Background
-
Which ambulatory care problems currently exist from the perspective of general practitioners and their patients in northern Germany?
-
How do these problems vary between urban, environ and rural regions?
Methods
Study design
Recruitment
Definition of recruiting areas/region types
Sample
Urban areas | Environs | Rural areas | |
---|---|---|---|
Age in years: | |||
mean ± sd: | 54,3 ± 7,7 | 50,6 ± 8,8 | 55,0 ± 9,7 |
Gender: | |||
Male | 18 | 14 | 12 |
Female | 6 | 5 | 10 |
Number of patients treated in practice in each quarter: | |||
Up to 749 patients | 42% | 5% | 9% |
750 patients and more | 58% | 95% | 91% |
Number of physicians working in practice: | |||
1 | 21% | 48% | 41% |
2 | 46% | 21% | 46% |
3 | 17% | 21% | 14% |
4 | 13% | 5% | - |
5 | 4% | 5% | - |
Years of practice experience: | |||
mean ± sd | 17,4 ± 10,0 | 12,4 ± 9,4 | 15,4 ± 9,2 |
Type of practice: | |||
Single practice | 25,0% | 52,6% | 50,0% |
Group practice (common accounting) | 54,2% | 42,1% | 36,4% |
Community practice (separate accounting) | 20,8% | 5,3% | 13,6% |
Urban areas | Environs | Rural areas | ||||
---|---|---|---|---|---|---|
18–49 years | 50 years and older | 18–49 years | 50 years and older | 18–49 years | 50 years and older | |
Age: | ||||||
mean (sd) | 34,9 ± 10,3 | 60,7 ± 8,2 | 37,9 ± 7,6 | 65,5 ± 8,0 | 40,1 ± 8,7 | 64,8 ± 9,1 |
Gender: | ||||||
Male | 7 | 13 | 10 | 15 | 7 | 17 |
Female | 16 | 13 | 10 | 10 | 15 | 12 |
Marital status: | ||||||
Married | 17,4% | 61,5% | 45,0% | 84,0% | 50,0% | 82,8% |
Estranged (living in separate homes) | 8,7% | - | 5,0% | - | - | 6,9% |
Never married | 60,9% | 3,8% | 45,0% | 4,0% | 22,7% | 3,4% |
Divorced | 13,0% | 23,1% | 5,0% | 4,0% | 27,3% | 3,4% |
Widowed | - | 11,5% | - | 8,0% | - | 3,4% |
Education (in CASMIN grade): | ||||||
Grade 1 (low) | 17,4% | 42,3% | 15,0% | 40,0% | 27,3% | 34,5% |
Grade 2 (medium) | 65,2% | 42,3% | 75,0% | 32,0% | 54,5% | 58,6% |
Grade 3 (high) | 17,4% | 15,4% | 10,0% | 28,0% | 18,2% | 6,9% |
Employment: | ||||||
Employed | 87,0% | 38,5% | 95,0% | 32,0% | 63,6% | 27,6% |
Not employed | 8,7% | 23,1% | - | 8,0% | 18,2% | 17,2% |
Retired | 18,2% | 38,5% | 5,0% | 56,0% | 18,2% | 51,7% |
Not reported | - | - | - | 4,0% | - | 3,4% |
Chronic disease (yes): | 47,8% | 65,4% | 50,0% | 56,0% | 50,0% | 48,3% |
Degree of disability (20–100, yes)a: | 17,4% | 42,3% | 30,0% | 24,0% | 27,3% | 27,6% |
Data collection
Guideline patient groups | |
---|---|
Introduction: We invited you today to discuss “regional variations in primary care”. | |
First of all, please tell us the reasons for your last three consultations with your GP. | |
What did you expect your GP to do for you? | |
What did your GP do? | |
Which problems exist in primary care in your area of living? |
Introduction: By conducting this study we would like to identify differences concerning the work of GPs in big cities, environs and rural areas with regard to typical expectations, needs and treatment requirements. | |
Please describe the most common reasons for consultations in your practice. | |
Which kinds of patients consult you most often? | |
What do you think, what are the differences between working in your region of registration and bigger cities respectively rural areas? Please think of your own experiences of being a general practitioner or accounts of colleagues working for example in bigger cities or rural areas. Can you give some examples? |
Transcription and protection of data privacy
Data analysis
Results
No | Main category | Rural areas | Environs | Urban areas | |||
---|---|---|---|---|---|---|---|
Subcategory | GP | Pat | GP | Pat | GP | Pat | |
1 | Problems due to demographic change | ||||||
Aging patients and GPs | X | X | X | X | X | ||
Lack of young recruits in primary care | X | X | X | X | |||
2 | Problems due to patient behaviour | ||||||
Certain patient types are very time consuming | X | X | X | X | X | ||
Patients misjudge the necessity of treatment and consult their GPs too late | X | X | X | X | |||
Patients misjudge the necessity treatment and consult their GPs about banalities | X | X | |||||
