INCONGRUOUS REFERRALS

1195

Edinburgh Regional Computing Centre. 1344 interviews were completed, representing 3. 1% of the mean list size. The questionnaire included social factors as well as symptoms, and covered four main groups of physical symptoms for all subjects, mental symptoms for adults, behavioural symp-

Views of General Practice INCONGRUOUS REFERRALS

for children, and social symptoms for adults. The quesphrased in simple norr-technical language, and were designed to be mutually exclusive and exhaustive. All the symptoms referred to the previous two weeks only. Each positive symptom was subjectively graded according to pain, disability, and seriousness, as perceived by the subjects themselves. Pain and disability were graded as none, slight, moderate, or severe; and perceived seriousness was graded as not serious, might be serious, or serious. In addition, the action taken was asked for, and this was classified into a ranking scale of 1 for no referral, 2 for an informal or lay referral, and 3 for a formal or professional referral. A lay referral was an informal referral to a pharmacist, relative, friend, or acquaintance, which did not primarily involve a professional role, as opposed to a formal professional referral. The grading scales were the same for physical, mental, and behavioural symptoms, but were slightly different for social symptoms, for which formal referrals were extended to include such things as departments of social work, housing, and social security. For this reason physical, mental, and behavioural symptoms were considered together as medical symptoms, for the purposes of computing incongruous referral scores. the extreme categories of symptom gradings were used in calculating these scores, which were therefore rigorously defined: toms

D. R. HANNAY*

E. J.

MADDOX†

Departments of Community Medicine and Social and Economic Research, University of Glasgow A survey of 1344 patients registered at a new health centre in Glasgow assessed the prevalence of symptoms and referrals together with subjective gradings of medical symptoms in terms of pain, disability, and perceived seriousness, and of social symptoms in terms of worry or inconvenience. These grading scales were used to define referral behaviour which appeared to be incongruous in the light of the respondents’ own perceptions of their symptoms. In this way incongruous referrals indicated the size of the medical and social symptom "iceberg" and "trivia". For both medical and social symptoms the "icebergs" were larger than the "trivia"; the medical-symptom "iceberg" was two to three times greater than the medical-symptom

Summary

"trivia". INTRODUCTION

"illness iceberg" was used by Lastl to describe the extent of unrecorded illness in the communitv. Morbidity studies done before2 and after3 the start of the National Health Service, have indicated that in Britain only about a third of those with symptoms refer themselves for medical advice. And in a cross-cultural survey the symptom iceberg was found to be of similar size in other Western countries, irrespective of the primary-care system.4 None of these studies, however, relate the severity of symptoms to referral behaviour, and the results do not fit in with the concern expressed by many general practitioners about the number of "trivial" conditions presented to them.56 The existence of unreported symptoms and "trivial" referrals suggest a conflict of expectations between doctors and patients. We have taken the patients’ own assessments of their symptoms as a basis for deciding whether the referral behaviour was explicable in terms of these perceptions or not. The term "incongruous" was used for referral behaviour which seemed contrary to what might reasonably have been expected from the subjective severity of the symptoms. In this way it was possible to define the symptom "iceberg" and "trivia" more precisely in terms of an individual’s own awareness, rather than by some external criteria. THE

term

METHODS

We studied patients registered with general practitioners at health centre in Glasgow. Random monthly samples without replacement were drawn from the health centre’s computer file during 1972. Patients were interviewed in their homes using a structured questionnaire from which the date were transferred to punch cards after coding. The results were analysed with SPSS computer programs using the on-line facilities from Glasgow University to the I.B.M. computer at the

tions

were

Only

(1.) Incongruous medical lay referral score.-The number of medical symptoms per subject for which the referral was none or lay when either the pain or disability was severe or the symptom was considered to be serious (i.e., medical symptom "iceberg"). (2.) Incongruous medical professional referral score.-The number of medical symptoms per subject for which the referral was professional when the pain and disability were none and the symptom was not thought to be serious (i.e., medical symptom "trivia"). (3.) Incongruous social lay referral score.-The number of social symptoms per adult for which the referral was none or lay when the worry or inconvenience was severe (i.e., social symptom "iceberg"). (4.) Incongruous social professional referral score.-The number of social symptoms per adult for which the referral was professional when the worry or inconvenience was slight (i.e., social symptom "trivia").

