General Practitioners
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Preventive Medicine in General Practice An Evaluation of the Consultations of Ten General Practitioners Jonathan Williams, M.B., Ch.B. D.C.H. General Practice Vocational Trainee, Bristol SUMMARY 1982). A recent survey of patients from 47 practices (20) that are Ten final year medical students observed 360 consultations suggested patients concerned about their lifestyles undertaken by 10 West Country General Practitioners. In and would welcome relevant advice, but in many cases they 31% of the consultations, General Practitioners initiated felt that they received insufficient health education from their preventive medical care. These consultations lasted 1.5 General Practitioners. On the other hand, Smail (1982) warns of the in an minutes longer than those in which no preventive measures ".... dangers over-enthusiastic approach to were initiated, and most patients reacted with interest or preventive care, particularly if the doctor gives a great deal of enthusiasm to the preventive care. In 11% of the consul- heavy-handed proscriptive advice. There is some risk of tations patients themselves sought preventive advice. These alienating the patient...." This study was designed to record consultations were not significantly longer than consultations the quantity and nature of preventive care undertaken during consultations of ten West in which patients sought only more immediate help or symp- Country general practitioners. The tom relief. General Practitioners reacted favourably to 85% reaction of the general practitioner to enquiries from the of the preventive enquiries. patient, and the response and attitudes of patients to the preventive advice during the consultation was also assessed, INTRODUCTION as was the duration of each consultation. Preventive medicine is not new. In 1919, the Chief Medical Officer stated; "The first duty of medicine is not to cure METHOD disease, but to prevent it" (1). However, although prevention Final year medical students from the University of Bristol has been an important feature of twentieth century medical spend two weeks attending surgeries and observing consul- practice, most resources have been channelled towards cura- tations of general practitioners in the South Western Region. tive medicine (2)-(4). Nevertheless, awareness of the import- Of forty general practitioners due to receive a student during ance of the prevention of diseases and the promotion of the same two week period, ten, whose practices were in health in medical practice has increased rapidly in recent market towns of comparable size and socio-economic years (5)-(8). General Practice has been identified as an ideal environment in Devon and Somerset, were selected for study. setting for prevention (9), (10); the general practitioner has A pilot study of forty consultations was undertaken to ensure frequent contact with the majority of a defined population, the feasibility of recording the necessary information, without including those at risk. He or she is perceived as credible and disturbing the patient or the doctor during the consultation. trustworthy, communicates on a one to one basis with the The protocol was sent to the ten medical students who patient and is supported by a primary care team. The poten- obtained the permission of their general practitioners to tial for preventive medicine in general practice is beginning to record certain information about each consultation; viz., the be explored (11)?(15). age and 'social class' of each patient (divided into three Despite recent advances, the Royal College of General classes, 'professional', 'clerical' or 'manual'). However, in Practitioners in 1981 (16) professed ignorance of the extent order to avoid the possibility of altering the general practi- and thoroughness with which General Practitioners under- tioner's normal behaviour during consultation, the nature of took preventive care. A subsequent random selection of 5% the other information recorded was not disclosed. of 1302 tape recorded consultations undertaken by 16 The protocol defined prevention: "the promotion of a General Practitioners showed that prevention was discussed healthy lifestyle", and primary or secondary prevention: "the in 23% of consultations (17). A postal questionnaire of 193 avoidance of the causes of any disease, or its diagnosis and General Practitioners (18) found a high level of interest in treatment at an early preclinical stage". Examples of preven- certain preventive activities, particularly smoking prevention. tive medical care given were: stopping smoking, measuring However, an evaluation of 8,500 patients, notes from 38 blood pressure, combating obesity by diet or exercise, screen- practices (19) found that information about