Urban patients have less confidence in their GP’s abilities | X | X | X | ||||
3 | Problems through structural inequalities | ||||||
Not enough GPs in rural areas lead to long waiting times and crowded practices | X | X | X | X | |||
The work-life balance of the GP is threatened by long working hours | X | X | X | X | |||
(Too) many GPs in urban areas lead to high competition rates and to the poaching of patients | X | ||||||
(Too) many GPs in urban areas lead to a higher fluctuation of patients | X | X | |||||
A lack of parking spots leads to long commutes in urban areas (for GPs and patients) | X | X | |||||
Long distances lead to long commutes in rural areas (for GPs and patients) | X | X | X | X | |||
4 | Problems through the ambulatory compensation system | ||||||
GPs’ budgets are not adequate | X | X | X | X | X | ||
Some consultations are not financially compensated for GPs | X | X | X | ||||
5 | Problems with specialist care | ||||||
A lack of specialists leads to long waits for appointments | X | X | X | X | X | X | |
GPs have to assume duties of the specialists | X | X | X | X | |||
Specialists do not inform or inadequately inform their patients’ GPs | X | X | |||||
6 | Problems with inpatient care | ||||||
GPs must provide follow-up care for patients discharged with still healing wounds | X | X | X | ||||
Staff shortage in hospitals in rural areas | X | X | |||||
Lack of cooperation/communication between GPs and hospitals | X | X | X | ||||
Discharge reports are incorrect or missing | X | X | X | ||||
Prescribed medications from hospitals must be reduced by the GP on an outpatient basis | X | X | |||||
GPs and patients consider some hospital therapies/diagnostics unnecessary | X | X | X |
Category 1: Problems due to demographic change
“We are three people in [town in rural Schleswig-Holstein], one is about 70 […], I plan on working for a maximum of five more years and then there is only one person left for over 500,000 people [sic]” (Section 303, rural GP group)
Category 2: Problems due to patient behaviour
“I often have chest pain, for example, […], but then don’t go to the doctor’s because I say to myself: “Nah, then I have to queue up there.” […] I live far away too, and to go to the doctor’s just for that […], I’d rather not. One says to oneself, okay, it will go away again. […]” (Section 238, rural patient group)
“Yes, well, in rural areas a GP is still considered a guide, while in urban areas patients just come and say “I need a referral to a, b, c, d.”, and you won’t see them in your consulting room. (Section 286, urban GP group)
“Of course [one has] those kind of patients, […] which always go directly to a specialist, where we do not write a referral and therefore do not receive a medical report, then, […] in a worst case scenario, one receives a completely botched patient, who went to the wrong specialist with incorrect symptoms and […] which are overwhelmed with management of their […] diseases” (Section 338, urban GP group)
Category 3: Problems through structural inequalities
“In our area […] one barely has a chance being accepted as a regular patient of a general practitioner, in every practice you hear “Sorry, we cannot accept any more patients.“. That’s what we hear in our town. There are far too many physicians missing, […]” (Section 249, environs patient group)
“[…] one has to create clear boundaries […], so that they don’t come Friday night at 10 p.m. and say: “I have had a runny nose for three weeks.” One has to clearly state this. It cannot work that way and they seem to register that relatively quickly.” (Section 309, rural GP group)
“[…] but spontaneously I can think of five [physicians] right now, who all say “I cannot go on vacation anymore because I lose 50 patients every time, that I simply cannot afford to lose.”, that definitely happens in [city in northern Germany].” (Section 398, urban GP group)
“There is no bus anymore, the small train companies died out long ago.” (Section 356–359, rural GP group)
“I [worked] in a rural region […]. I parked in the yard, went in and left again. Here you have to look for a parking spot, park the car, do some little things and have to consider the traffic and whatever else…” (Section 268, urban GP group)
