Type 2 diabetes continuing medical education for general practitioners: what works? A systematic review.

AIMS: To perform a systematic review of studies that have assessed the effectiveness of interventions designed to improve healthcare professionals' care of patients with diabetes and to assess the effects of educational interventions targeted at general practitioners' diabetes management. METHODS: A computer search was conducted using the Cochrane Library, PubMed, Ovid MEDLINE, Scopus, EMBASE, Informit, Google scholar and ERIC from the earliest date of each database up until 2013. A supplementary review of reference lists from each article obtained was also carried out. Measured changes in general practitioners' satisfaction, knowledge, practice behaviours and patient outcomes were recorded. RESULTS: Thirteen out of 1255 studies met the eligibility criteria, but none was specifically conducted in rural or remote areas. Ten studies were randomized trials. Fewer than half of the studies (5/13, 38.5%) reported a significant improvement in at least one of the following outcome categories: satisfaction with the programme, knowledge and practice behaviour. There was little evidence of the impact of general practitioner educational interventions on patient outcomes. Of the five studies that examined patient outcomes, only one reported a positive impact: a reduction in patient HbA1c levels. CONCLUSIONS: Few studies examined the effectiveness of general practitioner Type 2 diabetes education in improving general practitioner satisfaction, knowledge, practices and/or patient outcomes. Evidence to support the effectiveness of education is partial and weak. To determine effective strategies for general practitioner education related to Type 2 diabetes, further well designed studies, accompanied by valid and reliable evaluation methods, are needed.

To Drive or Not to Drive: Assessment Dilemmas for GPs.

Introduction. Most Australians are dependent on their cars for mobility, thus relinquishing driving licences for medical reasons poses challenges. Aims. To investigate how general practitioners (GPs) recognise and manage patients' fitness to drive, GPs' attitudes and beliefs about their role as assessors, and GPs' experiences in assessing and reporting to driving authorities and identify GPs' educational needs. Methods. Mixed methods: questionnaire mailed to GPs from three rural and two metropolitan Divisons of General Practice in Victoria, Australia. Results. 217/1028 completed questionnaires were returned: 85% recognised a patients' fitness to drive, 54% felt confident in their assessment ability, 21% felt the GP should have primary responsibility for declaring patients' fitness to drive, 79% felt that reporting a patient would negatively impact on the doctor-patient relationship, 74% expressed concern about legal liability, and 74% favoured further education. Discussion. This study provides considerable information including recommendations about GP education, the assessment forms, and legal clarification.

Impact of Master of Family Medicine degree by distance learning on general practitioners' career options.

INTRODUCTION: This study investigated the impact of a Master of Family Medicine degree (via distance education) on GPs' career options, and in particular, whether they were more likely to adopt university positions after the course. A secondary aim was to examine whether those who undertook a research project as part of their Masters took up different career options than Masters graduates who undertook a more clinically orientated course. METHODS: A questionnaire survey was posted to all 192 graduates of the Master of Family Medicine degree. Approximately one fifth of these resided overseas, with the majority in Hong Kong. RESULTS: The response rate was 68%. Graduates stated that they benefited from the course, particularly in the areas of clinical knowledge and improvement in 'academic' skills. Changes in careers, with increases in non-clinical appointments, did occur after the course for both the Research and Clinical Masters graduates. DISCUSSION: Responses to the survey indicated that graduates benefited in completing the course and changes in their career direction following graduation. However, whether the Masters course provided new skills to enable career change, or the GPs were in the process of change anyway, cannot be determined with certainty. Further studies, including interviews, are required to establish the impact of a distance education higher degree. CONCLUSION: The research output of general practice remains behind that of its specialist colleagues. Higher degrees for GPs might encourage them to undertake more academic pursuits, but the precise relationship still remains uncertain.

Electronic decision support in general practice. What's the hold up?

BACKGROUND: The uptake of computers in Australian general practice has been for administrative use and prescribing, but the development of electronic decision support (EDS) has been particularly slow. Therefore, computers are not being used to their full potential in assisting general practitioners to care for their patients. OBJECTIVE: This article examines current barriers to EDS in general practice and possible strategies to increase its uptake. DISCUSSION: Barriers to the uptake of EDS include a lack of a business case, shifting of costs for data collection and management to the clinician, uncertainty about the optimal level of decision support, lack of technical and semantic standards, and resistance to EDS use by the time conscious GP. There is a need for a more strategic and attractive incentives program, greater national coordination, and more effective collaboration between government, the computer industry and the medical profession if current inertia is to be overcome.

