no significant association with the hypnotic product consumed. At the 3-month follow-up low-frequency drug use was reported by 22.9% (8/35) of temazepam users, 33.3% (5/15) of nitrazepam users and 38.9% (7/18) of zopiclone users. The total cost of service provision was GBP154.40 per patient (1999/2000 prices). The mean incremental cost per quality-adjusted life-year (QALY) at 6 months was GBP3418; this figure was insensitive to changes in costs. A simple model also showed that extending the evaluation period beyond 6 months may improve the cost-effectiveness of CBT. The incorporation of hidden costs associated with hypnotic drug treatment (e.g. accidents) also reduces the cost per QALY ratio, although to a much lesser degree. CONCLUSIONS: In routine general practice settings, psychological treatment for insomnia can improve sleep quality, reduce hypnotic drug use, and improve health-related quality of life at a favourable cost among long-term hypnotic users with chronic sleep difficulties. These positive outcomes appear robust over time, persisting for at least 1 year among the more treatment-adherent patients. While these benefits may be reduced among those patients presenting with higher levels of psychological distress, the present study clearly indicates that older age per se presents no barrier to successful treatment outcomes. Further research should assess the long-term clinical and cost-effectiveness of psychological treatments for insomnia among non-hypnotic-using patients, and establish the minimum psychological treatment input required.

Residential rehabilitation for drug users: a review of 13 months' intake to a therapeutic community.

BACKGROUND: Residential rehabilitation based on 'therapeutic community' treatment for drug users is a treatment option which is attractive to GPs and others referring drug users for treatment. Whilst there is evidence that maintenance-based programmes for drug users are effective, there have been fewer attempts to evaluate the effectiveness of abstinence-based programmes which are relatively more intensive and expensive interventions. OBJECTIVE: This paper reports and evaluates the outcomes for 13 months' intake of 138 drug users to a residential community. METHODS: We carried out a retrospective cohort study using existing clinical and residential record data. The setting is a residential rehabilitation centre run by the charity Phoenix House in Sheffield, UK, offering a 1-year programme for heroin addicts including community detoxification overseen by primary care specialist doctors and residential rehabilitation. Participants were all patients who entered treatment between 1 February 1998 and 28 February 1999 inclusive. An analysis was carried out of clinical records and other records kept by clinicians and staff at the centre. Outcome measures were numbers of days of retention in treatment and reasons for departure, categorized as completed treatment, planned or unplanned departure and expulsion from the programme. For patients who underwent in-house detoxification, a further outcome measure was whether or not detoxification was complete at discharge. RESULTS: Heroin was the main drug of abuse in 85% of admissions. Mean length of time for which individuals had been drug dependent was 8 years (range 1.3-20.1 years). The mean length of stay was 80.2 days (range 1-394, 95% confidence interval 61.8-98.6). Thirty-four individuals (25%) completed 90 days or more. No association was found between length of stay and age, sex, route of administration, polydrug use, length of time addicted or age of first addiction. Sixty-five per cent of those who received in-house detoxification completed the detoxification period. When patients were classified as 'successes' or 'failures' by reason for departure from the programme, 94 (68.1%) were classified as failures and 18 (13.0%) as successes. Data were unavailable for 26 patients. Success was not associated with any characteristic at entry apart from being drug free as opposed to requiring detoxification (P = 0.048, chi-square = 6.06, df = 2). CONCLUSION: This study shows overall low levels of programme completion and high levels of unplanned departure and eviction from the programme amongst these long-term drug users. On the other hand, the importance of abstinence for those who achieve it in residential rehabilitation should not be underestimated, nor should the possibility that long-term outcomes are influenced by the learning process involved in the intervention. It may be possible to operate better selection procedures in order to optimize outcomes.

Deaths from drugs of abuse in Sheffield, 1998: the role of prescribed medication.

Characteristics of recent drug abuse-related deaths in the city of Sheffield were examined from the coroner's records. Almost all of those who died of poisoning from a drug of abuse were known to be dependent on heroin yet less than half were receiving treatment. Benzodiazepines were frequently detected alongside opiates during toxicology, the source of which was likely to be the deceased's own prescription.

Supporting GPs whose performance gives cause for concern: the North Trent experience.