socialsymptoms

306

(22-8,%))

of all

subjects

had at least

one

medical

symptom for which they did not seek professional or formal advice although they said that either the pain or disability was severe, or that they thought that the symptom was serious. The frequency distribution for the incongruous rnedical professional referral scores was as follows:

a new

"Present address: Department of General Practice, University of Glasgow, Woodside Health Centre, Glasgow G20 7LR.

†Present address: Department of Social and Preventive Medicine, versity, Melbourne, Australia.

Monash Uni-

subjects had at least one medical they sought professional advice the pain and the disability as both although they graded

126 (9-4%) of all symptom for which

think the symptom was serious. social Incongruous lay referral was less common. 36 (3.7%) of all adults had one or two social symptoms for which they did not seek formal advice although they said a lot of worry or inconvenience was being caused:

none, and

did

not

1196

l

The

5 (U - 3 -/,,)

distribution for the incongruous social professional referral scores was as follows:

frequency

of all adults had one or two social symptoms for which they sought professional advice although they said that only slight worry or inconvenience was being caused. The incongruous medical and social referral scores are not directly comparable because medical referrals included those of all ages (total 1344) whereas the social referrals were for adults only (964), and the grading systems for the two groups were slightly different. In addition, the proportion of adults with social symptoms was smaller than the proportion of all subjects with medical symptoms. However, it is possible to adjust for this in order to compare the four incongruous referral scores. This can be done by using the numbers of subjects and adults with medical and social symptoms (respectively, 1183 and 226) as the bases for calculating percentages, rather than the total numbers of subjects and adults (1344 and 964). 28

(2.9%)

The amount of incongruous referral is similar for both medical and social symptoms, with more people not seeking formal advice when they probably should do, than the other way round. The data for incongruous medical lay referrals suggest that the "iceberg" of medical symptoms is about two-and-a-half times the size of the possible "trivia" which are taken to doctors. There does not appear to be the same difference between the possible "iceberg" and "trivia" for social symptoms. DISCUSSION

The incongruous referral scores were an attempt to handle the concepts "iceberg" and "trivia" in a way which did not involve value judgements about whether symptoms were or were not appropriate for professional referral. The only definitive decisions concerned the cutoff points which were used for the symptoms gradings. In the event these were as rigorous as possible, so that incongruous referral scores were only computed for those whose referral behaviour appeared inexplicable in terms of their own assessments of their symptoms. Identification of such referral patterns might throw some light on the illness "iceberg" in the community and on those who go to doctors with "trivia"; and the analogy has been extended to social symptoms to see how far social agencies (of which the social-work department is only one) "fit" the perceived problems of people in the

community. Several studies have looked at hidden morbidity in the in Britainand in other countries (e.g., the studies of hidden morbidity amongst housewives in Holland8 and of the health requirements of an urban population in Russia9) but none of these studies attempted to define what symptoms and illnesses were appropriate for

community

medical referral. There have also been surveys of the workload of general practice in Britain Canada," and New Zealand, 12 13 and of normal demands for medical care (e.g., Bogatzriew’s study in Russia14) but none of these attempted to assess the quality of the demand. A study of health referral patterns in Los Angeles" reported that 80% of medical referrals were "inappropriate", and a follow-up of patients in Germany" concluded that 11 % of the conditions were " trifling"-but the criteria used in reaching these conclusions seem to take no account of the perceptions of the patients concerned. 22-8% of all subjects in the present study had at least one medical symptom for which they did not seek medical advice, when there seemed to be good reason for doing so. The proportion of those comprising the medical symptom "trivia" was much smaller than this, being just under 10% of subjects who referred at least one medical symptom for professional attention when there seemed to be no reason for this from their own evaluation of the symptom. At a conference on integration in the reorganised N.H.S., one of the themes brought out was the desire of the professional groups to be rid of what they described as "trivia"," and Mechanic18 has concluded that frustration with trivia amongst British general practitioners decreased the quality of care provided. The frequency distributions for the incongruous social lay and professional referral scores show that less than 4% of adults were part of a social symptom "iceberg" and less than 3% had social symptom "trivia". The "iceberg" was greater than the "trivia" for both medical and social symptoms, but the most striking difference is the preponderance of the medical symptom "iceberg". Bygren19 screened 2500 adults in Stockholm and concluded that the ratio of met to unmet medical needs was 1/1 whereas the equivelant ratio for social needs was 5/3. These findings confirm our impression that there is more unmet medical than social need in the

