Towards a typology of general practitioners' attitudes to general practice

Sm . Sd. .Wed. Vol . 30, No. 5, pp . 537-547, 1990

0-77-953690 $3 .00+0 .00 Pergamon Press Pie

Printed in Great Britain

TOWARDS A TYPOLOGY OF GENERAL PRACTITIONERS' ATTITUDES TO GENERAL PRACTICE ROMGLA S . BUCKs, 1 ANGELA WILLIAMS,' MICHAEL J . WHITFIELD I* and DAVID A . ROUTH' Department of Epidemiology & Community Medicine, General Practice Unit, University of Bristol and 'Department of Psychology, University of Bristol, Whiteladies Road, Bristol BS8 2PR. England Abstract-Current knowledge about the origins of variations in general practitioners' (GPs') prescribing and referral behaviour is limited . Differences are as yet unexplained by demographic factors such as list size or geographic location. Drawing on social psychological theory it is suggested that attitudes towards general practice held by GPs may be predictive of GP behaviour . A classification of GP types on the basis of expressed attitudes may represent the first step towards this goal . This research demonstrates that GPs in Avon have identifiable attitudes to general practice which can be classified into separate types . Uses of such a classification and implications for further research are also discussed . Ket words-general

practitioner. typology, attitudes

out in Manchester in 1981-82 [6] . There were wide variations in prescribing rates per 100 consultations, from a prescription written in half the consultations to one written in 95 . Likewise some GPs referred 2 patients in every 100 consultations, one as many as 25 . These differences were not related to list size or age structure, or the geographical location in which the GPs practised . If demographic variables are not predictive of these differences then some more personal variable must be operating to cause such large variations in behaviour . It was our hypothesis that GPs with different attitudes to general practice would refer and prescribe in different ways and that `types' of GP attitudes would be found upon examination of GPs' responses to a questionnaire, about their views of their role as GPs and their feelings about being a GP . Thus our study aimed firstly, to determine Avon GPs' own beliefs about what constitutes general practice and secondly, to ascertain to what extent differences in prescribing and referral behaviour could be explained by these views . This paper reports the initial stages of the study ; the development of an empirical typology of GP attitudes based on the results of an attitude questionnaire sent to all GPs in Avon .

INTRODUCTION Background

General practice exists at the interface between self and hospital treatment of illness . As such it plays an important role in the care of the sick in the community : 90% of all episodes of illness presented to the National Health Service are dealt with by GPs [I]. The exact definition of this role is much debated . Most of the attempts to define general practice have come from institutions within the medical profession P . 31, or from individuals expressing a personal view ; We can juxtapose the view that a GP's role is strictly "the diagnosis, treatment and cure of disease . . . an approach which relies on machinery and applied technology" [4], with the assertion that GPs are responsible for more than mere human technical failure . In the words of the RCGP, this view maintains that; "his diagnosis will be composed in physical, psychological and social terms . He will intervene educationally, preventively and therapeutically to promote his patients health" [2] . However, general practice is a profession characterized by idiosyncrasy and thus by a great degree of variability in both standards and approach, and because the role of the GP has been defined by the institutions rather than individuals it is not clear to what extent these ideals reflect the views of the GPs about whom they speak . An examination of GPs' views about their own role is important therefore, not least because they are "likely to influence doctors' behaviour in the consultation" [5] and thus to influence the prescription, referral, management and treatment outcomes of the consultation process . The degree of variability in GPs' behaviour can be illustrated by the prescription and referral rates found in a survey of urban general practice carried

Construction of a typology

"The primary goal of a typology is to construct an orderly scheme for the classification and description of social phenomena" [7] . The simplest method of classifying subjects is a monothetic one; groups are created by a set of 'rigid and successive logical divisions' which generate unique criteria for membership of each group . Members that do not satisfy all the criteria cannot be included in the groups . A classification that is too inflexible to accommodate the possible variations in subjects' responses is therefore inappropriate for psychological data . A more appropriate method is a polythetic one, in which subjects are classified as members of the same type if they share a large number of similar characteristics, but they do not have to be identical [8] .

-Address correspondence to : Dr Michael 7 . Whitfield, Department of Epidemiology & Community Medicine, General Practice Unit . University of Bristol, Canynge Hall, Whiteladies Road . Bristol BS8 2PR, England . 537

538

ROMOLA S. BUCKS et al .

Cluster analysis is a method which divides subjects into groups polythetically ; in our study we used K-means cluster analysis (BMDP, program KM [9]) . Cluster analysis is descriptive, i .e . it is essentially exploratory in nature . Its purpose is to reveal any underlying structure or patterns in the data and thus generate hypotheses [10] . Critique of precious typologies

