moxml 0.1.9 → 0.1.11

data/spec/fixtures/round-trips/niso-jats/bmj_sample.xml

@@ -0,0 +1,1068 @@
+<?xml version="1.0" encoding="UTF-8"?>
+<!DOCTYPE article PUBLIC "-//NLM//DTD JATS (Z39.96) Journal Publishing DTD v1.3 20210610//EN" "JATS-journalpublishing1-3.dtd">
+<article article-type="research-article"
+  dtd-version="1.3"
+  xml:lang="en"
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+  xmlns:xlink="http://www.w3.org/1999/xlink"
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+  <processing-meta
+    tagset-family="jats"
+    base-tagset="publishing"
+    mathml-version="2.0"
+    table-model="xhtml" />
+  <front>
+    <journal-meta>
+      <journal-id journal-id-type="pmc">bmj</journal-id>
+      <journal-id journal-id-type="pubmed">BMJ</journal-id>
+      <journal-id journal-id-type="publisher">BMJ</journal-id>
+      <issn>0959-8138</issn>
+      <publisher>
+        <publisher-name>BMJ</publisher-name>
+      </publisher>
+    </journal-meta>
+    <article-meta>
+      <article-id pub-id-type="other">jBMJ.v324.i7342.pg880</article-id>
+      <article-id pub-id-type="pmid">11950738</article-id>
+      <article-version vocab="JAV"
+        vocab-identifier="http://www.niso.org/publications/rp/RP-8-2008.pdf"
+        article-version-type="VoR"
+        vocab-term="Version of Record">version-of-record</article-version>
+      <article-categories>
+        <subj-group>
+          <subject>Primary care</subject>
+          <subj-group>
+            <subject>190</subject>
+            <subject>10</subject>
+            <subject>218</subject>
+            <subject>219</subject>
+            <subject>355</subject>
+            <subject>357</subject>
+          </subj-group>
+        </subj-group>
+      </article-categories>
+      <title-group>
+        <article-title>Evolving general practice consultation in Britain: issues of length and
+          context</article-title>
+      </title-group>
+      <contrib-group content-type="authors">
+        <contrib contrib-type="author" corresp="yes">
+          <name>
+            <surname>Freeman</surname>
+            <given-names>George K</given-names>
+          </name>
+          <role>professor of general practice</role>
+          <role>guarantor</role>
+          <role degree-contribution="lead"
+            vocab="CRediT"
+            vocab-identifier="http://credit.niso.org"
+            vocab-term="Writer &#8212; original draft"
+            vocab-term-identifier="http://credit.niso.org/contributor-roles/writing-original-draft/"
+          >Writer
+            of the original draft</role>
+          <role degree-contribution="lead"
+            vocab="CRediT"
+            vocab-identifier="http://credit.niso.org"
+            vocab-term="Writing - Review &amp; Editing"
+            vocab-term-identifier="http://credit.niso.org/contributor-roles/writing-review-editing/">Review
+            and editing</role>
+          <xref ref-type="aff" rid="aff-a" />
+          <xref ref-type="corresp" rid="cor1" />
+        </contrib>
+        <contrib contrib-type="author">
+          <name>
+            <surname>Horder</surname>
+            <given-names>John P</given-names>
+          </name>
+          <role>past president</role>
+          <role degree-contribution="supporting"
+            vocab="CRediT"
+            vocab-identifier="http://credit.niso.org"
+            vocab-term="Writing - Review &amp; Editing"
+            vocab-term-identifier="http://credit.niso.org/contributor-roles/writing-review-editing/"
+          >Review
+            and editing</role>
+          <xref ref-type="aff" rid="aff-b" />
+        </contrib>
+        <contrib contrib-type="author">
+          <name>
+            <surname>Howie</surname>
+            <given-names>John G R</given-names>
+          </name>
+          <role>emeritus professor of general practice</role>
+          <role degree-contribution="supporting"
+            vocab="CRediT"
+            vocab-identifier="http://credit.niso.org"
+            vocab-term="Writing - Review &amp; Editing"
+            vocab-term-identifier="http://credit.niso.org/contributor-roles/writing-review-editing/"
+          >Review
+            and editing</role>
+          <xref ref-type="aff" rid="aff-c" />
+        </contrib>
+        <contrib contrib-type="author">
+          <name>
+            <surname>Hungin</surname>
+            <given-names>A Pali</given-names>
+          </name>
+          <role>professor of general practice</role>
+          <role degree-contribution="supporting"
+            vocab="CRediT"
+            vocab-identifier="http://credit.niso.org"
+            vocab-term="Writing - Review &amp; Editing"
+            vocab-term-identifier="http://credit.niso.org/contributor-roles/writing-review-editing/"
+          >Review
+            and editing</role>
+          <xref ref-type="aff" rid="aff-d" />
+        </contrib>
+        <contrib contrib-type="author">
+          <name>
+            <surname>Hill</surname>
+            <given-names>Alison P</given-names>
+          </name>
+          <role>general practitioner</role>
+          <role degree-contribution="supporting"
+            vocab="CRediT"
+            vocab-identifier="http://credit.niso.org"