Divisions, general practice and continuous quality improvement. What is the connection?

BACKGROUND: Quality improvement in general practice needs to take into account not only the clinical behaviour of individual general practitioners but also the system within which they work. DISCUSSION: Continuous quality improvement (CQI) is an approach to helping clinicians work toward 'best practice' through system wide support. Its emphasis is on the improvement of processes through leadership, a team approach, the use of data, and small scale quality improvement projects. CONCLUSION: CQI may be useful for divisions of general practice to develop and improve their infrastructure and also to support quality improvement in individual general practices.

Promoting evidence-based medicine in general practice-the impact of academic detailing.

BACKGROUND: We undertook a project to promote evidence-based medicine (EBM) within a network of GPs (the Monash Division of General Practice) in Melbourne, Australia. A principal promotional strategy was to conduct practice visits ('academic detailing'). OBJECTIVES: The aim of this study was to measure the impact of academic detailing on GP attitudes and knowledge of EBM. METHODS: All 132 GP members of the division were invited by mail to accept a practice visit about EBM. The GPs had been randomized to one of two groups: to receive academic detailing during the study period or to be visited at a later date. The practice visit consisted of a 30- 45 minute discussion about EBM and the barriers to its practice. Pre- and post-intervention questionnaires were used to measure change in knowledge of and attitudes to EBM over a 3-month period in both groups. RESULTS AND CONCLUSIONS: Academic detailing led to a significant improvement in knowledge scores and self-perceived understanding of EBM, but had little influence on GP attitudes toward it. It is not known whether this would lead to change in clinical behaviour among GPs.

Personal doctoring. Its impact on continuity of care as measured by the comprehensiveness of care score.

OBJECTIVE: To determine the impact of personal provider continuity on continuity of care as measured by the comprehensiveness of care score. DESIGN: Retrospective cross sectional analysis of medical records. SETTING: The setting was a four doctor practice on the New South Wales Central Coast of Australia. METHOD: The subjects were 131 male and 123 female patients with a mean age of 42.7 years (SD 25.9) median age of 42 years and an age range of 1-95 years. The main outcome measures were a comprehensiveness score for each patient in the personal provider continuity and discontinuity of care group over a two year period. RESULTS: The overall comprehensiveness scores in the personal provider continuity group was 7.38 (95% CI: 7.04-7.71) compared to 6.03 (95% CI: 5.7-6.35) for those in the discontinuity group (p < 0.000). A linear regression model revealed that 15.8% of the total variance of the comprehensiveness score is explained by the two independent variables 'modified continuity index' (13.6%) and 'age' (2.2%). Nonrelated independent variables are gender, number of visits and number of years attending the practice. CONCLUSION: Personal doctoring significantly improves continuity of care as measured by the comprehensiveness of care score, and this observation is essentially age independent. These findings clearly suggest that patients should be encouraged to find and stay with one doctor, and that practices should develop systems to enable patients access to their usual provider. Both strategies, combined with the awareness of potential gaps in our service provision, will increase the likelihood of achieving increased continuity of care.

The patient perspective survey. Can consultations for complex health problems be enhanced?

BACKGROUND: Patients with complex health problems pose particular difficulties due to the interaction between psychosocial factors and physical disease. The aim of this study is to investigate the usefulness of a paper based instrument (the Patient Perspective Survey, or PPS) to enhance general practitioner-patient communication and patients' self reported coping skills. METHODS: A previously validated questionnaire was modified and distributed to a self selected group of 21 GPs. They recruited 77 patients with complex health problems and asked them to complete a PPS questionnaire. The patients then returned for an extended consultation to discuss the results of the questionnaire with the GP. Patients and GPs subsequently completed PPS evaluation forms. RESULTS: The PPS was useful for patients with chronic conditions with mixed physical and psychological components. It appeared to enhance the GP-patient relationship and gave patients a better understanding of their coping skills. DISCUSSION: Patients with complex health problems can use paper based questionnaires to improve the quality of communication between themselves and their GPs.

Changing GPs' clinical behaviour. What can divisions do?

