There is a chapter on aero medical repatri- ation, increasingly important ..... Teleradiology has developed ahead of other specialties in the USA, where it is fully ...
Family Practice © Oxford University Press 2002
Vol. 19, No. 4 Printed in Great Britain
Book reviews
Quality indicators for general practice: a practical guide for health professionals and managers. Martin Marshall, Stephen Campbell, Jenny Hacker, Martin Roland (eds). (201 pages, £19.50.) Royal Society of Medicine Press Ltd, 2001. ISBN 1-85315-488-1.
book as it espouses sensible, credible measures that can be introduced gradually by those who deliver care to patients. The idea that doctors should do it all at once can be readily debunked with this practical guide. LAURENCE BUCKMAN GP in London and a negotiator for the BMA with the UK Government. He is leading discussions on quality in the new GP contract
This is a terrific book. It is a reference source for all who seek to use indicators to measure quality. That means everyone in the health business everywhere. Unlike many volumes on the subject, the group from the National Primary Care Research and Development Centre in Manchester University have written a practical guide on how to use clinical data sources as quality audit tools. Even more useful are the easily accessible ‘Recommended quality indicators’ sections in grey boxes at the end of each of the main chapters. One could almost read these and put the indicators to work without looking at the rest of the text, but this would be a mistake. Each chapter explains why the particular disease presents a problem, reviews the evidence for using certain measures as indicators (including diagnosis, treatment and follow-up) and then considers the data sources and references them. After reading any of the central 19 short chapters, few readers would find themselves unable to think of ways to introduce quality measures into their clinical practice, or to enable others to do so. For example, in the chapter on urinary tract infections, there is a good review of current opinion on the management of these conditions, including the role of urine culture in diagnosis. I have not read the evidence for the use of dipsticks before (as much of the published work is American), but found the comparisons with microscopy interesting. Equally welcome is the reinforcement of the need to refer children promptly to prevent renal scarring. Finally, the chapter ends with its list of recommended sensible quality indicators laid out in almost a cookery book style that any practice could implement without much intrusion into the crowded day. For those who might find this hard, the editors have prepared a set of operational manuals on their university website that readers can use in their practices as well as a formidable list of references. In thinking about performance, it is important to consider using the right indicators for an area that interests the reviewer. This caveat needs to be reinforced within primary care organizations that would seek to regulate family doctors to death. Even bureaucrats will get something out of this
Personal medical service pilots: modernising primary care? Richard Lewis, Stephen Gillam, Clare Jenkins (eds). (143 pages, £14.99.) King’s Fund Publishing, 2001. ISBN 1-85717-452-6. The Labour government in the UK has set out to modernize public services. One policy example relevant to primary care is provided by the pilot schemes for Personal Medical Services (PMS), which started in 1998. The editors of this book, through their work with the King’s Fund in London, have evaluated some of these pilots. These experimental schemes were designed to overcome the perceived limitations of the existing contract for GPs. They aimed to encourage innovation and to improve access to health care, especially for marginalized groups. Some pilots created posts for salaried GPs, in existing practices or in new units, and others employed nurse practitioners, occasionally as the leaders of primary health care teams. They have served populations ranging from 2000 to 24 000 or so, sometimes concentrating on the homeless or refugees. The largest group was based on the patient lists of three practices (which merged to become a single partnership) in Surrey. This highly readable yet scholarly book considers the policy background and includes an evaluation of pilots in London. Later chapters, mostly written by the key health professionals concerned, describe the challenges and achievements in early schemes across England. There are particularly thoughtful chapters from nurseled pilots, by Lewis, Gardner and Baraniak. These discuss the tensions that could arise in relations between nurse practitioners and doctors. Some of these seemed to come from legal uncertainties, relating to malpractice cover, prescribing and providing death certificates. Schemes elsewhere provided practical and educational support to 426
Book reviews