BACKGROUND: The North Trent scheme to address the problem of GPs whose performance gives cause for concern was implemented in 1997. This paper describes the structure and process of the scheme and evaluates the main outcomes. METHODS: We used non-participant observation and semi-structured interviews with representatives of the seven Health Authorities (HAs) of North Trent including medical and prescribing advisors and senior primary care managers. Twenty-one GPs who were members of the Performance Review Quartets (PRQs) were also interviewed. Qualitative data were analysed using a constant comparative method to identify emergent themes. RESULTS: Performance indicators were agreed between HAs and the profession in the seven North Trent localities. The scheme identified 18 GPs whose performance gave cause for concern, of whom 15 GPs in six practices received a formal visit. Educational plans were agreed and implemented with three GPs. The remaining 12 received administrative and clinical support. Three of the 18 GPs initially refused to co-operate with the scheme. Two of these have since agreed a practice visit following a visit by a senior local medical committee representative. The performance indicators used in the scheme have not been specific to individual GPs except those in single-handed practices. Some indicators used by PRQs related to cost effectiveness rather than quality of care for individual patients. Current resources were adequate for the small number of underperforming GPs identified by the scheme. CONCLUSIONS: The North Trent scheme has identified a number of underperforming GPs, 83% of whom have been willing to participate in a supportive intervention. The scheme will need some modification with the advent of primary care trusts and the proposed assessment and support centres.

Postnatal depression -- biological or cultural? A comparative study of postnatal women in the UK and Taiwan.

AIM: The aim of the study was to compare the factors which are associated with postnatal depression in the UK (United Kingdom) and Taiwan. BACKGROUND/RATIONALE: A comparative study of postnatal women in the UK and Taiwan was undertaken to investigate postnatal care and the prevalence of postnatal depression. DESIGN/METHODS: The Edinburgh Postnatal Depression Scale (EPDS) was used to determine the prevalence of postnatal depression. A semistructured interview and validated questionnaire were used to collect data on maternal satisfaction with postnatal care and the factors associated with postnatal depression. A one in three random sample of women from two community midwife teams in Sheffield, UK and three public health stations in Keelung, Taiwan took part in the study. RESULTS/FINDINGS: Fifty (94% response rate) women from Sheffield and 101 (83% response rate) women from Keelung, who were at low risk for maternal or foetal problems during labour and the postnatal period, agreed to participate. The prevalence of postnatal depression in the British and Taiwanese women was almost equal; 18% in the UK and 19% in Taiwan. In Taiwan, the prevalence of postnatal depression had a negative association with relationship with partner (Spearman correlation=-0.34, P < 0.001) and self-confidence (Spearman correlation=-0.28, P < 0.01, Spearman correlation). In addition Taiwanese women who felt more anxious after birth (10.9 +/- 7.9, P < 0.001, t-test) had a higher chance of postnatal depression. In the UK, there was a significant negative association between adaptation to the new role of motherhood and score on the EPDS (Spearman correlation=-0.47, P < 0.001). The overall scores for maternal satisfaction were 28.1 and 24.3 in the UK and Taiwan, respectively (P < 0.001, t-test). British women reported a better quality of care during the postnatal period in terms of emotional support and physical care. CONCLUSIONS: The findings of this study suggest that further cross cultural investigation could shed light on the relative balance of biological and cultural factors which may be associated with the onset of postnatal depression. As the prevalence of postnatal depression is similar in both cultures despite large differences in culture and postnatal care systems, some support is given to a hypothesis that postnatal depression has at least some biological determinants as well as cultural/social ones.

Keeping families of heroin addicts together: results of 13 months' intake for community detoxification and rehabilitation at a family centre for drug users.