Previous approaches have used a monothetic classification method or have generated doctor types on the basis of observation and experience . Mechanic's [I I] dichotomization based on two a priori dimensions, 'scientific orientation' (use of 19 diagnostic procedures and laboratory aids), and 'social orientation' (GP's views on 'proper scope of medicine'), divides subjects at the median point of each dimension . Subjects above the median point are classified as high and below as low, This results in a four part classification ; withdrawers (low social, low diagnostic use), technicians (low social, high diagnostic use), counsellors (high social, low diagnostic use) and moderns (high social, high diagnostic use) . Although this is a two dimensional solution, the classification method is imposed on GPs' responses rather than generated from them . More recently Calnan [12] drew on Huntington's [13] sociological analysis of general practitioners and social workers which defined six GP types : the 'real doctor' (sic) ; the father figure; the internal physician ; the family doctor ; the psycho-physician ; and the psychotherapist . These types are related to three dimensions of the GPs' role : the GP's orientation to medicine (medical or social), to the patient and to other health professionals . Calnan investigated the degree to which Huntington's three-fold typology fits GP's perceptions of their role . He generated a 15-item questionnaire incorporating these dimensions with additional questions about financial incentives . Since factor analysis revealed only one significant factor, this was used to differentiate subjects on the basis of their medical/ social orientation and interest in financial incentives . Those who scored highly (>20), on the scale (5-25) derived from this factor, had a social orientation and were not interested in financial incentives, while those whose scores were low (<8), showed a medical orientation and were interested in financial incentives . Even having enhanced the possible differences between subjects by cutting out 66% of the questions and all those scoring between 9 and 20 on factor I, Calnan found no support for Huntington's typology . It is doubtful that such classifications would fall naturally out of data on doctor's views and we would therefore question the usefulness of these distinctions for the understanding or prediction of variability in GPs' behaviour. The original version of our questionnaire was devised, validated and replicated by Grol [14, 15] to study a sample of 56 GPs in Holland . Factor analysis generated four main factors which were labelled (sic) ; 'the GP's views about control over the execution of his job', 'the measure of faith in the changeability of patients and the GPs' role therein', 'views on taking risks' and 'views on doctor-patient relationship' . Views on risk taking were found to correlate significantly

with referrals (r = 0 .36) and views on the doctorpatient relationship were found to correlate with 'non-specific prescriptions' (r = 0 .39) . This is the first evidence that GPs' attitudes may predict prescribing behaviour. Problems associated with developing classifications include a posteriori interpretation by the experimenter with the risk of resultant bias, and . until recently, the relative lack of non-parametric alternatives to multivariate tests . Our ordinal data would violate some of the major assumptions in most multivariate tests, e .g . multivariate normal distributions and continuous data . For these reasons principal components analysis (PCA) and cluster analysis were chosen . When combined, these tests allow the researcher to postpone interpretation of the results until the very last stage of the analysis and PCA has been shown to be more stable than factor analysis when using 'non-standard data' [16] . This is because it does not involve the use of a statistical model with distributional assumptions [17, 18] . In summary, we used PCA and K-means because they are exploratory techniques which are both subtle and robust and allow a posteriori interpretation . METHOD

In May 1987 all GPs in Avon (525) . were circulated with a questionnaire to determine their views on what constitutes general practice and how they feel about their role . The questionnaire was based on an original developed in Holland by Dr R . Grol at the Department of General Practice in Nijmegen University [14] . It was piloted, after translation, on a group of Royal College of General Practitioners examiners in the U .K ., prior to use with the Avon sample . The questionnaire consists of a series of questions asking GPs how responsible they feel the GP is for a range of medical and psychosocial tasks, how competent s/he feels in carrying out those tasks and what sorts of feelings they have when dealing with these tasks . Further, there were a series of attitude statements asking the GPs their opinions on such things as external control of general practice and taking risks with patients' health . Replies were given on 5 point Likert response scales ; strongly agree to strongly disagree . Of the total sample, 424 (81%) replied but of these 53 were excluded from the analysis because they had few patients in Avon or because they had restricted practice lists, being hospice or student health service doctors . This left a responding set of 371 GPs, 78 .6% of the eligible sample . The nonresponders were compared with the responders in terms of age, gender, list size and position in practice and no significant differences were found . There were however, fewer single handed doctors in the 'responding sample 11 ;424 (2,6%) than in the total sample 27/525 (5 .1%) . ANALYSIS AND FINDINGS

Analysis of the patterns of responding showed that those questions, with a few exceptions . which asked about the responsibilities of the GP and his or her competence to carry out those responsibilities were being answered in very similar ways, i .e . the



GPs' attitudes to general practice distributions were highly skewed . It appeared that the questions had accessed some 'normative view' about the GP . Evidence [19] leads us to suspect that this was because subjects perceived the Unit of General Practice as evaluating their responses and the GPs therefore answered in such a way as to present the best impression of themselves as representatives of general practice [20] . However, those questions which asked the GP about his or her views on risk taking . external control of general practice and attitudes to giving patients information for example, gave rise to much greater variations in responses . We therefore chose to concentrate on these questions, when attempting to generate a typology of GPs' attitudes. A full list of these 27 questions can be found in Table 2 . In order to ensure that there was no redundancy of information and to reduce the number of variables [16] to analysed by cluster analysis, we applied PCA, using the correlation matrix and then fed the component scores generated by this process into a K-means cluster analysis (BMDP, 4M & KM [9]) . Jones [21] suggested that if principal components with eigenvalues of one were chosen, insufficient amounts of variance might be explained in the data . He therefore proposed that researchers take all components with eigenvalues greater than 0 .7 . The data set was divided randomly in half and the following analyses carried out on one half of the

*Since cluster analysis requires complete data, 27 subjects data could not be correctly classified .