solo GPs, so overcoming their isolation. Yet others have increased the provision of specialist services in primary care, through commissioning specialists or employing GPs with special interests. The book concludes with an overall view of the significance of PMS, which now covers 24% of the population. The new system may have enabled improvements in quality of care, efficiency of provision and access to care especially for underserved groups, but the authors are sensibly cautious in their conclusions. They also point out that the benefits of the pilot schemes may be spread more generally, through a new national contract currently being negotiated for GPs. JOHN WILMOT GP in Warwickshire and Senior Lecturer, Centre for Primary Health Care Studies, University of Warwick
Principles and practice of travel medicine. Jane N Zuckerman (ed.). (513 pages, £150.) John Wiley & Sons Ltd, 2001. ISBN 0-471-49079-2. Foreign travel has grown by over 7% per year in the last few decades. The elderly and chronically ill account for an increasing number, and by 2010 it is estimated there will be nearly one billion international tourist arrivals. Tourists now travel further afield seeking out more exotic locations with increasing health risks. Whilst abroad, many try hazardous new pursuits with further associated health risks. Add to tourism the increasing number of overseas workers and refugees with their own health care needs, and it is clear that there is a need for a quality information source. The medical literature has lagged behind this travel explosion until now. Jane Zuckerman has compiled the most comprehensive up to date text on travel medicine ever. There are nearly 50 international experts contributing to this extensively referenced and indexed hardback of over 500 pages. Each section is covered in impressive detail, allowing a deep understanding of the principles. For instance, the usual sections on the infectious diseases of viral, bacterial and parasitic origins deal with the nature of the infectious agent, the epidemiology, pathology, clinical features and diagnosis, management, treatment and prevention. There is a section on travellers with special needs including children, pregnant women, the immunocompromised, the elderly, the disabled, the chronically ill, expatriates and the increasing problem of refugees. The section on environmental hazards covers poisons, venomous bites and stings, educating the reader on the various venomous animals including the safest methods of dealing with such incidents. There is a chapter on aero medical repatriation, increasingly important as there are now around 1000 air ambulance transfers into the UK per year.
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The section on aviation medicine is extremely comprehensive, going beyond routine travel. It starts by educating the reader of the physical gas laws and then relates this to respiratory physiology before looking at the effects on the traveller, and includes aviation psychology. In addition, there is a useful table of conditions that render patients unfit for air travel. Expedition and sea/ cruise medicine are also covered, and there is a chapter devoted to the increasingly popular sport of scuba diving. I have found the book easy to read and highly informative. It has covered topics not usually found in other foreign travel texts, which will be useful when dealing with the demands of today’s various travellers. As a reference book, it will be invaluable and will replace my usual reference sources. GARY E ARAM Lecturer in The Department of General Practice and Primary Health Care at Leicester University, and a GP with a special interest in foreign travel medicine
Guide to education and training for primary care. Yvonne Carter, Neil Jackson (eds). (372 pages, £24.50.) Oxford University Press, 2002. ISBN 0-19-263293-0. This book has an ambitious title and the back cover states that it will help Primary Care Groups/Trusts build a clear education and training strategy. As I opened it, I wondered whether it was only going to cover the education of doctors, whether it might include nurses, or even the full range of people covered by Primary Care Trusts, such as practice managers, pharmacists and dentists. The answer, as so often happens in books with each chapter written by different authors, is that it depends which chapter you are reading. Thus Chapter 3 looks at the broad range of interprofessional and multiprofessional education and training, whilst the next chapter on clinical governance concentrates exclusively on GPs. In the main, the book focuses on the postgraduate training and continuing education of GPs. The first chapter begins: “The organisation and funding of education and training systems within the NHS in England is complex and difficult to understand” and is followed by a full guided tour of SIFT, MADEL, NMET and all the other acronyms used. This is scarcely an inspiring or visionary start for someone living in England, let alone elsewhere in Britain or further afield. Following chapters cover a wide range of topics such as the principles of assessment, use of new technologies in education, and there is a brave attempt to cover research methods in medical education in a single chapter. The words ‘quality’ and ‘clinical effectiveness’ are recurrent themes, but there is evidence of poor editing, with overlap when discussing the same topic in different chapters, and lack of referencing.
