Test before fielding

Some time ago we wrote of the many different ‘jobs’ covered in general practices, neglecting on that occasion to state the obvious – that every ‘job’ must be executed according to the law.¹ Our guest editorialist brings us right up to date with the changing law relating to abortion and its implications for primary care providers.² Infectious disease reporting is another job governed by law. The benefits of knowing about the spread of infectious disease and being able to institute measures to contain that spread are self-evident, so doctors willingly engage in such reporting as part of their job. However, any additional task over and above providing clinical care to patients needs to be easy and time-efficient, as well as important, before asking it of doctors. An essay in this issue draws attention to the complex and illogical manner of recent changes to the reporting system for sexually transmitted diseases.³ Certainly the function is important, but the process is neither easy nor time-efficient, as illustrated in this story. The New Zealand Ministry of Health has acknowledged the problems and are working to remedy them (see response to the article by Dr Stefanogiannis, Deputy Director of Public Health). Perhaps the important message from this experience is that IT solutions need to be thoroughly tested before they are fielded in primary health care.

There are many ways to test healthcare interventions through research: the use of research results critically depend on the research design. In this issue we publish a study suggesting that repeat prescribing processes and registrars’ introduction to practices could do with tightening up - but due to its design can do no more than this.⁴ A strength of this study is its wide range of stakeholder involvement and careful presentation, but the design means that it is not generaliseable: most general practices are not represented in this study and there is no evidence to suggest that similar results would have been produced if they had been included. Designing and carrying out research that can be used to develop national policy is an important task for primary care research so that immature or inappropriate solutions are not fielded.

On the matter of medicines, we have an analysis of adherence to insulin treatments for diabetes in one region.⁵ As a nation we probably have the most comprehensive data for dispensed medicines anywhere in the world. These data were used to identify widespread problems with uptake of oral insulins, implying that interventions are needed to assist patients in the region to have optimal treatment for their diabetes.

Systematically referring to existing literature to developed a balanced understanding of an issue has been a valid research approach for more than 40 years.⁶ In this issue we publish two literature reviews. Hilder’s review grapples with definitions of the roles involved in assisting patients with limited English language competency to navigate health services, specifically exploring the terms ‘healthcare navigation’, ‘Community Health Worker’ and ‘interpreter’.⁷ The point is that if a person is to fill a role to meet a healthcare need, that role should be explicitly articulated using correct language. The other systematic review more classically examines whether patient leaflets have any impact on participation in screening programmes: it appears that they do.⁸

We present two clinical audits.^9,10 One audits the use of faecal immunological tests, that are now not recommended for use outside the bowel cancer screening programme.⁸ A tiny minority of patients had general practitioner (GP) initiated tests in the audited large general practice (~0.001%). This result is reasonably reassuring of the practice’s clinicians’ commitment to following national recommendations. The other audit reports on the outcomes of a cohort of GP patients whose varicose veins were treated with cyanoacrylate glue embolization.⁹ This is a new treatment. Varicose vein treatment was traditionally in the surgical domain but is now increasingly becoming a general practice special interest. A range of treatments are now being tested and compared. Just this month the New England Journal of Medicine published a comparison of long-term (five-year) outcomes of three treatments, not including the new process explained in this article.¹¹ We look forward to hearing in the future about the long-term outcomes of cyanoacrylate glue embolization. GP use of publicly funded investigations such as Magnetic Resonance Imaging (MRI) is another extension of traditional general practice. Although others have found that GP referrals for MRIs lack diagnostic relevance, in the context of a clear treatment pathway Kara and colleagues have shown that GP initiated MRI referrals are usually appropriate.¹²

Another clinically oriented paper investigates how nurses manage difficult conversations around child obesity, now that this is a mandatory component of Before School Checks for children.¹³ Honing their communication skills seems to be at the core of successfully dealing with these challenges.

Medical education continues to develop. In this issue we have a case study about the effects on the development of professionalism of compulsory student engagement in a ‘reflection’ group rather than leaving reflective professionalism to be implicitly learned.¹⁴ Our case study in this issue also contains an implicit plea for medical students to be taught in a way that allows them to accept other possibilities than traditional biomedical solutions in helping patients to recover from pain and disability.¹⁵ Illustrated by a story of a 15-year-old girl’s recovery from chronic knee pain, the authors make a case for the role of neuroplasticity in pain resolution.

So this issue of the Journal is full of things that have been tested and things needing to be tested further. May you enjoy sorting one from the other.