Abstract
BACKGROUND. It is difficult to implement change in general practice. It is not known how best to conduct effective continuing medical education in general practice. General practitioners' criteria for good clinical practice vary and it is unknown whether systematic education by hospital specialists could be expected to reduce variation between general practitioners. AIM. A study was undertaken to describe general practitioners', microbiologists' and urologists' strategies for diagnosis, treatment, and follow up of female patients with symptoms of urinary tract infection, a common reason for consultation in general practice. The findings of the study were to be used as a base upon which to discuss the advantages and disadvantages of using hospital specialists as a resource in general practitioners' peer group based continuing medical education. METHOD. Three vignettes together with several proposals for diagnosis, treatment and follow up were presented in a questionnaire to general practitioners, microbiologists and urologists in Denmark. The case histories concerned three female patients (aged 10, 30 and 60 years) who consulted their general practitioner for advice. The female patients were otherwise healthy and well known to the practice. General practitioners', microbiologists' and urologists' recommendations for good clinical practice were compared. RESULTS. A total of 154 general practitioners (77%), 45 microbiologists (51%) and 54 urologists (61%) who were eligible for the study responded to the questionnaire. There was considerable variation in the management strategies proposed by doctors within each specialty and between the specialties. Microbiologists and urologists were more likely to suggest treating the 30-year-old woman by giving advice and a prescription by telephone compared with their general practitioner colleagues. Conversely, the microbiologists and urologists were more likely to suggest asking the 10- and 60-year-old patients to attend the clinic for examination compared with the general practitioners. The general practitioners reported asking the patients to return for follow up more commonly than the hospital specialists. CONCLUSION. Large variation in suggested strategies for diagnosis, treatment and follow up was shown both within and between specialties. Continuing medical education of general practitioners based on small peer group discussions using hospital specialists as a group resource would not necessarily reduce variation in clinical practice between general practitioners. A need for evidence-based rather than consensus-directed guidelines would be needed in order to reduce variation in clinical practice between doctors.
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