smoking habits ing procedures, family planning, accident avoidance, stress was recorded in only 23% of the notes. avoidance, immunisation and control of alcohol intake. Many further questions remain. "We need to ask how All prevention initiated by patients was noted and thege- many patients on a practice list will visit their doctors when neral practitioner's reaction to the preventive enquiry was well in order to discuss preventive measures such as diet, graded (a) enthusiastic (b) interested (c) disinterested or (d) exercise, or means of changing a health-threatening habit, dismissive. Preventive action or advice initiated by the and how much time or informed discussion general practi- general practitioner, either related to a problem presented by tioners will be willing to devote to the interview" (Taylor, the patient (for instance, discussion about smoking with a 68 Bristol Medico-Chirurgical Journal Volume 103 (iv) November 1988 patient presenting with a cough) or unrelated (for example, The general practitioners initiated 149 preventive measures in the a course of 111 of the 360 consultations. measuring the blood pressure of a patient with sprained (30.8%) (Table III) 68% of the preventive care was related to the ankle) was recorded. The reaction of the patient during the given patient's presenting complaint. consultation to the doctor's measure was also preventive Table III graded as above. Every consultation was timed to the nearest minute. Type and Frequency of G.P.-Initiated Prevention The was undertaken in the second week of the study Preventive Measure Number Patients % Total student attachment when the had of of general practitioner Consultations become accustomed to the presence of an observer. Students were asked to begin at the start of a day's surgery, and Smoking reduction 49 13.6 B.P. measure 42 observe as many consecutive consultations undertaken by the 11.7 Weight/diet/exercise 22 6.1 general as possible in the course of routine practitioner Accident avoidance 13 thus surgeries such as ante-natal or child 3.6 surgeries; special Lifestyle/stress 10 2.8 clinics were not included. Information about each consul- Screening 8 2.2 tation was recorded on a questionnaire. Alcohol 3 0.8 Immunisation 1 0.3 Family planning 1 0.3 RESULTS Total 149 All ten general practitioners agreed to participate in the and 360 consultations were observed (mean=36 con- study, There was no con- significant difference in the care sultations, range 15-112 consultations). Amongst these preventive received by males and females, or between social classes. sultations, 16% involved patients under fifteen years, 34% of However, as shown in Table children under fifteen were fifteen to four, 28% were forty five to IV, years patients aged forty received four significantly less preventive care from their sixty four, and 22% were sixty five years and above. Fifty general practitioners than older patients. per cent of patients consulting were female, 17% of patients were 'professional', 55% were 'clerical' and 28% were of Table IV 'manual' social class. G.P.-Initiated Prevention By Age In the 360 consultations, 39 patients (10.8%) enquired about prevention; three of these patients asked two questions Age Prevention No Total % Prevention (years) Prevention Consultations on prevention making a total of 42 patient-initiated preven- by Age Group tive are shown in Table I. enquiries. These enquiries 0-14 6 50 56 10.7 15-44 46 78 124 Table I 37.1 45-64 30 71 101 29.7 Type and Frequency of Patient-Initiated Prevention 65+ 29 50 79 36.7 Total 111 49 360 Patient-Initiated Prevention Number ^2=14.2 deg. of freedom =3 P<0.01 Enquiry about blood pressure 12 Advice re diet or exercise 9 The weight, proportion of consultations in which care 7 preventive Family planning was varied given, considerably between the ten general prac- Request for a screening procedure 5 titioners (range 6.6%-86.7%, The of Advice re smoking 3 mean=32%). majority patients reacted at the time of the consultation to Lifestyle/stress 2 favourably the medical care Immunisation 2 preventive (Table V). The reaction of Accident avoidance 1 patients receiving preventive advice which could be con- sidered Alcohol 1 inappropriate (for instance an enquiry about smoking Total 42 in non-smokers) was recorded as such. Table V The patient-initiated prevention was increasingly sought from manual through to professional classes, although this Reaction of Patients to G.P.-Initiated Prevention trend did not reach statistical significance. Patients aged 14 Reaction Patient % Consultations and under asked fewer on than older of questions prevention G.P.- and females asked more about Involving patients, questions prevention Initiated Prevention (not statistically significant). General practitioners reacted favourably to the majority