Audit: a project on peer review in general practice.

A project of group-based peer review by general practitioners is described. Attention is given to the motivation of general practitioners to participate in audits, to the threat posed by peer review and to the use of criteria. The recruitment and motivation were successful. A total of 253 general practitioners took part, divided into 23 groups. This represented approximately 30% of all general practitioners in the area and 72% of all general practitioners specifically approached by us. The threat posed by audit disappears rapidly for most physicians once they have started auditing. The use of predefined criteria developed by 'experts', representing an optimal way of work for the general practitioner, appeared to be quite feasible in this project. From the results several conclusions are drawn as regards the planning and implementation of peer review under general practitioners.

Work satisfaction of general practitioners and the quality of patient care.

The emotional reactions of 57 general practitioners to three aspects of work was assessed by means of questionnaires. The quality of patient care was assessed by means of observations of general practice consultations, assessment of audiotaped consulting hour contacts and an analysis of the referral and prescription figures. A distinction was made between the degree of positive and the degree of negative feelings general practitioners have about their work. Many positive feelings (satisfaction, feeling at ease) correlated with more openness to patients, more attention to psychosocial aspects of the complaints but also with a higher rate of referral to medical specialists. On the other hand, many negative feelings (frustration, tension, lack of time) correlated with a high prescription rate and with giving little explanation to patients. To some extent the way that work is experienced by general practitioners correlated with the quality of care for the patients, but what constitutes cause and effect requires further study. A reflection of a doctor's own feelings about work should become part of training, continuing education and medical audit programmes.

Some difficulties in comparing morbidity between countries.

During a two-month period in general practice we compared morbidity records from the teaching practices at Southampton, UK, and Nijmegen, The Netherlands. Although the commonest conditions - emotional disorders, upper respiratory tract infection, and musculo-skeletal disorders - were equally prevalent, obesity was five times as prevalent and hypertension and urinary tract infection were twice as prevalent in Nijmegen as in Southampton. The Dutch doctors were far more ready to prescribe oral contraception to women over 50 years old. We met many difficulties in what had appeared to be a simple project and our results may reflect important differences about doctors' attitudes to care as well as differences in morbidity.