community. Because of the

high rate of mobility in Glasgow due slum clearance and redevelopment, many of those drawn from the computer file were not at the address given for them.2O Young adults were found to be under-represented amongst those interviewed presumably because they were the most likely to move, and the least likely to attend the health centre, which was the only way a change of address within the Glasgow area could be recorded. If anything the effect of the non-response rate would be to underestimate the size of the symptom iceberg. Our findings suggest that the symptom "iceberg" is a greater problem than "trivia", so official campaigns to discourage people from troubling their doctors unnecessarily may be misdirected. There certainly appears to be a lack of fit between the expectations of those who provide services and the perceptions and referral behaviour of those who are supposed to use such services. This behaviour is the result of a complex interaction between personal and environmental factors, as well as the response to individual symptoms. For instance, of the 360 subjects with one or more incongruous medical lay referrals, 21 (6-9%) also had incongruous medical professional referrals, so that the same person might be part of the symptom "iceberg" and "trivia". to

This study was made possible by a grant from the Social Science Research Council. We thank the Departments of Community Med)cine and Social and Economic Research for their encouragement, the

1197

general practitioners at the Woodside Health Centre for permission to

interview their patients, Mrs E. McLaren, Mrs H. Scobbie and Mrs M. Wyllie for their help as interviewers, and Mrs M. Steele for secretarial assistance. Requests for reprints should be addressed to D. R. H. REFERENCES 1. Last, J. M. Lancet, 1973, < 28. 2. Pearce, I. M., Crocker, C. H. The Peckham Experiment. London, 1943 3. Butterfield, W. J. H. Priorities in Medical Care. London, 1968. 4. Butler, J. R. Br. J. Sociol. 1970, 21, 241. 5. Cartwright, A. Patients and their Doctors. London, 1967. 6. Mechanic, D. Medical Sociology. New York, 1968. 7 Wadsworth, M. E. J, Butterfield, W. J.H., Blaney, R. Health and Sicknessthe Choice of Treatment, London, 1971. 8 van der Velden, H. G. M. Tijd. soc. Geneesk. 1973, 51, 140. 9. Iwanow, K. P. Zdrow. Publ. 1969, 80, 893. 10 Bernstein, J. M., Dolan, L. J. Update, 1972, 4, 993. 11. McFarlane, A. H., O’Connell, B. Q. Can. med. Ass. J. 1969, 101, 259 12. Meredith, H. C. N. Z. med. J. 1972, 76, 247. 13. Ridley Smith, R M. ibid. 1973, 79, 240. 14. Bogatzriew, I. D. Zdrow. Publ. 1969, 80, 883. 15. Cauffman, J. C. Am. J. publ. Hlth. 1974, 64, 331. 16. Wesiack, W. Munch. med. Wschr. 1971, 113, 1023. 17. Dopson, L. Pulse, June 27, 1973. 18 Mechanic, D.J. Hlth. soc. Behav. 1970, 11, 87. 19. Bygren, L. O. Scand.J. soc. Med. 1974, suppl. no. 8. 20. Hannay, D. R. Lancet, 1972, ii, 371.