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I did not learn much new from this book, except in two chapters. Chapter 7 by John Schofield and Neil Jackson interestingly compares quality assurance in health care with car production in Japan, and the final chapter by Rosslynne Freeman takes a broad perspective on mentoring in education, nursing and medicine. She also clearly distinguishes education from training, an issue that is fudged in other parts of the book, but does highlight the tensions between ‘education’ and ‘service’. Training is a process of acquiring skills to carry out a specific task with a known outcome, whereas education is preparation for the unknown and retrieving knowledge to respond accurately to complex problems. Surely the time spent as a GP registrar is education. Therefore, having finally got rid of the term ‘GP trainee’, should we not change the name of ‘GP trainer’ as well? What about ‘GP educator’?
material on the principles of adult learning. Even one of its more attractive features, the ‘teaching case’, needs to be used with caution as important issues are overlooked in the text and potentially devalued to a novice reader. The book is also insufficiently explicit and the reader must use his or her awareness as an experienced teacher to fill in the gaps. It is also not specific enough in the advice it offers. For example, in the chapter on ‘Observing, Developing and Reflecting on Residents’ Teaching Strategies’, the section on self-reflection demands that the learner develops self-awareness, but no advice is offered on ‘how to see the obvious’. This book could be of use in an education centre library as a resource from which experienced teachers can draw course materials. Used with care in this fashion, it has much to offer.
DAVID MEMEL Senior Teaching Associate in Primary Health Care, University of Bristol and a GP in Bristol
ROBERT K McKINLEY Senior Lecturer in General Practice and Primary Health Care, University of Leicester
Residents’ teaching skills. Janine C Edwards, Joan A Friedland, Robert Bing-You (eds). (280 pages, hardback US$ 42.95.) Springer Publishing Company, 2002. ISBN 0-8261-1436-9.
Making changes last. Jeffrey A Kottler. (174 pages, £23.50.) Brunner-Routledge, 2001. ISBN 1-58391-086-7.
This volume is intended to be a “primary text book for brief courses, workshops, seminars and conferences on resident [doctors in training] teaching skills”. It is a densely packed volume in two parts, the first entitled ‘Information and ideas’ and the second ‘Materials for teaching skills programmes’. The authors of this book exhort clinicians to embrace the spirit of Sir William Osler, especially the search for the ‘teachable moment’ in every encounter between learner and teacher. This exhortation is developed in the chapter on ‘Social Learning Theory’ in which the authors describe why everything we do as doctors is teaching for our students, trainees and peers. The rest of the first section is a distillate of the authors’ practice and experience of teaching, with extensive reference to American educational literature. Although highly context specific to North American secondary care, there is much of value for the discerning reader who wishes to teach others to teach: about teaching techniques, the importance of observation of teaching both as a learner and a supervisor and the basics of organizing a teaching skills programme. The second part of the book contains an abundance of material for developing teaching skills. Some of this is excellent, for example the section on small group teaching. The material in identifying and managing impaired performance of doctors in training is potentially most useful. The book, however, is not a self-learning text. It does not contain sufficient educational theory; there is no
The author states that, “The goal of this volume is to help you examine the ways that change persists in a variety of contexts and make adjustments in the way you work with clients in order to capitalize on the most potent effects”. How does the author set about achieving these tasks and to what extent does he succeed? The book is divided into nine chapters, each of which is subdivided into small sections, many of which are less than a page long. I found that this made the book easy to read through quickly but I was left with a rather confused blur, as many of the chapters and the short sections seemed to convey a similar message. After an introductory chapter about the process of change, there follows the longest chapter, ‘Stories of personal change’. A couple of chapters discuss the change process in more detail and the final chapters explore the process of lasting change. The author points out ad nauseam throughout the book that change is easy but maintaining that change is not. There are numerous anecdotes to illustrate this theme both from Kottler’s own life and from his clients and acquaintances. The book impressed on me how important maintaining change is in all facets of our lives. I came to this book following a difficult patch in my own life, as a result of which I resolved to make some changes in both my professional and personal spheres. I doubt if this book will help these changes to last. It is packed full of ideas but they are hard to tease out and remember and the style grates with me. Will it help me in my work with patients? Again, I doubt it. The author seems to forget much of the time that he is supposed to be writing for ‘therapists’ rather than lay people. In any case, it is hard to think of such a book being all that