539

Table 1 . Values of Jolliffe er .1.'s [221 ratio No . of clusters

value of ratio

3 4 5 6 7 8 9 10 11

0 .6809 0 .5317 0 .5375 0,46910 .5015 0 .5196 0 .5033 .5202 0 0 .5099 0 .5169

'Minimum value of the ratio . subjects . A PCA was conducted, from which 15 components with eigenvalues greater than 0 .7 were found . explaining 78% of the variance . K-means cluster analysis was then used to divide the data into a number of clusters . Solutions ranging from 2 to I I clusters were calculated and the optimum number of groups decided upon using Jolliffe et aL's method [22] : the ratio of the average within cluster distance to the average between cluster distance was calculated and plotted for each cluster solution (see Table 1) . At the point at which the curve troughed, i .e . the ratio was at its smallest, the number of clusters in the solution was 5 . Using the cluster means found in the 5 cluster solution to seed a new cluster analysis, the test was rerun using all the data, thus allocating all 344 subjects' to the 5 clusters . Two methods were used to check the robustness of this solution . Firstly, a discriminant function analysis was conducted (see Table 3) . This resulted in 96 .2%

Table 2 . Attitude questions I . When in doubt it is preferable to refer to a specialist than to wait and see 2 . It ought to be compulsory for GPs to attend at least one refresher course a year 3 . There is no harm in patients looking up to their doctor 4 . General practitioners do not have time to practise preventive medicine 5 . A GP must prefer the certain to the uncertain 6 . Increased governmental interference with the NHS will be detrimental to the social and financial position of the GP 7 . It is not in the interest of patients for all general practitioners to work for the NHS 8 . When a cancer patient asks what is wrong with him, the GP must give an honest answer 9 . However difficult patients may be. if you keep trying it is possible to change them 10 . Patients quickly lost interest when you start talking about healthy lifestyles 11 . Giving detailed explanations to patients tends to worry them rather than reassure them 2. A GP cannot always be willing to deal with non-medical problems 13 . A GP should do everything possible as far as physical matters are concerned, to dig up the cause of a complaint 14. The qualification of a GP should be dependent on the result of periodic tests 15 . I find giving health education to patients dull and boring 16. Many patients are what they are ; as a GP you won't be able to change that 17 . GPs should always be willing for patients to see their referral levers 18 . The well-being of my patients depends a great deal on my care 19 . There are a number of patients to whom it would be useless to explain things, as they would not understand 20. As a GP you must always be aware that each complaint can be the beginning of a serious illness 21 . General practitioners should not interfere with people's lives by telling them to stop smoking, lose weight or get more 22, When a GP prescribes medicine he must always explain in detail what its effects are 23 . You cannot change the majority of patients 24, Patients have the right at all times to demand information from the GP about their health 25 . The evidence relating diet to health is too uncertain and contradictory for me to advise my patients on what to eat 26. The GP must not take any risks with physical illnesses 27. Patients get upset when I ask them if they smoke when smoking is not directly related to their presenting problem Table 3. Classification matrix for discriminant analysis of the clusters Number of cases classified into group Group % Correct I 2 .3 4 5 Total

4 Total

s5M

a 5-a

97 .7 93 .1 97 .3 98 .9 95 .2 97 .4

43 0 0 0 2 44

0 67 0 0 0 67

0 3 36 0 0 39

0 I I 86 3 91

I I 0 I 99 102

44 72 37 87 104 344

exercise



540

RomcU 5. Buctcs et

al .

correct reclassification of subjects to clusters (this scores, were also used to discriminate between them) . result must be treated with caution as the same Secondly, Andrews' [23] curves were calculated for variables used to construct the groups, the question each cluster and the function plotted on a Calcomp* plotter, The curves appear at first glance to be very similar (see Fig . 1); closer inspection reveals that their ampli-The function is: f(l) =x ; 2 + .x sin t +x cos l + x sin 2t + .x cos 2t + - - over the range -
GPs' attitudes to general practice

Fig

541



points of intersection with the y axis . If we superA method of interpreting cluster solutions [24] is to impose all curves onto the same plot (No . 6) the compare the typical member of each cluster . The result is a curve of similar shape but well spread . typical member is defined as a hypothetical subject We would therefore suggest that the clusters are whose scores on the 27 attitude statements are the probably distinct but that, at present, they lack median scores for each variable for each group . sufficient distinguishing features to give them good Examination of these typical members yielded the separation. descriptions of the clusters (Table 4) . There are some



GPs' attitudes to general practice

543

Table 4 . Cluster differences: attitude data (the divisions of the questions are suggestions only)

The typical member of cluster I 44 subjects Average within-cluster distance = 4 .8143

Preventive medicine

Risk taking

Strongly disagrees : that GPs have no time to practice preventive medicine, that health education is dull . that GPs should not interfere by telling patients not to smoke, that the evidence relating diet to health is uncertain and that patients get upset when told to stop smoking . Partly disagrees : that patients lose interest when the GP talks about healthy lifestyles .

