Sean Hilton

Proto-professionalism: how professionalisation occurs across the continuum of medical education

Introduction  Professionalism and its assessment across the medical education continuum have become prominent topics in recent years. We consider the nature of professionalism and how it emerges and relates to the work carried out by doctors and doctors‐in‐training.

Behavioural counselling in general practice for the promotion of healthy behaviour among adults at increased risk of coronary heart disease: randomised trial

Abstract Objective: To measure the effect of behaviourally oriented counselling in general practice on healthy behaviour and biological risk factors in patients at increased risk of coronary heart disease. Design: Cluster randomised controlled trial. Participants: 883 men and women selected for the presence of one or more modifiable risk factors: regular cigarette smoking, high serum cholesterol concentration (6.5-9.0 mmol/l), and high body mass index (25-35) combined with low physical activity. Intervention: Brief behavioural counselling, on the basis of the stage of change model, carried out by practice nurses to reduce smoking and dietary fat intake and to increase regular physical activity. Main outcome measures: Questionnaire measures of diet, exercise, and smoking habits, and blood pressure, serum total cholesterol concentration, weight, body mass index, and smoking cessation (with biochemical validation) at 4 and 12 months. Results: Favourable differences were recorded in the intervention group for dietary fat intake, regular exercise, and cigarettes smoked per day at 4 and 12 months. Systolic blood pressure was reduced to a greater extent in the intervention group at 4 but not at 12 months No differences were found between groups in changes in total serum cholesterol concentration, weight, body mass index, diastolic pressure, or smoking cessation. Conclusions: Brief behavioural counselling by practice nurses led to improvements in healthy behaviour. More extended counselling to help patients sustain and build on behaviour changes may be required before differences in biological risk factors emerge.

Student attitudes to undergraduate interprofessional education

Interprofessional education in health care has been the focus of increasing attention in recent years. However, there is still great debate about when and how to introduce it in undergraduate studies. St George’s Hospital Medical School with the Joint Faculty of Health Care Sciences of Kingston University was ideally placed to introduce, as part of its 1996 new curriculum, a Common Foundation Programme (CFP). This incorporated degree students in medicine, radiography, physiotherapy, and nursing learning together for the first term of their courses. As part of the evaluation of the CFP, students’ attitudes to the course and each other were surveyed at the beginning and the end of the term, for the 1998 and 1999 intakes. The results showed that students arrive at university with stereotyped views of each other, and that these views appeared to become more exaggerated during the CFP. Students felt that the CFP would enhance interprofessional working, but there were concerns that it forced them to learn irrelevant skills. Students whose parents worked as health care professionals, held stronger stereotyped views. Our findings challenge any notion that students arrive without preconceived ideas about the other professions. Further work is needed to appropriate models for interprofessional education, to enable graduates to work effectively in today’s environment.

Controlled evaluation of the effects of patient education on asthma morbidity in general practice

Two different patient education programmes for asthma in general practice were evaluated in a controlled trial. Knowledge, self management, and morbidity due to asthma were assessed in 339 patients by means of a questionnaire. One group then received a maximum education programme, a second group received a limited education programme, and a third acted as a control group. 274 patients were reassessed after one 1 year. In both the intervention groups, understanding of asthma was greater after the trial. Only in the maximum intervention group was a significant improvement in knowledge of asthma shown. Neither group showed any change in self-management ability or asthma morbidity that differed significantly from changes in the control group. These simple informational education programmes were ineffective when applied to a general practice population. Further studies of factors affecting attitudes, beliefs, and actions are needed to improve the advice and support given to asthma patients.

Evolution of statin prescribing 1994–2001: a case of agism but not of sexism?