Book reviews
helpful for generic ‘therapists’. It presupposes an essentially behaviourist approach. Therapists versed in this approach probably don’t need the book and those that aren’t probably don’t want it. PAUL SACKIN GP in Cambridgeshire. VTS course organizer and assistant editor Education for Primary Care
Handbook of women’s health: an evidence-based approach. Jo Ann Rosenfeld (ed.). (625 pages, £47.50.) Cambridge University Press, 2000. ISBN 0-521-78833-1. This is a beautiful book. It is nicely published in hardback with good quality paper. The book is stuffed full of facts, with extra special points highlighted in grey boxes, although there are no pictures or diagrams. It is an American book by famous American authors. Jo Ann Rosenfeld, assistant Professor at Johns Hopkins School of Medicine, is the editor who has written many books on women’s health. There are sections on preventive care, psychosocial health, sexuality, genitourinary medicine, breast disorders and psychological disorders. To give the reader an idea of the breadth of this book, there are specific chapters on cigarette smoking, nutrition, exercise, vaginitis, woman battering and eating disorders. There is even a chapter dedicated to special issues with lesbian parents. It has set out to give an evidence-based approach, and the mass of quoted studies on each subject and the references at the end of each chapter are extremely useful. I can’t wait to look up the study on Seventh Day Adventists that showed that increasing nut intake lowered the risk of developing CHD. There are many references to the different ethnic groups in the USA, which again is fascinating: for example, the different rates of gonorrhoea or cervical cancer amongst blacks, whites, Korean, Hispanic or native Alaskans. There is also a useful chapter on managing medical problems in pregnancy. From the UK perspective, Cambridge University Press have published a book to compete with the best selling Oxford University Press textbook ‘Women’s Health’, edited by McPherson and Waller. I have to claim an interest at this point, as I have been a contributor to this book and know it well. They are like chalk and cheese. The OUP text is British, the CUP Handbook of Women’s Health is North American. Thus, the CUP ‘Handbook of Women’s Health’ has to talk about “women who are uninsured or underinsured” as an issue. Also, on every facet of confidentiality or consent, it gives the American Law or recommendations, or that it varies from state to state, as opposed to mentioning the Gillick case for underage contraception in the UK. Similarly, on screening issues—a large part of this new book—the ‘Handbook of Women’s Health’ cites the American Cancer Society recommendations; that all women over
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the age of 40 years should have annual clinical breast and pelvic examinations, even though they discuss the poor sensitivity and specificity of these tests. Thus, although the evidence base is there, it is not used critically by the authors as much as I would have expected. I enjoyed reading this book and it has a huge raft of data for doctors interested in worldwide issues of women’s health. I liked the style, with its irrepressible American enthusiasm and naivety; for example, when discussing post-partum changes in desire and function “other factors such as role overload may affect sexual desire”. When talking to adolescent girls, it recommends the opening phrase “How are you doing in school?” as a friendly and caring way of starting to elicit signs of depression. I tried this out on my own surly 14 year old and cannot print the reply. Perhaps we really are two cultures divided by a common language, or perhaps I’m just suffering from ‘role overload’. SALLY HOPE GP Woodstock, Oxon, Honorary Fellow of the Department of Primary Care, University of Oxford
Postnatal depression: facing the paradox of loss, happiness and motherhood. Paula Nicholson. (236 pages, £8.99.) John Wiley & Sons Ltd, 2001. ISBN 0-471-48527-6. This book is one of a series “designed to provide expert advice to ordinary people struggling with everyday problems”. It is written by a research psychologist and the text draws heavily on pre- and post-natal interviews with 24 women. As such, it is very readable but, understandably, heavily anecdotal. In our evidence-based age, one must wonder about the generalizability of these findings—for a start, how were the subjects selected? Certainly, the topic is timely and important. The most recent ‘Confidential Inquiry into Maternal Deaths’ has shown that other causes of maternal death are being tackled successfully, leaving post-natal depression as the single remaining biggest killer. In the period covered by the Inquiry (1997–1999), there were about 70 deaths due to suicide within 12 months of birth, compared with 35 deaths from the second most common cause, thromboembolism. Family doctors must therefore learn to focus more on the emotions of women during and after delivery, rather than concentrating on the physical side of motherhood alone. The recent trend to reduce the number of ante-natal visits, justified by a saving of time with no disadvantageous physical outcome, may yet prove to have been short-sighted. What the book has to say seems valid clinically; the stories of the women ring true. But it is not going to be of real use to the family doctor in managing his heartbreaking cases of post-natal depression. It is at best an awareness-raising essay. In the patients’ library, however, this book could be extremely useful, giving permission,