BACKGROUND: The increasingly complex challenge for medical practitioners to keep up to date and use the best available evidence in their clinical decision making has led to important studies on the effectiveness of various strategies to change clinician behaviour. Divisions of General Practice can develop an evidence based framework to support this change. OBJECTIVE: The aims of this paper are to: discuss effective interventions to change clinicians' behaviour describe the theories which underlie these strategies suggest a framework for Divisions of General Practice to design and implement effective programs. DISCUSSION: Continuing medical education and guideline implementation serve to highlight the impact of various change strategies. The interventions and the theories that underlie them, whether they be from a social, behavioural or organisational perspective, offer Divisions of General Practice an opportunity to support GPs in their ongoing professional need for quality improvement.

Diabetes mellitus and its complications in a Hungarian population.

The aim of this study was to examine the disease characteristics and complications of diabetes mellitus in patients in a Hungarian rural community. Data relating to age, sex, date of onset of diabetes, fasting blood glucose values and all diseases associated with diabetics were retrieved from the medical records of patients. Almost six percent (5.7%) of the population has diabetes mellitus. The percentage of Type I diabetic patients in this population was 5.8 percent. The prevalence of diabetes was slightly but not significantly higher in females than in males. The mean age of the diabetic population was 52.1 +/- 11.3 for male and 53.47 +/- 15.7 for the female patients. The peak age of onset of diabetes mellitus was in the sixth decade of life. The mean fasting blood sugar value was 10.64 +/- 0.6 and 10.57 +/- 0.5 mmol L(-1), in male and female diabetic patients (n = 103), respectively. Diabetic patients presented with many signs and symptoms in the general practice setting. The findings of this study showed that diabetics present with many disease conditions and signs and symptoms in the general practice setting. Many of these conditions are known to be associated with diabetes while others are not. As a result of the adverse effects of diabetes mellitus on the cardiovascular system and on body metabolism as a whole, the damage and morbidity caused by diabetes mellitus may have been underestimated. The results of this study have shed light on the unrecognised complications of diabetes mellitus.

Distance education. Part 1. Conceptualization and development.

INTRODUCTION: The Graduate Diploma/Masters in Family Medicine were developed at Monash University as distance education courses from a previous on-campus version of a Masters course in response to real and perceived needs for more flexible forms of delivery. METHOD: Conceptualization and development involved consultation with experts in distance education and the application of adult learning principles, phenomenology and constructivism in course design. CONCLUSION: Despite initial difficulties and delays, course objectives were met through the application of standardised distance learning and teaching methods applied to four core and 15 clinical elective subjects. These were developed within a three year period for delivery in a predominantly paper based format.

Distance education. Part 4. Supervision of family medicine research at a distance. A formative evaluation.

INTRODUCTION: A survey on supervision of research projects was undertaken among current general practitioner students, recent graduates and supervisors of a Masters of Family Medicine degree. The aim was to describe and compare the experience of the three groups and, in particular, to identify the problems associated with distance supervision. METHODS: A self-administered questionnaire survey was distributed to current students (n = 21), graduates (n = 16) and current supervisors (n = 7). RESULTS: Forty out of 44 doctors returned completed questionnaires. Distance was a relatively minor barrier to successful supervision, provided that the student and supervisor established good communication patterns and were able to respond to each other with minimal delay. The commencement of the study and its final write-up were critical phases in the supervision process. DISCUSSION: Communication, including emotional and psychological support, was at least as important as expert opinion in helping Masters students to successfully complete their research projects. Attention must be paid to establishing good understanding and regular means of communication at the beginning of the supervisory process.

Distance education. Part 5. Family medicine research at a distance. Guidelines for supervisors.

INTRODUCTION: This paper recommends guidelines for the supervision of Masters degrees or similar postgraduate courses, in which research projects are supervised at a distance. METHODS: The guidelines are based on the experiences of the authors with a five year old Masters of Family Medicine degree and a formative evaluation conducted by questionnaire survey among its students, graduates and supervisors. RESULTS: It is important to establish ground rules for communication at an early point in the supervisory process. Supervisors need to take into account psychosocial, pedagogical and organisational aspects of their mentorship of students. DISCUSSION: These guidelines are relevant to courses where there remains a strong one-to-one relationship between supervisors and students. In these cases, 'distance' need not be a barrier provided that both sides are aware of and committed to maintaining good patterns of communications with each other.

Distance education. Part 3. Assessment of and feedback to students at a distance.