Category 4: Problems through the ambulatory reimbursement system
“[…] he says: “Honestly, I would love to prescribe you [massages], but I have far too many old patients who need them and that I should exercise.”. That’s it. Then I didn’t get massages prescribed from him. I went somewhere else and had massages prescribed.” (Section 96, urban patient group)
“[…] sometimes I write referrals, simply to ease the strain on my budget because the specialists have such expensive medications that I, being a general practitioner, cannot afford to prescribe them anymore. It’s that simple. I often write referrals […] to neurologists for this reason, it isn’t possible any other way.” (Section 70, rural GP group)
“Yes, sometimes it’s simply life-coaching, […] people… ask whether they should sell their house after a divorce, or if they should quit their job or not quit their job, or they face life-changing decisions which they seem to not be able to make on their own. I find it astonishing.” (Section 161–163, urban GP group)
“[…] Well, starting at severe depression and psychosis, one does get an appointment for the patients, but not for all our burn-out patients, where one would really like to have a specialist’s opinion on whether or not it is a depression or just shirking, etc. So, sometimes one is dependent on specialist colleagues. We are left alone. We also feel misused and, sometimes, I have the feeling that once we have convinced the patients that they should see a psychiatrist, half the work has already been done. […]” (Section382, rural GP group)
Category 5: Problems with specialist care
“And, or one uses the telephone and sometimes has to declare the patients more ill than they really are so that they get an appointment quickly, otherwise it doesn’t work out at all… Even then… one cannot constantly call someone and declare catastrophes […] (Section 238, environ GP group)
“The [orthopedists] are completely booked, it takes three to four weeks […] of course it’s annoying, […], running around in pain the entire time, so you take random pain medication, which in turn causes stomach problems and when you go to your appointment after 4 weeks, then the pain might not even be so bad anymore […].” (Section 280, urban patient group)
“[…] And in other cases, we have to bridge the waiting times until the necessary therapy in whatever form (to solidify an inpatient treatment or as outpatient therapy) can be administered through specialists. (Section 382–384, rural GP group)
Category 6: Problems with inpatient care
“Discharge management is a huge problem, you know? Patients often receive a “bloody discharge” on Friday afternoons… with luck medications are provided until Sunday evening. There is no way to access the medical report, the patient is at home, the daughter is standing in the practice […] at 1 p.m. on Friday.” (Section 442, environ GP group)
“[…] the [hospital] in [rural district in Lower Saxony]. I know that they have extreme problems filling the vacant positions because I have talked to one of the medical directors on the phone, who said that no one wants to live in the country, which is why so many physicians from abroad are hired, then there are language barriers, and they have to be integrated […] (Section 407, rural GP group)
“One could certainly make things easier, if the hospital-GP cooperation was improved. It is always a bit annoying, always having to call, but somehow I always had the feeling that I was properly announcing the patient. And now it’s pfft, send him/her over and pfft. Then the colleague there starts at the very beginning again, has no information whatsoever and I don’t like that.” (Section 322, rural GP group)
“Something that is very time consuming is the transition from inpatient to outpatient care. To get the patient back to the point where he is treatable as an outpatient and doesn’t have to live with just the hospital’s ideas. […] to get rid of the hundreds of medications. One has to bring the patient to an outpatient level.” (Section 86–88, environ GP group)