Strongly disagrees : that the GP must prefer the certain to the uncertain . Partly disagrees : that when in doubt it is preferable to refer, that the GP must lake no risks with physical illness, that a GP should do everything possible to dig up the cause of a complaint and that the well-being of the GP's patients depends on his care . Partly agrees : that each complaint can be the beginning of a serious illness .

Information giving

Control of general practice

Strongly disagrees: that explanations worry patients . Partly disagrees : that there are some patients to whom it would be useless to explain . Partly agrees: that GPs should be willing for patients to see their referral letters, that a GP must explain the effects of medicine and that patients have the right to demand information about their health . Strongly agrees : that cancer patients should be told what is wrong with them.

Partly disagrees: that it is not in the interests of patients for all GPs to work for the NHS and that the qualification of GPs should depend on periodic tests. Feels neutral : that increased governmental interference would be detrimental to GPs . Partly agrees: that GPs should attend one refresher course a year.

GP influence over patients Partly disagrees : that many patients are what they are, that you cannot change the majority of patients, that a GP cannot always deal with non-medical problems and that there is no harm in patients looking up to their doctor . Partly agrees : that however difficult patients may be it is possible to change them .

The typical member of cluster 2 72 subjects Average within cluster distance - 4 .9344

Preventive medicine

Risk taking

Strongly disagrees : that GPs should not interfere in patients' lives by telling them to stop smoking . Partly disagrees : that GPs do not have time to practice preventive medicine . that health education is boring, that the evidence relating diet to health is uncertain and that patients get upset if the GP asks if they smoke. Partly agrees : that patients lose interest when GPs talk about healthy lifestyles.

Partly disagrees : that the well-being of the GP's patients depends on his care, that the GP must not take any risks with physical illness and that a GP must prefer the certain . Feels neutral: that when in doubt it is preferable to refer and that the GP should do everything possible to dig up the cause of a complaint . Partly agrees: that each complaint can be the beginning of a serious illness .

Information giving

Control of general practice

Partly disagrees: that patients should be able to see their referral letters . Feels neutral : that patients have the right to demand information about their health and that explanations worry patients . Partly agrees: that cancer patients should be told what is wrang with them, that some patients will not understand explanation and that GPs must explain the effects of medicine to patients .

Partly disagrees : that the qualification of a GP should depend on tests . Feels neutral : that GPs should attend one refresher course per year and that it is not in the interests of patients for all GPs to work for the NHS . Partly agrees : that increased governmental interference in the NHS would be detrimental .

Partly disagrees : that it is possible to change patients . Partly agrees : that there is no harm in patients looking up to their GP, many patients are what they are . that you cannot change the majority of patients and that a GP cannot always deal with non-medical problems.

The typical member of this group is in favour of preventive medicine but feels that patients get bored with healthy lifestyles . S, he feels that patients should be given explanations but that they should not see referral letters and they will not always understand anyway . S he feels that the patient's health is not the responsibility of the GP. may take risks but is aware that each complaint can be serious . S/he feels that the GP cannot change patients, and that government should not interfere in the NHS, nor should GPs have to take tests . S he agrees that the GP cannot always deal non-medical problems . We feel that these views represent a GP who is somewhat 'traditional' in approach, perhaps also, 'speculative' .

Preventive medicine

Risk taking

Strongly disagrees : that GPs should not interfere in patients' lives by telling them not to smoke. Partly agrees : that GPs do not have time to practice preventive medicine, that patients lose interest when the GP talks about healthy lifestyles . Feels neutral : that health education is dull, that the evidence relating diet to health is uncertain and that patients get upset when asked if they smoke and smoking is not related .

Partly agrees : that when in doubt it is preferable to refer, that a GP must prefer the certain to the uncertain, that the well-being of patients depends on the GP's care and that the GP must take no risks with physical illness . Strongly agrees : that a GP must do everything possible to dig up the cause of a complaint and that each complaint can be the beginning of a serious illness .

GP influence over patients

The typical member of cluster 3 37 subjects Average within . cluster - 5.1106

The typical member of this group is strongly in favour of preventive medicine, s/he is also in favour of information giving and feels that patients are capable of understanding . S/he will take some risks with patients' health but disagrees that patients' health is the responsibility of the GP. S/he disagrees that patients cannot be changed and although ss he is ambivalent about governmental control of the NHS and against tests, s/he approves of refresher courses. The member is against patients looking up to their doctor, but prepared to deal with non-medical problems . We interpret these views as indicative of a 'modem', optimistic GP .

Table 4 continued oeerleaf ]



RoMOLA S . BUCKS er al .

544

Table 4-ronuvued]

Information giving

Control of general practice

Feels neutral: that patients should be able to see their referral letters . Partly agrees: that cancer patients should be told about their disease, that explanations worry patients, that patients have the right to demand information from their GP, that there are some patients to whom it would be useless to explain as they would not understand and that GPs must explain the effects of medicine .