+            vocab-term="Writing - Review &amp; Editing"
+            vocab-term-identifier="http://credit.niso.org/contributor-roles/writing-review-editing/"
+          >Review
+            and editing</role>
+          <xref ref-type="aff" rid="aff-e" />
+        </contrib>
+        <contrib contrib-type="author">
+          <name>
+            <surname>Shah</surname>
+            <given-names>Nayan C</given-names>
+          </name>
+          <role>general practitioner</role>
+          <role degree-contribution="supporting"
+            vocab="CRediT"
+            vocab-identifier="http://credit.niso.org"
+            vocab-term="Writing - Review &amp; Editing"
+            vocab-term-identifier="http://credit.niso.org/contributor-roles/writing-review-editing/"
+          >Review
+            and editing</role>
+          <xref ref-type="aff" rid="aff-b" />
+        </contrib>
+        <contrib contrib-type="author">
+          <name>
+            <surname>Wilson</surname>
+            <given-names>Andrew</given-names>
+          </name>
+          <role>senior lecturer</role>
+          <role degree-contribution="supporting"
+            vocab="CRediT"
+            vocab-identifier="http://credit.niso.org"
+            vocab-term="Writing - Review &amp; Editing"
+            vocab-term-identifier="http://credit.niso.org/contributor-roles/writing-review-editing/"
+          >Review
+            and editing</role>
+          <xref ref-type="aff" rid="aff-f" />
+        </contrib>
+      </contrib-group>
+      <aff id="aff-a">Centre for Primary Care and Social Medicine, Imperial
+        College of Science, Technology and Medicine, London W6 8RP</aff>
+      <aff id="aff-b">
+        <institution-wrap>
+          <institution>Royal College of General Practitioners, London SW7 1PU</institution>
+          <institution-id institution-id-type="ISNI">0000 0001 2161 785X</institution-id>
+        </institution-wrap>
+      </aff>
+      <aff id="aff-c">Department of General Practice, University of Edinburgh, Edinburgh EH8 9DX</aff>
+      <aff id="aff-d">Centre for Health Studies, University of Durham, Durham DH1 3HN</aff>
+      <aff id="aff-e">Kilburn Park Medical Centre, London NW6</aff>
+      <aff id="aff-f">Department of General Practice and Primary Health Care, University of
+        Leicester,
+        Leicester LE5 4PW</aff>
+      <author-notes>
+        <fn fn-type="con">
+          <p>Contributors: GKF wrote the paper and revised it after repeated and detailed comments
+            from all of the other authors and feedback from the first referee and from the <italic>
+            BMJ</italic> editorial panel. All other authors gave detailed and repeated comments and
+            cristicisms. GKF is the guarantor of the paper.</p>
+        </fn>
+        <corresp id="cor1">Correspondence to: G Freeman <email>g.freeman@ic.ac.uk</email></corresp>
+      </author-notes>
+      <pub-date date-type="pub" publication-format="print" iso-8601-date="2002-04-13">
+        <day>13</day>
+        <month>4</month>
+        <year>2002</year>
+      </pub-date>
+      <volume>324</volume>
+      <issue>7342</issue>
+      <fpage>880</fpage>
+      <lpage>882</lpage>
+      <history>
+        <date date-type="accepted" iso-8601-date="2002-02-07" publication-format="print">
+          <day>7</day>
+          <month>2</month>
+          <year>2002</year>
+        </date>
+      </history>
+      <permissions>
+        <copyright-statement>Copyright &#x00A9; 2002, BMJ</copyright-statement>
+        <copyright-year>2002</copyright-year>
+      </permissions>
+      <funding-group specific-use="Crossref">
+        <award-group>
+          <funding-source id="mul1" country="UK">Scientific Foundation Board of the RCGP (<institution-wrap>
+              <institution>Royal College of General Practitioners</institution>
+              <institution-id institution-id-type="doi" vocab="open-funder-registry"
+                vocab-identifier="10.13039/open_funder_registry">10.13039/100010334</institution-id>
+            </institution-wrap>
+            )
+<named-content content-type="abbreviation">RCGP</named-content>
+          </funding-source>
+        </award-group>
+        <funding-statement>Funding: Meetings of the working group
+          in 1999-2000 were funded by the Scientific Foundation Board
+          of the RCGP.</funding-statement>
+      </funding-group>
+    </article-meta>
+  </front>
+  <body>
+    <p>In 1999 Shah<xref ref-type="bibr" rid="B1">1</xref> and others said that the Royal College of
+      General Practitioners should advocate longer consultations in general practice as a matter of
+      policy. The college set up a working group chaired by A P Hungin, and a systematic review of
+      literature on consultation length in general practice was commissioned. The working group
+      agreed that the available evidence would be hard to interpret without discussion of the
+      changing context within which consultations now take place. For many years general
+      practitioners and those who have surveyed patients' opinions in the United Kingdom have
+      complained about short consultation time, despite a steady increase in actual mean length.