Objective: To study trends in the use of lipid lowering drugs in the UK, and to assess which patient factors influence prescribing. Methods: Routinely collected computerised medical data were analysed from 142 general practices across England and Wales that provide data for the Doctors’ Independent Network database. Subjects included were people aged 35 years or more with treated ischaemic heart disease, averaging annually over 30 000. The temporal trend from 1994 to 2001 in prescription of lipid lowering drugs and daily statin dose and the odds ratios (ORs) for receiving a statin prescription in 1998 were examined. Results: Lipid lowering drug prescribing increased greatly over time, entirely because of statins, so that in 2001 56.3% of men and 41.1% of women with ischaemic heart disease received lipid lowering drugs. However, 33% of these patients were on a < 20 mg simvastatin daily equivalent. In 1998 the OR for receiving a statin fell from 1 at age 55–64 to 0.64 at 65–74 and 0.16 at 75–84 years. The age effect was similar in those without major comorbidity. Revascularised patients were much more likely to receive a statin than those with angina (OR 3.92, 95% confidence interval (CI) 3.57 to 4.31). Men were more likely to receive a statin than women (OR 1.62, 95% CI 1.54 to 1.71) but this difference disappeared after adjustment for age and severity of disease (OR 1.06). Geographical region had little effect but there was a very weak socioeconomic gradient. Conclusions: Although prescribing has increased, many patients who may benefit from lipid lowering drugs either do not receive it or are undertreated, possibly because of lack of awareness of the relative potency of the different statins. Patients with angina and the elderly are less likely to receive treatment that may prevent a coronary event.

Psychological and social predictors of changes in fruit and vegetable consumption over 12 months following behavioral and nutrition education counseling.

This study assessed psychological and social factors predicting 12-month changes in fruit and vegetable consumption achieved by 271 men and women from a low-income population randomized to brief behavioral and nutrition education counseling. Greater increases in fruit and vegetable intake were achieved in the behavioral than in the nutrition education condition (1.49 vs. 0.87 portions per day, p=.021). Increases were predicted by baseline social support for dietary change but not by baseline psychological measures. However, short-term (8-week) changes in dietary self-efficacy, encouragement, anticipated regret, perceived benefits, and knowledge of recommended intake predicted 12-month changes in fruit and vegetable consumption independently of gender, age, ethnicity, income, and baseline intake. These factors accounted for 51% of the superiority of behavioral counseling over nutrition education.

Psychological Factors Associated With Fruit and Vegetable Intake and With Biomarkers in Adults From a Low-Income Neighborhood

Fruit and vegetable consumption is below recommended levels in the population, paricularly in low-income groups. This study assessed factors associated with self-reported intake and 2 biomarkers (potassium excretion and plasma vitamin C) in 271 adults living in a low-income neighborhood. Attitudinal barriers to change were negatively related to reported intake and to potassium excretion. Poor knowledge of recommended consumption was associated with low reported intake, low potassium excetion, and low plasma vitamin C concentration. Self-efficacy was related to reported intake but not to biomarkers. The authors conclude that several of the psychological factors associated with self-reported intake were also related to biomarkers in this population and that these may therfore be particularly appropriate targets for intervention.

Using patient and general practice characteristics to explain variations in cervical smear uptake rates.

Objectives: To produce practice and patient20variables for general practices from census and family health services authority data, and to determine the importance of these variables in explaining variation in cervical smear uptake rates between practices. Design: Population based study examining variations in cervical smear uptake rates among 126 general practices using routine data. Setting: Merton, Sutton, and Wandsworth Family Health Services Authority, which covers parts of inner and outer London. Main outcome measure: Percentage of women aged 25-64 years registered with a general practitioner who had undergone a cervical smear test during the five and a half years preceding 31 March 1992. Results: Cervical smear uptake rates varied from 16.5% to 94.1%. The estimated percentage of practice population from ethnic minority groups correlated negatively with uptake rates (r=-0.42), as did variables associated with social deprivation such as overcrowding (r=-0.42), not owning a car (r=-0.41), and unemployment (r=-0.40). Percentage of practice population under 5 years of age correlated positively with uptake rate (r=0.42). Rates were higher in practices with a female partner than in those without (66.6% v 49.1%; difference 17.5% (95% confidence interval 10.5% to 24.5%)), and in computerised than in non- computerised practices (64.5% v 50.5%; 14.0% (6.4% to 21.6%)). Rates were higher in larger practices. In a stepwise multiple regression model that explained 52% of variation, five factors wre significant predictors of uptake rates: presence of a female partner; children under 5; overcrowding; number of women aged 35-44 as percentage of all women aged 25-64; change of address in past year. Conclusions: Over half of variation in cervical smear uptake rates can be explained by patient and practice variables derived from census and family health services authority data; these variables may have a role in explaining variations in performance of general practices and in producing adjusted measures of practice performance. Practices with a female partner had substantially higher uptake rates.