Partly disagrees: that the qualification of GPs should depend on the results of periodic tests . Partly agrees : that it ought to be compulsory for GPs to attend refresher courses, that increased governmental interference in the NHS will be detrimental to the social and financial position of GPs and that it is not in the interest of patients for all GPs to work for the NHS .

GP influence over patients Partly disagrees : that however difficult patients may be if you keep trying it is possible to change them . Partly agrees: that there is no harm in patients looking up to their doctor, that many patients are what they are, that you cannot change the majority of patients and that a GP cannot always deal with non-medical problems .

Preventive medicine The typical member of Strongly disagrees: that GPs do not have time to cluster 4 practice preventive medicine and that GPs should 87 subjects not interfere in patients' lives by telling them not to Average within-cluster smoke . distance = 4 .6790 Partly disagrees : that health eduction is boring, that patients lose interest when the GP talks about healthy lifestyles, that the evidence relating diet to health is uncertain and that patients get upset if the GP asks if they smoke and it's not related to their problem.

Risk taking Feels neutral: that a GP should prefer the certain to the uncertain . Partly agrees: that when in doubt it is preferable to refer, that a GP should do everything possible to dig up the cause of a complaint that patients' well-being depends on the GP and that the GP must not take any risks with physical illness . Strongly agrees: that each complaint can be the beginning of a serious illness .

Information giving

Control of general practice

Partly disagrees : that explanations worry patients and that patients should be able to see their referral letters . Partly agrees : that cancer patients must be told what is wrong with them, that GPs must explain the effects of medicine, that patients have the right to demand information about their health but that some patients will not understand this information.

Partly disagrees : that the qualification of a GP should depend an periodic test . Feels neutral: that it is not in the interest of patients for all GPs to work for the NHS . Partly agrees : that increased governmental interference in the NHS would be detrimental to the social and financial position of GPs and that GPs should attend refresher courses once a year .

GP influence over patients

The typical member of this cluster is strongly in favour of preventive medicine . S/he is not sery happy taking risks with patients' health preferring the certain to the uncertain. This member feels that patients should be given information about their health . that this will not worry them but that some might not understand . S, he is against patients seeing referral letters . S he is ante tests but pro refresher courses . S/he is unsure of the GP's ability to change patients, and feels there is no harm in patients looking up to their doctor . This approach seems to indicate 'doctor-centred' attitudes and a desire to be 'careful'.

Feels neutral that : the OP cannot change the majority of patients and that however difficult patients may be it is possible to change them . Partly agrees : that many patients are what they and a GP cannot change that, that there is no harm in patients looking up to their GP and that a GP cannot always be willing to deal with non non-medical problems .

The typical member of cluster 5 104 subjects Average within-cluster distance-4 .7070

The typical member of this group does not believe preventive medicine is his/her responsibility . though s,, he is more than happy to give advice about lifestyle . S; he is not happy about taking risks and feels that each complaint could be the beginning of something serious. S : he feels that patients are beyond the scope of the GP to change but that there is no harm in patients looking up to their GP. &he agrees that GPs cannot always deal with non-medical problems . Although in favour of refresher courses s/he is opposed to control of general practice and though s/ he feels that patients should have explanations made to them, they will not always understand and some may be worried by these explanations . We feel this adds up to attitudes that are representative of a 'traditional', 'old style' GP .

Preventive medicine

Risk taking

Strongly disagrees : that GPs do not have time to practice preventive medicine, that GPs should not interfere in peoples' lives by telling them to stop smoking and that health education is dull . Partly disagrees: that patients lose interest when the GP starts talking about healthy lifestyles, that the evidence relating diet to health is too uncertain to advise patients on what to eat and that patients get upset when asked if they smoke and smoking is not related to their presenting problem .

Partly disagrees: that a GP must prefer the certain to the uncertain. Feels neutral : that when in doubt it is preferable to refer . that the well-being of the GP's patients depends on his care and that the GP must not take any risks with physical illness . Partly agrees: that a GP must do everything possible to dig up the cause of a complaint and that the GP must be aware that each complaint can be the beginning of a serious illness . Table 4 cominued]

GPs' attitudes to general practice

545

Tabir 4-continued)

Information giving

Control of general practice

Partly disagrees : that detailed explanations lend to worry patients and there are a number of patients to whom it would be useless to explain as they would not understand . Partly agrees : that GPs should always be willing for patients to see referral letters, that cancer patients must be told, that GPs must always explain the effects of medicine and that patients have the right to demand information about their health . GP influence over patients Feels neutral : that a GP cannot always deal with non-medical problems, that there is no harm in patients looking up to their doctor, that many patients are what they are and the GP cannot change that and that you cannot change the majority of patients . Partly agrees : that however difficult patients may be if you keep trying it is possible to change them .

