Dealing with doubt. How patients account for non-specific chronic low back pain.

Objective: To explore the ways that persons with long standing chronic low back pain respond to the problem of medical doubt about the presence of organic pathology.

Method: Qualitative analysis of accounts provided by 12 persons attending a back pain rehabilitation clinic in NW England.

Results: Subjects rejected the notion that they were culpable for their pain.

Improving schools' asthma policies and procedures.

Collaboration between a health trust and an education authority is helping children with asthma to lead full and active lives at school. Evaluation of the training package, which is delivered by school nurses for school staff, suggests all schools can benefit from a structured approach involving pupils, teachers and parents.

Assessing the appropriateness of paediatric hospital admissions in the United Kingdom.

Background: In order to assess whether the documented rise in paediatric admissions was due to inappropriate admissions, an objective measure of the appropriateness of paediatric admissions, modified for use in the United Kingdom, was used to measure the level of inappropriate admissions. The relationship of appropriateness of admissions to age, gender, time of admission and source of referral was investigated.

Methods: A retrospective review was carried out of a sample of paediatric records in 13 NHS district general hospitals in South Eastern England between April 1990 and March 1991 using the Paediatric Appropriateness Evaluation Protocol (PAEP) modified for use in the United Kingdom.

Development of the Paediatric Appropriateness Evaluation Protocol for use in the United Kingdom.

Background: This paper describes a study to develop and test an instrument to measure the level of appropriate admissions and days of care in the paediatric hospital population.

Methods: The American version of the Paediatric Appropriateness Evaluation Protocol (PAEP) was modified by the consensus views of a panel of paediatricians and general practitioners. Reliability was tested in a pilot study in a random sample of 47 admissions from two district general hospitals.

Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care.

Objective: To compare the cost effectiveness of general practitioners and nurse practitioners as first point of contact in primary care.

Design: Multicentre randomised controlled trial of patients requesting an appointment the same day.

Setting: 20 general practices in England and Wales.

Psychiatry by videophone: a trial service in north west England.

In this paper we report on the use of a video link between two general practices and a hospital based mental health team in North West England to provide a trial telepsychiatry service for individuals with depression and anxiety related disorders. Patients (n = 16) took part in an evaluation of the service by both structured questionnaire and semi-structured interview. The results of the evaluation study suggest that patients may be highly critical of telemedicine systems and that they do so not simply on the grounds of the technical quality of video links, but also because the remote link increases the difficulty that the patient faces in expressing deep scated emotional and existential problems.

Chronic low back pain in general practice: the challenge of the consultation.

Background: Chronic low back pain (CLBP) is a symptom commonly presented to GPs, accounting for a significant proportion of their workload. It is also a common reason for sickness absence, and thus of national economic importance.

Objectives: This qualitative study aimed to provide an understanding of how GPs understood CLBP, how they approached the consultation with CLBP patients and how they conceptualized the management of this problem.

Medical knowledge and the intractable patient: the case of chronic low back pain.

Chronic low back pain (CLBP) is endemic in Western societies, and while a good deal of attention has been paid to the lay experience of such pain, much less sociological attention has been paid to the way in which medical ideas about it have been formulated. This paper takes the latter course, tracing the development of clinical notions about the relationship between pathological signs and expressed symptoms from the 1820's to the 1930's, and then placing these developments in the context of postwar notions of 'somatization'. We point to the extent to which the disparity between expressed symptoms, pathological signs and perceived disability in CLBP has led to the moral character of the sufferer forming a constant subtext to medical discourse about the condition.

The benefits of back pain.

Background: Chronic lower back pain (CLBP), without definable cause, is a symptom commonly presented to GPs, accounting for a significant proportion of their workload; it is also a common reason for sickness absence, and thus of national economic importance.

Objectives: This qualitative study aims to explore how sufferers of CLBP describe their pain and its impact on their lives, and how their problem is dealt with in the consultation with their family doctor.

Method: Semi-structured interviews were carried out with a sample of attenders at a back pain clinic set up in general practice.

Outcome of anxiety and depressive disorders in primary care.

Background: Factors related to the outcome of depression and anxiety in primary care are not fully understood.

Method: Adult patients in general practice with depressive, anxiety or panic disorder (n = 148; DSM-III-R criteria) were studied prospectively for six months to determine the factors most closely associated with outcome. The Psychiatric Assessment Schedule, Hamilton Depression Rating Scale, Clinical Anxiety Scale and Life Events and Difficulties Schedule interviews were performed at index consultations and repeated six months later.