INTRODUCTION: Assessment of students at distance, in a course with over 20 units (subjects), provides special challenges in providing timely, accurate and detailed feedback both formatively and summatively. METHOD: A description of assessment practices including reflective journals, essays, critical appraisal of literature, case studies or teaching presentations in video and written format, clinical audits, and large research projects is provided. The impact of a multitude of criterion-referenced methods of students, teachers and administrative services as well as quality assurance issues are measured. CONCLUSION: Students preferred multiple levels of formative and summative assessment using criterion referencing to exams. These methods were thought to be contextually relevant to clinical practice and examined knowledge, cognition and performance appropriately. Length of assessment task, difficulty with English as a second language and lack of detail or clarity on written feedback posed problems for a number of students. Quality assurance procedures have been put into place to rectify some of these problems.

Distance education. Part 2. Student characteristics, program characteristics, administration and future direction.

INTRODUCTION: A descriptive analysis of student and program characteristics was undertaken. METHOD: Data were obtained using student enrollment forms, periodic surveys and regular feedback which formed part of the formative evaluation. RESULTS: In the five year period 1992-1996, 433 doctors enrolled in the Graduate Diploma, of which 56 proceeded onto Masters. Of the 433, 60% were male. The mean age of students was 41 years, with rural (49%) and solo (45%) practitioners over-represented; 20% held the FRACGP and 15% resided outside Australia. Around 20% deferred or withdrew during the five year period. Of the 56 Masters enrollments, 16 had completed the degree in minimum time, with a further 30 completing within two years. Reasons for enrollment were largely professional with many students expressing the need to overcome isolation and gain intellectual stimulation. CONCLUSION: This Diploma/Masters course which has a strong clinical component has attracted considerable interest among established general practitioners. The program appears to have succeeded because of its flexible delivery, lack of exclusive research orientation and its firm grounding in general practice.

[Knowledge of professional rules of ethics among professional nurses]. / Der Bekanntheitsgrad berufsethischer Grundregeln innerhalb der Berufsgruppe der Pflegenden.

During recent years numerous publications on ethical issues appeared in German nursing literature. Nursing theorists repeatedly refer to the Code of Ethics of the International Council of Nursing (ICN). The implementation of codes of ethics is discussed as an indispensable stage within the development of independent nursing ethics. However, it is not clear whether nurses in Germany know about the ICN Code of Ethics or other codes of ethics. The authors' objective is to learn more about how much is known about codes of ethics by practical nurses in four selected hospitals. In addition, it is of interest to know, which advantages nurses might associate with codes of ethics and secondly from which sources nurses prefer to receive ethical education. The study shows that only 25% of the participants know about codes of ethics. It also reveals that further education offered by hospitals or the basic nursing education are seen as the most important source of information related to ethics. The major advantage of codes of ethics seen by the participants is to provide guidance in the decision-making process of ethical dilemma situations in nursing. Secondly the Code of Ethics is regarded as a useful framework to define obligations and rights of nurses in the relationship with patients and relatives. The results of the study indicate that the ICN Code of Ethics is practically unknown among nurses and should be discussed more extensively by practical nurses and nursing theorists.

The experiences of one divisional group of GPs in introducing computers into clinical practice.

OBJECTIVES: To explore the experiences of GPs who have introduced computers into their practices, particularly for clinical use. METHODS: GPs who have introduced computers into their practice for clinical use were identified by a telephone survey of the membership of the Monash Division, Melbourne, Victoria. Eleven 'clinical users' participated in semi-structured interviews to elucidate their experiences of installing computers in their consulting rooms, including their beliefs on how this process could have been given more support. RESULTS: Sixty-two of 67 practices participated in the initial telephone survey. Sixteen percent of responding practices were using computers for clinical purposes, with 11% issuing computerised prescriptions. Interviews with clinical users revealed that most had learned about computer hardware and software through their own independent enquiries. However, the GPs believed that divisions have an increasing role in providing training, education, and offering independent advice about the purchase of appropriate computer systems. DISCUSSION: This group of GPs adopted computers for clinical purposes without much assistance from the medical profession. Their experience of the process of computerisation illustrated that lack of training posed problems as did lack of support. Half of the sample felt that divisions may be able to provide training and education, independent advice and act as a forum to discuss and develop ideas, and thus ease some of the problems associated with adopting new technologies. CONCLUSION: Several suggestions are made for GPs and divisions to assist in the process of computerisation.