BACKGROUND: Heroin addiction is a major public health problem affecting both the addicted individuals and their children, who have been shown to have poor social, educational and health status and to be at higher risk of abuse than their peers. Whilst the antenatal effects of parental drug use and the overall poor outcomes for these children have been widely studied, there has been little emphasis on the effectiveness of treatment interventions and even less emphasis on evaluating the effect on children of the standard treatments aimed at their parents' drug use. OBJECTIVES: The aim of the present study was to evaluate the effect on heroin-addicted parents and their children of a family-based drug treatment intervention using a records-based methodology, and to identify any factors at admission which may influence outcome. This study is a pilot for a prospective Europe-wide study using a similar methodology prospectively in several treatment modalities. METHODS: A retrospective cohort study was carried out using existing clinical and residential record data. The setting was a residential family centre run by the charity Phoenix House in Sheffield, UK, offering a 6-month (180 days) family-based programme for heroin addicts including community detoxification overseen by primary care specialist doctors and residential rehabilitation. All adults and children who entered the centre between July 1997 and July 1998 were included in the study (26 adults and 33 children, in 23 family groups). An analysis was made of clinical records and records kept on the adults and children by the clinicians and staff at the centre. The main outcome measures for the adults were length of stay and reason for departure (treatment complete, early planned discharge, unplanned discharge, eviction); and for the children were reason for departure and discharge destination (with parent or taken into care). RESULTS: Mean length of stay was 110 days, and only 11 children (33%) and nine adults (35%) completed 150 days or more. Length of stay was found to be significantly correlated with parental age at admission (P < 0.01). Twelve children (37%) and nine adults (35%) were deemed to have completed treatment successfully. Of the remainder, 14 children (42%) and 11 adults (42%) left because of definite treatment failure. Successful treatment completion was found to be correlated with increased parental age (Pearson's r = 0.612, P = 0. 001). Poly-drug users were significantly less likely to complete treatment successfully (Fisher's exact test, P = 0.012). Twenty children were in the care of their parents on admission, and 24 were able to go home with their parents. There was no association between residence with parents pre- and post-admission (McNemar's chi-squared test = 1.6, P > or = 0.1). CONCLUSIONS: Whilst overall high rates of treatment success are not expected in abstinence-based programmes, the outcomes for the adults in this setting are comparable with published results in other residential settings, and there is some evidence that some families may have stayed together who might otherwise have been separated. Older adults who were not poly-drug users had significantly better outcomes. The records-based methodology proved successful, but centres need to keep detailed and preferably long-term records on children if their outcomes are to be evaluated more fully.

Can methadone maintenance for heroin-dependent patients retained in general practice reduce criminal conviction rates and time spent in prison?

A retrospective analysis was made of the criminal records of 57 patients successfully retained in methadone maintenance at two general practices in Sheffield. Their criminal conviction rates and time spent in prison per year were compared for the periods before and after the start of their methadone programme. Overall, patients retained on methadone programmes in the general practices studied had significantly fewer convictions and cautions, and spent significantly less time in prison than they had before the start of treatment.

Portfolios in continuing medical education--effective and efficient?

INTRODUCTION: A cross over comparison between 'traditional' continuing medical education (CME) activities and portfolio-based learning in general practice is described. METHOD: Thirty-two volunteer general practitioners (GPs) were divided into two cohorts; each cohort spent six months following a 'traditional' route to postgraduate educational accreditation (PGEA) and six months following a portfolio-based learning route supported by three CME tutors. OUTCOME MEASURES: These were the submission of a completed portfolio with evidence of the completion of learning cycles and participants reflections on the educational process. Qualitative and quantitative evaluation data were collected by questionnaire, semi-structured interview, participant observation and review of completed portfolios. RESULTS: The themes identified by GPs as hopes for the portfolios were largely fulfilled and the anxieties generally confounded. The flexibility of the portfolio learning process was particularly important to the participants. The breadth of topics covered by the portfolios was extremely wide and comparison with the submissions for 'traditional' PGEA showed a much smaller spread of learning activities and fewer subjects of study. EFFECTIVENESS: The use of the portfolios of critical incidents and the completion of learning cycles with application to practice provided evidence of the effectiveness of such learning. EFFICIENCY: The mean number of hours spent by GPs preparing the portfolios was 24.5 +/- 12 (SD) which was significantly more than the 15 hours of PGEA awarded. CONCLUSIONS: This study demonstrates that a portfolio-based learning scheme can meet the needs of GPs relevant to their professional practice; it can give learners control over how, what and when they learn and encourage active and peer-supported learning; it can build personal and professional confidence and be thought both valid and reliable by participants. Learning outcomes can also be reliably assessed by PGEA within the context of an individually created learning plan.

Empowering research: statistical power in general practice research.