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Family Practice—an international journal
as it does, to nearly all new mothers to have feelings of inadequacy and despair. Its stories of struggling women may well encourage a patient to consult her doctor or midwife, reassured, at least in part, that her painful emotions do not make her an unnatural freak. There are self-help suggestions that could also prove useful. PAT TATE GP and Psychotherapist in Cambridge Parenting well when you’re depressed: a complete resource for maintaining a healthy family. Joanne Nicholson, Alexis D Henry, Jonathan C Clayfield, Susan M Phillips. (234 pages, US$ 17.95.) New Harbinger Publications, 2001. ISBN 1-57224-251-5. The four authors have impressive credentials in their respective fields of psychology, occupational therapy, psychiatric rehabilitation and counselling, as well as clinical and personal experience of family mental illness. However, this book is the product of research involving a much larger group of people from many disciplines. These included parents and family members, service providers, welfare agency administrators and policy makers, who co-operated in a 3-year research programme— the ‘Parenting Options Project’—which was aimed at developing skill-training materials and strategies for parents with depressive, bipolar and other mental illness. The chapters deal with issues such as managing mood, balancing the demands of parenting with the needs of the depressed parent, coping with family finances, feeding and providing for both children and parents, communication, play, hospitalization and other forms of family separation, and negotiating in the legal and welfare fields. Although some details of the latter relate to the American system, the general principles remain relevant. The general approach is cognitive/behavioural, but owes most to well-directed common sense rather than theory. Like the title, the text is addressed directly and personally to the reader and is written in a style particularly suited to its intended audience. Mindful of the difficulties a depressed person may have in maintaining concentration, the writers have divided the text into short sections. They use clear headings and plain English with a minimum of jargon, and they have interspersed explanations and advice with short clinical vignettes, bulleted checklists, questionnaires, tables and exercises. This maintains interest and creates an interactive element to draw the reader into the process. They manage to avoid being patronizing, but encourage readers to believe they have the capacity to be good enough parents despite the difficulties of their illness and to use their good periods to make contingency plans for the bad times, so that they keep some control of what will happen. They are urged to look after themselves as well as their children, and to feel they too have rights and needs which at times should take precedence.
The book is dedicated “to parents and children living with depression”. It deserves to find a ready audience, not only as a self-help book for depressed parents, but also among their older children and the various professionals who have dealings with them, family doctors, social workers, teachers and the rest, to aid their understanding of their relative or client’s illness and how best to help them. Indeed, there is much here that would be valuable to any parents trying to juggle the conflicting demands and needs of their children and themselves. The subtitle ‘a complete resource for maintaining a healthy family’ says it all. MARIE CAMPKIN Retired GP in London The father’s book: being a good dad in the 21st century. David Cohen. (297 pages, £8.99.) John Wiley & Sons Ltd, 2001. ISBN 0-470-84133-8. I think I must have been asked to review this particular book because someone somewhere has encountered my kids! Unfortunately, there is nothing in this book that would have enabled me to do anything differently. It is a mixture of tabloid-style quizzes and wisdom gained by the author in undertaking a PhD on what makes children laugh. This includes an explanation of Piaget’s theories about babies and objects, with a final paragraph refuting it. Great for the PhD but not a lot of use in a ‘How to’ style book. Other areas covered include: ‘Does memory start in the womb?’ ‘You are pregnant—how do I feel?’ ‘Woody Allen versus history, the mysteries of mirrors’. This kind of mixture of pop-psychology combined with semiserious psychobabble seemed unsatisfying at all levels. However, I was pleased to learn that my self-assessment result on the ‘Attitudes to discipline’ quiz found me to be a liberal stable parent. There was no explanation of what this meant or how to anticipate the problems that this style might create. Much of the book is aimed at reassuring fathers that they are doing OK. Detailed analysis of the IQ test is followed by a final plea that it is normal for parents to want their children to shine but history is full of geniuses who developed late. Perhaps the overall theme of the book can best be summed up by a phrase from the introduction—“good enough fathering”. One area in which the book is strong is quotations. I learnt that Dylan Thomas’ immortal lines—“Do not go gentle into that good night rage, rage against the dying of the light” was written on witnessing his father’s death. On that note, which the author feels is the last farewell a child could give, I will leave you in peace. Your reviewer is a father of three who are the cleverest things in the world to me although at times they have driven me to distraction. GEOFF ROBERTS GP, Chairman of Surrey Heath PCG and joint lead for Clinical Governance