General practitioners' perceptions of the tolerability of antidepressant drugs: a comparison of selective serotonin reuptake inhibitors and tricyclic antidepressants

Abstract Objective: To examine inceptions and discontinuations of antidepressants in general practice. Design: An observational study analysing data from an ongoing cross sectional postal survey. Every three months a representative sample of 250 doctors recorded prescribing activity for four weeks. This provided 4000 general practitioner weeks of recording per year. Setting: A representative panel of general practitioners in England, Wales, and Scotland. Subjects: Patients who began a new course of an antidepressant or had their treatment stopped or changed by the general practitioner between 1 July 1990 and 30 June 1995. Main outcome measures: Numbers of patients prescribed a new course of antidepressant; numbers discontinuing treatment; the ratio of antidepressant discontinuations to antidepressant inceptions; reasons for discontinuation; proportion of switches to another antidepressant. Results: There were 13 619 inceptions and 3934 discontinuations of selective serotonin reuptake inhibitors and tricyclic antidepressants during the study. The number of newly prescribed courses of antidepressants increased by 116%, mostly due to an increase in prescribing of serotonin reuptake inhibitors. The ratio of total discontinuations to inceptions was significantly lower for serotonin reuptake inhibitors (22%) than for tricyclic antidepressants (33%). Differences persisted when controlled for age and sex of patients and severity of depression. However, there was more switching away from selective serotonin reuptake inhibitors when they failed (72%) than from tricyclic antidepressants (58%). Conclusions: Selective serotonin reuptake inhibitors are less likely than tricyclic antidepressants to be discontinued. A prospective study is needed in general practice to assess the implications of differences in discontinuation rates and switches on clinical and economic outcomes. Key messages The number of new prescriptions for antidepressants increased by 116% between 1990 and 1995, mostly due to increased prescribing of selective serotonin reuptake inhibitors In an observational study in general practice the ratio of antidepressant discontinuations to antidepressant inceptions was lower for selective serotonin reuptake inhibitors than for tricyclic antidepressants Data suggest that selective serotonin reuptake inhibitors are tolerated better in the general practice setting than tricyclic antidepressants However, there may be more switching away from selective serotonin reuptake inhibitors when they fail (72% in this series) than from tricyclic antidepressants (58%) Prospective studies are required in general practice to evaluate the implications of differences in discontinuation rates and switching on clinical and economic outcomes

Estimation of fruit and vegetable intake using a two-item dietary questionnaire: a potential tool for primary health care workers

BACKGROUND AND AIM High fruit and vegetable intake is associated with health benefits for cancer and cardiovascular disease. An increase is therefore integral in recommendations for the prevention of chronic disease. However, measuring intake requires either extensive dietary assessment or the measurement of specific bio-markers which is neither cheap nor feasible for the routine assessment of an individuals diet in a community or primary care setting. Within the context of a study evaluating a dietary counselling programme to increase fruit and vegetable intake our aim was to assess the use of a simple tool to estimate fruit and vegetable intake. METHODS AND RESULTS We studied associations between bio-markers [plasma ascorbic acid, beta-carotene and alpha-tocopherol 24-hour urinary potassium excretion] and a two-item fruit and vegetable consumption questionnaire in 271 subjects (105 men and 166 women), aged 18 to 70 years. After controlling for age, sex, vitamin supplement use, smoking and body mass, those reporting a daily intake of > or = 5 portions of fruit and vegetables had higher potassium excretion (difference 15.6 [95% confidence interval: 6.2 to 25.0] mmol/24 h), urinary potassium/creatinine ratio (1.2 [0.5 to 2.0]) and plasma vitamin C (10.0 [-0.9 to 20.8] mumol/L) than those reporting < or = 2.5 portions per day. beta-carotene (p = 0.04), vitamin C (p = 0.01) and potassium excretion (p < 0.001) were associated with fruit rather than vegetable intake. The two-item questionnaire had high specificity; over 3/4 of participants who reported low intake also had bio-markers below the upper third of the distribution. CONCLUSION Self report of fruit and vegetable intake through a simple questionnaire is confirmed by bio-markers for those eating less than five portions of fruit and vegetables a day. Although the tool is amenable to improvements for the detection of vegetable portions, it may prove useful for monitoring dietary preventive approaches in primary care without the use of invasive and costly biochemical measurements.