+      Recently Mechanic pointed out that this is also true in the United States.<xref
+        ref-type="bibr" rid="B2">2</xref> Is there any justification for a further increase in mean
+      time allocated per consultation in general practice?</p>
+    <p>We report on the outcome of extensive debate among a group of general practitioners with an
+      interest in the process of care, with reference to the interim findings of the commissioned
+      systematic review and our personal databases. The review identified 14 relevant papers. <boxed-text>
+        <sec>
+          <title>Summary points</title>
+          <p>
+            <list list-type="bullet">
+              <list-item>
+                <p>Longer consultations are associated with a range of better patient outcomes</p>
+              </list-item>
+              <list-item>
+                <p>Modern consultations in general practice deal with patients with more serious and
+      chronic
+                  conditions</p>
+              </list-item>
+              <list-item>
+                <p>Increasing patient participation means more complex interaction, which demands
+      extra
+                  time</p>
+              </list-item>
+              <list-item>
+                <p>Difficulties with access and with loss of continuity add to perceived stress and
+      poor
+                  performance and lead to further pressure on time</p>
+              </list-item>
+              <list-item>
+                <p>Longer consultations should be a professional priority, combined with increased
+      use of
+                  technology and more flexible practice management to maximise interpersonal
+      continuity</p>
+              </list-item>
+              <list-item>
+                <p>Research on implementation is needed</p>
+              </list-item>
+            </list>
+          </p>
+        </sec>
+      </boxed-text>
+    </p>
+    <sec sec-type="subjects">
+      <title>Longer consultations: benefits for patients</title>
+      <p>The systematic review consistently showed that doctors with longer consultation times
+        prescribe less and offer more advice on lifestyle and other health promoting activities.
+        Longer consultations have been significantly associated with better recognition and handling
+        of psychosocial problems<xref ref-type="bibr" rid="B3">3</xref> and with better patient
+        enablement.<xref ref-type="bibr" rid="B4">4</xref> Also clinical care for some chronic
+        illnesses is better in practices with longer booked intervals between one appointment and
+        the next.<xref
+          ref-type="bibr" rid="B5">5</xref> It is not clear whether time is itself the main
+        influence or whether some doctors insist on more time.</p>
+      <p>A national survey in 1998 reported that most (87&#x0025;) patients were satisfied with the
+        length of their most recent consultation.<xref ref-type="bibr" rid="B6">6</xref>
+        Satisfaction with any service will be high if expectations are met or exceeded. But
+        expectations are modified by previous experience.<xref ref-type="bibr" rid="B7">7</xref> The
+        result is that primary care patients are likely to be satisfied with what they are used to
+        unless the context modifies the effects of their own experience.</p>
+    </sec>
+    <sec>
+      <title>Context of modern consultations</title>
+      <p>Shorter consultations were more appropriate when the population was younger, when even a
+        brief
+        absence from employment due to sickness required a doctor's note, and when many simple
+        remedies
+        were available only on prescription. Recently at least five important influences have
+        increased
+        the content and hence the potential length of the consultation.</p>
+    </sec>
+    <sec>
+      <title>Participatory consultation style</title>
+      <p>The most effective consultations are those in which doctors most directly acknowledge and
+        perhaps respond to patients' problems and concerns. In addition, for patients to be
+        committed to taking advantage of medical advice they must agree with both the goals and
+        methods proposed. A landmark publication in the United Kingdom was <italic>Meetings Between
+        Experts</italic>, which argued that while doctors are the experts about medical problems in
+        general patients are the experts on how they themselves experience these problems.<xref
+          ref-type="bibr" rid="B8">8</xref> New emphasis on teaching consulting skills in general
+        practice advocated specific attention to the patient's agenda, beliefs, understanding, and
+        agreement. Currently the General Medical Council, aware that communication difficulties