Book reviews
The patient’s Internet handbook. Robert Kiley, Elizabeth Graham. (294 pages, £9.95.) Royal Society of Medicine Press Ltd, 2001. ISBN 1-85315-498-9. Some doctors fear that once their patients are connected to the web, their lives will become a nightmare and they eventually will be out of a job. The former is up to them; the latter is highly unlikely. Cybermedicine is bound to be challenging and the answer is to keep one jump ahead. If patients read this book first, then the doctor will be several jumps behind. The authors are experienced medical librarians at the Wellcome Trust, one of whom has written the companion volume for doctors. They have done a good job in explaining how patients can find relevant information. They are critical of the quality of much on-line information and give good advice on searching. Metasearch engines, which collate the output from many search engines, and gateways can be very valuable, but were not well covered. There is a useful list of ‘dos and don’ts’ for patients to ensure that they do not antagonize their doctor. However, a bit of jargon slips in when patients are advised to “prioritize their appointment objectives”. The field is changing rapidly, and corrections are available on the publisher’s website www.rsmpress.co.uk. GPs inevitably have less knowledge in specialized domains, in relation to both their hospital colleagues and also their expert patients, who are well served by patient support groups. A hundred disorders are considered in 120 pages, along with addresses of support organizations, on-line discussion and news groups, and summary documents. This is extremely well done and is a good reason to have this book in the practice library. The consultation is an opportunity to share knowledge, and the Internet is a powerful tool, but it will take some time for all of us, doctors, patients and carers, to learn to use it quickly and effectively. To ignore the Internet may result in ‘connected’ patients not viewing their doctor as a source of knowledge and wisdom. This would be sad, as much of the on-line information is misleading to the lay person, or commercially motivated, and needs expert interpretation. Who is better as a trusted knowledge broker than the GP? This book will help them fulfil this role. PETER PRITCHARD
Essentials of telemedicine and telecare. Anthony C Norris. (177 pages, £27.50.) John Wiley and Son, 2002, ISBN 0-471-53151-0. Telemedicine today means much more than ringing up a consultant for a chat. Videoconferencing allows a virtual
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consultation between patient, carer, GP, nurse and specialist. All can share knowledge and decision making in real time. In addition, complex data and images can be transferred from isolated outposts for specialist reporting. In the future, we may see remote monitoring of complex biomedical problems using telemetry. The NASA space programme has led the way with telemetry of astronauts and also applied the methodology in rural communities in the 1950s. In 1967, airlines developed a video link with Massachusetts General Hospital for dealing with medical emergencies in flight. To the harassed GP, having difficulty getting a second opinion, the prospect is appealing, but widespread, glitch-free, broadband links are needed before telemedicine can come into general use. In isolated areas, such as northern Norway and Canada, where patients can only be brought to specialist centres by air in winter, telemedicine has special advantages. Indeed, much pioneer work has been based on Tromsø and Calgary. Teleradiology has developed ahead of other specialties in the USA, where it is fully reimbursed under Medicare. Elsewhere, take-up has been patchy, depending on local enthusiasm. To expect busy specialists to drop everything while they have a teleconference is unrealistic but, with so many doctors retiring early, this could be done from home and be a nice little earner! As more of the population have broadband Internet links in the home, there would be nothing to prevent a patient having interactive video links with people giving medical advice. Many patients’ associations already offer good services, and there is plentiful medical advice open to all on the Internet. However, the quality of the advice varies and may not be monitored. Commercial motives could bias objectivity. This gives a strong message for GPs to get involved at an early stage to guide their patients towards interactive websites that are evidence based. Before policy makers will advise a move of telemedicine from pilot projects to everyday practice, it must be shown to be cost effective. Some of the benefits are difficult to cost, such as the educational potential of telemedicine leading to more cost-effective use of specialist services. This could be an important factor, as telemedicine has great potential for on-the-job learning from ‘hot’ situations. The author of this excellent book is a specialist in information management and he has reviewed the subject clearly and thoroughly. The book is well structured and has lucid chapter summaries, a reading list, Internet information sources and over 300 references. PETER PRITCHARD Medical adviser, Advanced Computation Laboratory, Imperial Cancer Research Fund