Partly disagrees : that it is not in the interest of patients for all GPs to work for the NHS and that the qualification of a GP should depend on periodic tests . Feels neutral : that increased governmental interference in the NHS will be detrimental to GPs. Partly agrees : that it ought to be compulsory for GPs to attend refresher courses .

interesting features of the clusters that differentiate between them . For example ; the typical member of cluster I is very strongly in favour of preventive medicine and health education, whereas the typical member of cluster 3 is more dubious about its value . The typical member of cluster 2 seems similar to that of cluster 3 except that they differ markedly in their readiness to refer rather than wait and see and their preference for the certain ; the cluster 3 member seems unwilling to take any risks with patients' health . Interesting too is the variation between typical members in their attitudes to their ability to change patients ; only cluster 5 and cluster l's typical members believe that they can change patients, clusters 2, 3 and 4's typical members believe that they cannot . As far as giving information to patients about their health and showing them referral letters, all typical members seem happy to do so to some extent, however cluster 2, 3 and 4's typical member felt that their patients would not be able to understand . Finally, whereas the typical members of clusters 1, 3, 4 and 5 were in favour of refresher courses of GPs and all were opposed to compulsory tests, that of cluster 2 was neutral about refresher courses. With the help of five independent raters we have given the clusters the following tentative titles : Cluster 1 : (n =44) these GPs seem to have an 'egalitarian' approach to general practice, they appear 'optimistic' and 'confident' . Mechanic has identified a doctor type similar to this calling them 'moderns' [11]. Cluster 2: (n = 72) the typical member suggests a doctor who is somewhat 'traditional' in his/her approach to general practice, but at the same time 'speculative' in taking risks . Cluster 3: (n = 37) the typical member seems to hold 'traditional' attitudes, perhaps reminiscent of an 'older style' of general practice but is more 'careful' about taking risks with health and is not in favour of preventive medicine. Cluster 4: (n = 87) the typical member of this cluster seems 'doctor centred' in approach, but acknowledges that the 'patient has rights' within the consultation, s/he is not prepared to take risks

The typical member is strongly pro preventive medicine and also in favour of giving patients information about their health and letting them see their referral letters . S ; he believes that patients will not be worried and will be able to understand. S,/he is neutral about taking risks with patients' health ; believing that a GP must keep in mind that each complaint can be the beginning of a serious illness although the GP need not always prefer the certain. S/ he is ante tests but in favour of refresher courses and GPs working for the NHS . This GP tends to be neutral about changing patients' behaviour and neutral about patients looking up to their doctor . This approach indicates a 'patient centred' GP who is 'balanced' in his/her approach .

with patients' health, preferring 'caution' and 'prevention' . Cluster 5: (n = 104) this typical member suggests a 'balanced' approach to general practice . and is much like cluster I, i .e . s/he is prepared to 'give responsibility away to the patient' and is pro preventive medicine, and 'patient centred' with respect to information giving . However, s/he is uncommitted about the influence of the doctor over the patient and the extent to which s/he will take risks . Kruskal-Wallis One Way Analyses of Variance (allowed for tied data) failed to yield any significant differences between the clusters in the number of GPs who were members of the Royal College of General Practitioners, the number of GPs from city rather than rural practices, or health centres rather than non-health centres . There were no gender differences in the make-up of the clusters . There were differences in the age and trainer breakdown of the clusters and in list sizes (K-W, P < 0.01, P < 0 .02, and P < 0 .05) . Cluster 3 was made Up of more older doctors, Clusters I and 5 of more trainers than in the other groups and of more doctors with list sizes less than 2000 patients (see Table 5) . When relating the clusters to answering patterns in the rest of the questionnaire, several questions were found to have been answered in a significantly different way . The majority of differences arose because cluster I tended to claim a greater degree of responsibility and competence for a range of tasks than the other clusters . Cluster 5 also claimed greater responsibility for some tasks than 2, 3 or 4 but less so than cluster 1 . These differences seem to corroborate the view that cluster 1 represents the confident GP . DISCUSSION AND CONCLUSION

This study has produced some stimulating results which potentially increase our understanding of GPs' attitudes and their relationship to behaviour . However, there are a number of caveats which must be born in mind when interpreting the data . First, the sample studied was non-random in that it contained all GP principals in contract with the

ROMOLA S . BUCKS et al.

546

Table 5. Cluster differences : demographic data Cluster I

Cluster 2

Cluster 3

Cluster 4

Cluster 5

Gender breakdown of clusters : 269(78.2%) male GPs 75(221 .8%) female

35 male

9 female

62 male 10 female

28 male 9 female

65 male 22 female

79 male 25 female

Age breakdown : 106 (30.8%) 26-35 yr 127 (36.9%) 36-45 yr 68 (19.8%) 46-55 yr 42 (12.2%) 56-65 yr 1 (0 .3%) over 65 yr

22(50 .0%) 16(36 .4%) 5(11 .4%) 1(2 .3%)

22(30.6%) 23(31 .9%) 17(23.6%) 10(13.9%)

1(2 .7%) 16(43 .2%) 11(29 .7%) 9(24 .3%)

15(17,2%) 37(42 .5%) 20(23 .0%) 14(16 .1%)

46 (44 .2%) 35 (33 .7%) 15 (149% ) 8(7 .7%)

1 (1 .1%)

List size : 50(14.8%) under 1000 33(9 .8%) 1000-1499 68(20.2%) 1500-1999 106 (31 .5%) 2000-2499 50 (14 .8%) 2500-2999 30 (8.9%) 3000 and 7 unknown