Comparison of out of hours care provided by patients' own general practitioners and commercial deputising services: a randomised controlled trial. I: The process of care.

Objective: To compare the process of out of hours care provided by general practitioners from patients' own practices and by commercial deputising services.

Design: Randomised controlled trial.

Setting: Four urban areas in Manchester, Salford, Stockport, and Leicester.

Does additional lubrication reduce condom failure?

It has been suggested that using additional spermicide with condoms provides added contraceptive effect and protection from infection, and that water-based lubricants may lower condom breakage rates. This questionnaire-based study investigated the use of additional lubrication with condoms amongst 525 female students presenting for post-coital contraception, and the current and past experience of condom and additional lubrication use amongst 481 controls attending the same health centre. Of those requesting post-coital contraception, 83% claimed condom failure as the cause, with 66% of the control group having also experienced condom failure at some time.

Why do people consult the doctor?

Background: Symptoms are an everyday part of most peoples' lives and many people with illness do not consult their doctor. The decision to consult is not based simply on the presence or absence of medical problems. Rather it is based on a complex mix of social and psychological factors.

'To call it work somehow demeans it': the social construction of talk in the care of terminally ill patients.

The nurse has an important role in helping the terminally ill patient come to terms with the imminence of death. Such work is highly demanding and often stressful, but is work which is accorded a high moral priority by respondents in the study reported in this paper. The paper explores the ways in which nurses work to respond to patients' expressed psychosocial problems and the emphasis that they placed on providing opportunities for patients to speak about their impending death.

Out of hours primary care centres: characteristics of those attending and declining to attend.

Objectives: To study the number, demography, and clinical details of patients who agreed or refused to attend centralised primary care centres for out of hours medical care and to study the satisfaction with the service of those who attended.

Design: Data collected by telephonists and doctors. Satisfaction questionnaires given to patients who attended.

Organisation of primary care services outside normal working hours.

Objective: To determine the use and organisation of out of hours services in primary care.

Design: Telephone survey.

Setting: Family health services authorities in England and Wales.

Specialist outreach clinics in general practice.

Objectives: To establish the extent and nature of specialist outreach clinics in primary care and to describe specialists' and general practitioners' views on outreach clinics.

Design: Telephone interviews with hospital managers. Postal questionnaire surveys of specialists and general practitioners.

Analysing general practitioners' referral decisions. II. Applying the analytical framework: do high and low referrers differ in factors influencing their referral decisions?

An analytical framework of the referral decision was applied to the question of whether general practitioners (GPs) with relatively high and relatively low referral rates differed in the types of factors that influenced their referral decisions. Interview data from six high referring and six low referring GPs were compared at all levels of the framework, using both quantitative and qualitative content analysis. High referrers were found to mention significantly more negative factors than low referrers, i.

Primary medical care outside normal working hours: review of published work.

Fundamental changes in the delivery of primary medical care outside normal surgery hours are under consideration in Great Britain. Published research into the provision and utilisation of out of hours services shows long term trends towards decreasing personal commitment among general practitioners and rising demand from patients for primary and hospital accident and emergency department care. Wide variations exist regionally, locally, and between practices.

Understanding variation in rates of referral among general practitioners: are inappropriate referrals important and would guidelines help to reduce rates?

Objectives: To determine the extent to which variation in rates of referral among general practitioners may be explained by inappropriate referrals and to estimate the effect of implementing referral guidelines.

Setting: Practices within Cambridge Health Authority and Addenbrooke's Hospital, Cambridge.

Main Outcome Measures: Data on practice referral rates from hospital computers, inappropriate referrals as judged by hospital consultants, and inappropriate referrals as judged against referral guidelines which had been developed locally between general practitioners and specialists.

How valuable is feedback of information on hospital referral patterns?

Objectives: To determine general practitioners' responses to and explanations for variation in rates of referral to hospital and how feedback of data on rates of referral could be used to facilitate practices in auditing their own referral behaviour.

Design: Visits by audit facilitators to general practices after feedback of details of rates of referral to hospital derived from annual reports in general practice.

Setting: 92 general practices in East Anglia.

Turning anecdotes into data--the critical incident technique.

This article describes the critical incident technique and offers practical guidance on how the technique can be used to investigate dilemmas in medicine. It extols the particular virtue of this research method for general practice that it can be used to exploit the natural tendency of doctors to tell anecdotes. How the principles of the technique relate to significant event analysis, a form of medical audit, is also discussed.