Round the World United States

Public Health MORTALITY STUDY OF WORKERS IN A POLYVINYL-CHLORIDE PRODUCTION PLANT B. W. DUCK J. T. CARTER B.P. Occupational Health Middlesex

Unit, Sunbury-on-Thames,

E. J. COOMBES B.P. Chemicals International

Ltd, Penarth,

Glamorgan Summary

Age-standardised mortality-rates for a population of 2100 male workers exto posed vinyl chloride for periods of up to 27 years do not show any excess of total or cause-specific mortality. 1 case of angiosarcoma of the liver was identified just outside the study period. There was no suggestion of an increased frequency of deaths from the more common malignant diseases.

SMALL-TOWN MEDICINE

Here in remote North Carolina there is a pleasant little town (population 2400-2500). On opposite sides of one of the main streets two doctors practise, not in partnership but in amity. The younger is also mayor, and he has a dacha outside the town with a small menagerie, as well as a marina which may be used by as many as 150 boats on a summer weekend. The two doctors are the sole medical staff of a hospital with 52 beds, 40 of which are staffed and serviced at present-most of the hospital is new building just becoming occupied. There is an X-ray department, a well-equipped clinical pathology laboratory staffed by technicians, operating-theatre and plaster-room, intensive-care unit, physiotherapy department, maternity department (all deliveries conducted by doctors, no midwives), and so on. The nurse-anaesthetist is always on call, but usually has to work only three or four hours a day. The basic hospital charge is$42 a day, which is about one-third as much as in the nearest university hospital 150 miles away. The administrator knew his job and had planned much of the development himself, though he was not trained to do the work, and described himself as a retired merchant. The medical work seems excellent, as far as one can tell without actually having been a patient there oneself. The building and equipment were paid for by the inhabitants of the locality, not by the County or State. The elder of the doctors is not insured against malpraxis. When the time came for him to renew his insurance, the company would not do it. This company is the major medical insurer in the State and it wished to jump premiums up by 82%. The two other companies concerned wanted to put them up by 46%. The State insurance commissioner would not allow either increase. The main insurance company was said to have paid out in claims less than 10% of the money paid in as premiums between 1969 and 1973, and less than 17% over a 17-year period. In their defence they say they must budget ahead, for claims can be brought for malpraxis suffered up to 10 years previously, and a 5-year lag is common. They have refused to renew insurance at lower premiums, so quite soon no doctor in North Carolina will be insured for medical defence, unless the North Carolina Medical Society, with the support of the tax commissioner, manages to establish its own insurance company. This has already been done in a few other States. Meanwhile, the senior of the two doctors, who has practised in the town for nearly 30 years, will take no new patients, but will go on looking after those whom he knows, in mutual trust. ’

INTRODUCTION

VINYL chloride has been polymerised at a factory in South Wales since 1948. Before 1968 vinyl-chloride monomer was also produced on the site. Vinyl chloride, a gas at atmospheric pressure, is polymerised under pressure in autoclaves to polyvinyl chloride (P.v.c.) which is then dried and bagged. Exposure to vinyl chloride is possible at any stage in the process, the highest exposure levels being during autoclave cleaning, a process which used to be done manually. Lower levels of exposure would almost certainly have been experienced by other workers at the polymer plant and by all workers on the monomer plant. The lowest levels of to have been encountered in the exposure were and bagging storage areas. Maintenance and superstaff also have had low or occasional would visory to chloride. exposures vinyl

likely

METHODS

When the first evidence of liver angiosarcoma in workers exposed to vinyl chloride became available in February, 1974,1 we began to look for similar cases among workers at the Penarth plant. All workers who had been exposed to vinyl chloride at any time since 1948 were identified from company records. Details of their exposure histories were taken, and they were traced to see if they were still alive. All men still working on the plant or elsewhere on site. were identified, and local electoral rolls for 1973 and 1974 were searched for retired and other former employees. All men known to have died were listed, and a list of untraced individuals was submitted to the Department of Health and Social Security for identification of those shown as dead on National Insurance records. Individuals who emigrated were not identified separately. Death certificates were obtained for all known deaths, and the causes of death were coded according to the International Classification of Diseases (8th revision) and checked by Office of Population Census and Surveys staff. Mortality experience in the exposed population was compared with that found in males aged less than 75 years in England and Wales for the period 1955-72. Deaths at ages over 74 years and before 1955 were excluded. The national