1](26 .2%) 2(4.8%) 7(16 .7%) 15(35 .7%) 4 (9.5%) 3(7 .1%)

8(11 .4%) 7(10.0%) 13(18.6%) 19(27 .1%) 16(22 .9%) 7(10_0%)

2(5 .6%) 4(11 .1%) 7(19 .4%) 14(38 .9%) 5(13 .9%) 4(11 .1%)

6(7 .0%) 9(10 .5%) 22(25 .6%) 25(29 .1%) 15(17 .4%) 9(10 .5%)

23(22 .3%) 11(10 .7%1 19(18 .4%) 33(32 .0%)

Member or non-member of RCGP : 114(33 .1%) members 230(66 .9%)non-members

15(34 .1%) 29(65.9%)

22(30.6%) 50(69 .4%)

12(32 .4%) 25(67 .6%)

31 (35 .6%) 56(64 .4%)

34(32 .7%) 70(67 .3%)

Trainers or non-trainers : 55 (16 .0%) trainers 289 (84 .0%) non-trainers

13(29.5%) 31 (70.5%)

9(12 .5%) 63(87 .5%)

2(5 .4%) 35(94 .6%)

10(11 .5%) 77(88 .5%)

21(20 .2%) 83(79 .8%)

City or rural practices: 195(56 .7%) in city 149(43 .3%) in rural

22(50.0%) 22(50.0%)

51 (70 .8%) 21 (29 .2%)

19(514%) 18(48 .6%)

43(49 .4%) 44(50.6%)

60(57.7%) 44(42 .3%)

Health centre or non-health centre : 128 (37 .2%) in HC 216(62 .8%) in non-HC

21(47.7%) 23 (52.3%)

25(34 .7%) 47(65 .3%)

12(32 .4%) 25(67 .6%)

35(40,2%) 52(59 .8%)

35 (33 .7%) 69(66.3%)

10

7(6.8%)

Avon Family Practitioner Committee and secondly, the number of subjects studied was not sufficiently large to generate sizeable clusters; cluster 3, for example, contains only 37 GPs . Thirdly, the cluster solutions cannot be regarded as all inclusive since not all GPs will fit into these clusters nor do the clusters represent all the groupings of possible attitudes, merely those present in our questionnaire . Although we cannot, therefore, make any generalizations from these results to other GPs in the U .K ., it seems reasonable to suggest that similar clusterings would be found elsewhere. We would suggest the study be seen as a pilot only. Fourthly, despite arguments in favour of using cluster analytic procedures on multivariate data, these techniques are not easy to interpret correctly . There is no tried and tested method for deciding on the number of clusters to employ in the solution . The analysis will provide an answer for as many or as few clusters as the researcher wishes . Jolliffe et al.'s [22]

or negatively about preventive medicine, some will take risks, some prefer certainty, some feel they can change their patients, some feel they cannot . Overall . the cluster members feel that patients should have explanations given to them but some are less sure of patients' ability to understand the information . These differences might prove good predictors of variations in GP-patient behaviour . For example, we could hypothesize that GPs who are in favour of prevention would be more inclined to communicate preventive information to their patients during the consultation and more open to questions from patients about 'healthy lifestyles' . GPs who hold the view that patients do not understand the information given to them might also be less likely to communicate information to their patients . In fact most of the differences found in the clusters are likely to be predictive of differences in doctor-patient communication and therefore possibly, the outcome of the consultation . Using this clustering technique to con-

method allows the researcher to decide on the number of clusters using a statistic, but this does not mean that a different number of clusters is in any way invalid . Tukey [25] summarizes this point succinctly ;

duct similar analyses of attitudes to general practice in patients and doctors, would allow a fascinating comparison of GP beliefs with patient beliefs . A matching of GPs and patients could be used to study doctor-patient relations . Mismatching of beliefs and

I am not denying the usefulness of clustering procedures . I am merely making clear that, to me at least, their results, like those of other data analytic procedures, are more or less strong suggestions, never sanctified infinitely trustworthy conclusions [p . 5031 . Notwithstanding the tentative nature of our solution, the study has shown that there are trends in GPs' attitudes which can be analysed and put to further use . Our cluster members feel either positively

attitudes might be more predictive of dissatisfaction with GP services than the size of the practice, its location or staffing levels . A second off-shoot of this research is the finding that GPs are unequal in their willingness to take risks. This difference has implications for the GP's management of a patient's problem . Medical education teaches undergraduates about the diagnosis and treatment of known diseases or illnesses. In general

