Challenges to alcohol and other drug discussions in the general practice consultation.

BACKGROUND: There is a widely held expectation that GPs will routinely use opportunities to provide opportunistic screening and brief intervention for alcohol and other drug (AOD) abuse, a major cause of preventable death and morbidity. AIM: To explore how opportunities arise for AOD discussion in GP consultations and how that advice is delivered. DESIGN: Analysis of video-recorded primary care consultations. SETTING: New Zealand General Practice. METHODS: Interactional content analysis of AOD consultations between 15 GP's and 56 patients identified by keyword search from a bank of digital video consultation recordings. RESULTS: AOD-related words were found in almost one-third (56/171) of the GP consultation transcripts (22 female and 34 male patients). The AOD dialogue varied from brief mention to pertinent advice. Tobacco and alcohol discussion featured more often than misuse of anxiolytics, night sedation, analgesics and caffeine, with only one direct enquiry about other (unspecified) recreational drug use. Discussion was associated with interactional delicacy on the part of both doctor and patient, manifested by verbal and non-verbal discomfort, use of closed statements, understatement, wry humour and sudden topic change. CONCLUSIONS: Mindful prioritization of competing demands, time pressures, topic delicacy and the acuteness of the presenting complaint can impede use of AOD discussion opportunities. Guidelines and tools for routine screening and brief intervention in primary care do not accommodate this reality. Possible responses to enhance AOD conversations within general practice settings are discussed.

The MacGyver effect: alive and well in health services research?

BACKGROUND: In a manner similar to the television action hero MacGyver, health services researchers need to respond to the pressure of unpredictable demands and constrained time frames. The results are often both innovative and functional, with the creation of outputs that could not have been anticipated in the initial planning and design of the research. DISCUSSION: In the conduct of health services research many challenges to robust research processes are generated as a result of the interface between academic research, health policy and implementation agendas. Within a complex and rapidly evolving environment the task of the health services researcher is, therefore, to juggle sometimes contradictory pressures to produce valid results. SUMMARY: This paper identifies the MacGyver-type dilemmas which arise in health services research, wherein innovation may be called for, to maintain the intended scientific method and rigour. These 'MacGyver drivers' are framed as opposing issues from the perspective of both academic and public policy communities. The ideas expressed in this paper are illustrated by four examples from research projects positioned at the interface between public policy strategy and academia.

Medical student selection in New Zealand: looking to the future.

AIMS: To review whether current New Zealand (NZ) medical student selection policies are likely to result in specialists prepared to work in areas of greatest health need in the future. METHOD: This paper describes approaches used to select medical students, with some details about NZ medical student cohorts. It then discusses the evidence linking selection and career choice. RESULTS AND CONCLUSIONS: Selection processes have to serve multiple purposes and no tools are ideal. The NZ medical student population is more diverse than previously with more females than males, and higher proportions of students who are Maori, Pacific, rural, Asian or born overseas. Tracking projects are already underway to obtain data to better understand the effect of student factors on career choice. The Maori and Pacific Admission Scheme and Rural Origin Medical Preferential Entry affirmative action pathways have been successful, but to increase the number of doctors who identify as Maori or Pacific will require a larger pool of students with strong educational backgrounds from which to select. The strongest evidence between selection and future practice exists for students from rural backgrounds - they are more likely to practice in rural areas and to enter general practice. Therefore, increasing the numbers or rural students, or broadening the definition of 'rural', should be considered.