Family Medicine

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World Book of Family Medicine – European Edition 2015 the inclusion of GPs in taskforces that promote a more rational use of antibiotics. The fact that these GPs are more motivated to prescribe fewer antibiotics than other GPs seems logical since they are more aware of the threat of antimicrobial resistance. Take-Home Messages GPs involved in study groups on the rational use of antibiotics are more aware of antimicrobial resistance. These primary care physicians prescribe fewer antibiotics and use more narrow-spectrum antibacterials than GPs not particularly interested in the rational use of antibiotics. These clinicians also use more rapid tests that can help GPs to better distinguish viral from the bacterial respiratory tract infections. An intervention aimed at promoting more prudent use of antibiotics for respiratory tract infections is able to improve the prescribing of antibiotics. However, strategies to improve the use of antibiotics seem to be less effective among GPs involved in study groups than in the general population of primary care physicians, mainly because the baseline prescription of antibiotics is much lower. Original Abstract http://www.woncaeurope.org/content/133-improving-prescribing-antimicrobial-drugs-primary-health-care References 1. Michael CA, Dominey-Howes D, Labbate M. The antimicrobial resistance crisis: causes, consequences, and management. Front Public Health 2014;2:145. 2. Mizgerd JP. Acute lower respiratory tract infection. N Engl J Med 2008;358:716–27. 3. Hopstaken RM, Stobberingh EE, Knottnerus JA, Muris JW, Nelemans P, Rinkens PE, et al. Clinical items not helpful in differentiating viral from bacterial lower respiratory tract infections in general practice. J Clin Epidemiol 2005;58:175–83. 4. Versporten A, Bolokhovets G, Ghazaryan L, Abilova V, Pyshnik G, Spasojevic T, et al; WHO/Europe-ESAC Project Group., Antibiotic use in eastern Europe: a cross-national database study in coordination with the WHO Regional Office for Europe. Lancet Infect Dis 2014;14:3817. 5. Bjerrum L, Munck A, Gahrn-Hansen B, Hansen MP, Jarbol DE, Cordoba G, et al. Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) – impact of a non randomised multifaceted intervention programme. BMC Fam Pract 2011;12:52. 6. Lervy B, Wareham K, Cheung WY. Practice characteristics associated with audit activity: a medical audit advisory group survey. Br J Gen Pract 1994;44:311–4. 7. Dallas A, van Driel M, van de Mortel T, Magin P. Antibiotic prescribing for the future: exploring the attitudes of trainees in general practice. Br J Gen Pract 2014;64:e561–7. 184
World Book of Family Medicine – European Edition 2015 Heinz-Harald Abholz, MD abholz@med.uni-duesseldorf.de 60 – Comprehensiveness and Continuity of Care - Core values Necessary for the Survival of General Practice Heinz-Harald Abholz, MD Emeritus Professor, Institut für Allgemeinmedizin, Universität Duesseldorf Germany Frankly spoken, General Practice is especially appreciated by politicians because it is cheap and effective. And providing good care for little expense truly is a value - especially in poorer countries. But it is also true for richer countries where specialized care is becoming rapidly more expensive because of the sophisticated developments in diagnostics, treatments and pharmaceutics – even if this progress involves only very small steps of being “better” in diagnosing or treating. In other words, specialists are making care more and more cost-ineffective. General practice can still be cost-effective because not all the possible diagnosing and treating is actually carried out in all “cases”. General practitioners (GP) decide on the “individual patient” and not on the “case”, e.g. they are not doing the same in all patients with a similar problem. This is basically different from the specialist, who usually does not know the patient well and therefore follows, more or less, a guideline, i.e. is doing more or less the same in each similar consultation. If one is not doing all that is possible, one is at risk to make mistakes, miss a diagnosis etc. There are two things reducing this risk: first of all, one has to reflect on all the possible things which can be done, but then decide on what can also be left out by following Bayes' theorem. This process needs sound medical knowledge as all possibilities must be known to become part of this reflection. Secondly, there has to be good knowledge of the patient and his/her lifecircumstances, his/her preferences and values and, last but not least, his/her way of handling/coping when being ill. Combining all these factors, a decision is a complex process and is made for just this patient in that particular situation and with these special findings – and often by discussing it with the patient. This way of decision-making saves money – otherwise often spent on futile diagnostic or therapeutic procedures. And it decreases stress for the patient by reducing the proportion of false-positive results (Bayes theorem) and by reducing over-treatment. What allows GPs to know their patients well? The GP is the only doctor seeing his/her patient over several years and under different circumstances of health and illness. Additionally, an emotional relationship between doctor and patient is established through the length of their association which allows them to understand one another instead of simply knowing the facts about him/her. With this background, GPs are at an advantage in noticing even subtle differences in his/her patient - in the way of behaving, moaning, talking, looking and expressing him or herself. This knowledge can be employed in “interpreting” the patient and his problems and wishes – and hence finding an appropriate decision for a certain situation. All this can only work if the doctor can see his/her patient often and under different circumstances. In other words, GPs have to provide comprehensiveness and continuity in care – and society has to guarantee this. This makes continuity and comprehensiveness not only popular 185
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