GPs' attitudes to general practice practice, very few problems presented by patients are so neatly diagnosed . They may present with problems at a very early and undifferentiated stage, or they may present with a combination of many social, psychological and physical ills that are difficult, if not impossible, to unravel [26] . Thus the GP may have to tolerate and make decisions in conditions of great uncertainty [27] . If GPs have differing tolerance levels they may decide to manage a patient in very different ways ; they may refer or prescribe when another GP would opt for a fixed return [28] . We would hypothesize then, that a GP who is more able to tolerate uncertainty would be more likely to postpone a decision about diagnosis or management until the signs and symptoms of the problem were clearer . The second stage of the study, looking at the prescribing and referral patterns of the different clusters, is planned . Given our reservations about the scope of the clusters, the next step towards predicting differences in prescribing and referral will be an in depth, semi-structured interview of some members of each cluster ascertaining their specific views on prescribing and referral, Despite the aforementioned difficulties, this study has opened up new pathways for research into variability in general practice . It has the advantage of being empirical in approach, multivariate in analysis and does not impose categories or distinctions onto GPs but extracts them from their own responses . It thus represents a sound attempt at categorization of doctors' attitudes . Acknowledgements-With grateful thanks to Professor B . J . T . Morgan of the Institute of Mathematics, University of Kent and Mr Anthony Hughes of the Department of Epidemiology and Community Medicine, University of Bristol . The research was supported by the Glaxo Research Fund .

REFERENCES I . General Medical Services Committee . Report to Special Conference Representatives of Local Medical Committees. BMA . Nov . 1986. 2 . Royal College of General Practitioners . Working party . The Future General Practitioner : Learning and Teaching, London. RCGP, (1986) . 3 . Leeuwenhorst Group. Working party appointed by the Second European Conference on the Teaching of General Practice : The General Practitioner in Europe. Netherlands, 1974 . 4 . McCormick J . The Doctor : Father Figure or Plumber . Croom Helm . London, 1979 . 5 . Cockburn J . . Killer D ., Campbell E . and Sanson-Fisher R . Measuring general practitioners' attitudes towards medical care. Family Pract . 4, 192-199, 1987 . 6 . Wilkin D ., Hallam L . . Leavey R . and Metcalfe D . Anatomy of Urban General Practice. Tavistock, London, 1987 .

547

7 . Fitzpatrick M . A . A typological approach to marital interaction : recent theory and research . Adr . exp . soc . Psychol. 18, 1-47, 1984 . 8. Sneath P . H . A . and Sokal R . R . Numerical Taxonomy : The Principles and Practice of .Numerical Classification . Freeman, San Francisco, Calif. . 1974. 9 . BMDP Statistical Software . University of California Press, Berkeley. Calif. . 1987 . 10. Krippendorff K . Clustering . In Multivariate Techniques in Human Communication Research (Edited by Monge P. R . and Cappella J . N .) . Academic Press . London, 1980 . 11 . Mechanic D. Practice orientations among general medical practitioners in England and Wales . Med . Care VIII, 15-25, 1970 . 12 . Calnan M . Images of general practice : the perceptions of the doctor . Soc . Sci. Med. 27, 579-586, 1988 . 13 . Huntington J . Social Work and General Medical Practice : Collaboration or Conflict? Allen & Unwin . London, 1983 . 14 . Grol R . Preventie van Somatische Fixatie : en de Attitude van de Huisarts . Unpublished report . Nijmeegs Universitair Huisartsen Institut, 1983 . 15 . Grol R ., Eijk J . van, Mokkink H ., Beek M . . Mesker P., Smits A . and Mesker-Niesten J . Taakopvatting van de huisarts en zijn handeln in de spreekkamer. Ge :ondheid & Samenlering 6, 31-40, 1985 . 16 . Taylor C . C . Cluster analysis . In The Analrsis of Stirrer Data : Vol. 1 : Exploring Data Structures (Edited by G'Muircheartaigh C . A . and Payne C . C .) . Wiley, London, 1977 . 17 . Jones B . Cluster analysis of some social survey data . Bull . Appl. Statist. 6, 25-56, 1979 . 18 . Chatfield C . and Collins A. 1 . Introduction to Multivariate Analrsis. Chapman & Hall . London . 1980 . 19 . Lalljee M ., Brown L . B . and Ginsberg G . P . Attitudes : disposition, behaviour or evaluation? Br . J . soc Psychot 23, 233-244, 1984 . 20 . Whitfield M . J . and Bucks R . S . General practitioners' responsibilities to their patients . Br. med. J. 297, 398-400, 1988 . 21 . Jolliffe I. T. Principal Components Analrsis. Springer, New York, 1986. 22 . Jolliffe 1 . T., Jones B . and Morgan B . 1 . T. Utilising clusters: a case-study involving the elderly . J . R . Statist, Soc. 145, 224-236, 1986 . 23 . Andrews D . F. Plots of high dimensional data . Biometrics 28, 125-136, 1972 . 24 . Forgy E. W . Cluster analysis of multivariate data: efficiency vs . interpretability of classifications . Biometrics 21, 768-769, 1965 . 25 . Tukey 1 . W . Methodological comments focused on opportunities . In Vultivariale Techniques in Human Communication Research ( Edited by Monge P . R . and Cappella J . N .) . Academic Press, London. 1980 . 26 . Fraser R . C. Clinical Method: A General Practice Approach . Butterworth, London, 1987 . 27. Wright H .1. and MacAdam D . B. Clinical Thinking and Practice : Diagnosis and Decision in Patient Care. Churchill Livingstone. London, 1979 . 28. Cummins R . 0 ., Jarman B. and White P . M . Do general practitioners have different "referral thresholds?" Br. med. J . 35, 15-18, 1981 .