BACKGROUND: Statistical power is a measure of the extent to which a study is capable of discerning differences or associations which exist within the population under investigation, and is of critical importance whenever a hypothesis is tested by statistics. Conventionally, studies should reach a power level of 0.8, such that four times out of five a false null hypothesis will be rejected by a study. Statistical power may most easily be increased by increasing sample size. OBJECTIVE: We aimed to assess the level of statistical power of general practice research. METHODS: A total of 1422 statistical tests in 85 quantitative original papers in the British Journal of General Practice were analysed for statistical power. RESULTS: The median power of tests analysed was 0.71, representing a slightly greater than two-thirds likelihood of rejecting false null hypotheses. Of 85 studies, 37 (44%) attained power of 0.8 or more. Ten studies had power of more than 0.99 suggesting 'over-powering'. Twenty-one of the papers surveyed (25%) had a likelihood of gaining significant results poorer than that obtained by tossing a coin when a null hypothesis is false. CONCLUSION: While achieving higher power than studies in similar surveys of other disciplines, the power of general practice research falls short of the 0.8 convention. Adequate power is essential so that effects which exist are not missed. Recommendations are made concerning power calculations prior to the start of research and reporting of results in journal articles.

General practice--a post-modern specialty?

The 'modern' view of the world is based on the premise that we can discover the essential truth of the world using scientific method. The assumption is made that knowledge so acquired has been 'uncontaminated' by the mind of the investigator. Post-modern theory, however, is concerned with the process of knowing and how our minds are part of the process, i.e. our perceptions of reality and the relationships between different concepts are important influences on our ways of knowing. The values of post-modern theory are those of uncertainty, many different voices and experiences of reality and multifaceted descriptions of truth. These values are closer to our experience of general practice than the 'modern' values of scientific rationalism and should be reflected in a new curriculum for general practice.

Portfolio-based learning: continuing medical education for general practitioners--a mid-point evaluation.

In October 1994 a project was initiated by the General Practice Continuing Medical Education Tutors in the Department of General Practice at Sheffield University. The project sought to evaluate the efficiency (effort expended) and effectiveness (distance travelled) of a model of continuing professional development for general practitioners through individual portfolio-based learning in co-mentoring groups. Learning demonstrated through the portfolio was accredited for the postgraduate education allowance of participants. This paper addresses the process of portfolio development at the mid-point of a year-long trial to ascertain the strengths, weaknesses and possible future development of such a process within the context of continuing medical education.

Surviving the 'heartsink' experience.

The authors describe a pilot workshop designed to help doctors achieve a greater understanding of and ability to cope with their 'heartsink' patients. Participants were asked to list their personal objectives in attending and a number of cases were discussed in the group. A 'heartsink survival kit' was provided which consisted of skills and strategies which are useful in difficult consultations and an approach to reassessing the goals of the relationship which might promote a more realistic understanding. The workshop was videotaped and two scenarios are presented. The implications for further training are discussed.

Heartsink patients: a study of their general practitioners.

BACKGROUND: A number of attempts have been made to investigate the heartsink, difficult, dysphoric or problem patient. Most studies have emphasized the role which the patient plays in evoking despair, anger and frustration in the doctor. However, one doctor's list of difficult patients may not necessarily be the same as another's. AIM: A study was undertaken to determine if the individual characteristics of general practitioners are associated with the number of heartsink patients they report on their patient lists. METHOD: Sixty out of 137 urban general practitioners drawn at random from the Sheffield Family Health Services Authority list were surveyed by structured interview and questionnaires in 1990. Outcome measures were interview data and scores on the 12-item general health questionnaire, Warr-Cook-Wall job satisfaction scale and the Bortner personality profile measure. RESULTS: Sixty per cent of the variance in the number of heartsink patients that general practitioners reported on their lists could be accounted for by the following four explanatory variables: greater perceived workload; lower job satisfaction; lack of training in counselling and/or communication skills; and lack of appropriate postgraduate qualifications. No other variables considered could account for the variance in the number of heartsink patients reported by general practitioners. CONCLUSION: The individual characteristics of doctors are associated with the number of heartsink patients reported by general practitioners. To reduce the number of such patients experienced, it may be necessary for general practitioners to reduce their workload and increase their job satisfaction and their level of relevant postgraduate training.