+        underlie many complaints about doctors, has further emphasised the importance of involving
+        patients in consultations in its revised guidance to medical schools.<xref ref-type="bibr"
+          rid="B9">9</xref> More patient involvement should give a better outcome, but this
+        participatory style usually lengthens consultations.</p>
+    </sec>
+    <sec>
+      <title>Extended professional agenda</title>
+      <p>The traditional consultation in general practice was brief.<xref ref-type="bibr" rid="B2"
+        >2</xref>
+        The patient presented symptoms and the doctor prescribed treatment. In 1957 Balint gave new
+        insights into the meaning of symptoms.<xref ref-type="bibr" rid="B10">10</xref> By 1979 an
+        enhanced model of consultation was presented, in which the doctors dealt with ongoing as
+        well as presenting problems and added health promotion and education about future
+        appropriate use of services.<xref ref-type="bibr" rid="B11">11</xref> Now, with an ageing
+        population and more community care of chronic illness, there are more issues to be
+        considered at each consultation. Ideas of what constitutes good general practice are more
+        complex.<xref ref-type="bibr" rid="B12"
+        >12</xref> Good practice now includes both extended
+        care of chronic medical problems&#x2014;for example, coronary heart disease<xref
+          ref-type="bibr" rid="B13">13</xref>&#x2014;and a public health role. At first this model
+        was restricted to those who lead change (&#x201C;early adopters&#x201D;) and enthusiasts<xref
+          ref-type="bibr" rid="B14">14</xref> but now it is embedded in professional and managerial
+        expectations of good practice.</p>
+      <p>Adequate time is essential. It may be difficult for an elderly patient with several active
+        problems to undress, be examined, and get adequate professional consideration in under 15
+        minutes. Here the doctor is faced with the choice of curtailing the consultation or of
+        reducing the time available for the next patient. Having to cope with these situations often
+        contributes to professional dissatisfaction.<xref ref-type="bibr" rid="B15">15</xref> This
+        combination of more care, more options, and more genuine discussion of those options with
+        informed patient choice inevitably leads to pressure on time.</p>
+    </sec>
+    <sec>
+      <title>Access problems</title>
+      <p>In a service free at the point of access, rising demand will tend to increase rationing by
+        delay. But attempts to improve access by offering more consultations at short notice squeeze
+        consultation times.</p>
+      <p>While appointment systems can and should reduce queuing time for consultations, they have
+        long tended to be used as a brake on total demand.<xref ref-type="bibr" rid="B16">16</xref>
+        This may seriously erode patients' confidence in being able to see their doctor or nurse
+        when they need to. Patients are offered appointments further ahead but may keep these even
+        if their symptoms have remitted &#x201C;just in case.&#x201D; Availability of consultations
+        is thus blocked. Receptionists are then inappropriately blamed for the inadequate access to
+        doctors.</p>
+      <p>In response to perception of delay, the government has set targets in the NHS plan of
+        &#x201C;guaranteed access to a primary care professional within 24 hours and to a primary
+        care
+        doctor within 48 hours.&#x201D; Implementation is currently being negotiated.</p>
+      <p>Virtually all patients think that they would not consult unless it was absolutely
+        necessary.
+        They do not think they are wasting NHS time and do not like being made to feel so. But
+        underlying general practitioners' willingness to make patients wait several days is their
+        perception that few of the problems are urgent. Patients and general practitioners evidently
+        do
+        not agree about the urgency of so called minor problems. To some extent general practice in
+        the
+        United Kingdom may have scored an &#x201C;own goal&#x201D; by setting up perceived access
+        barriers (appointment systems and out of hours cooperatives) in the attempt to increase
+        professional standards and control demand in a service that is free at the point of access.</p>
+      <p>A further government initiative has been to bypass general practice with new
+        services&#x2014;notably, walk-in centres (primary care clinics in which no appointment is
+        needed) and NHS Direct (a professional telephone helpline giving advice on simple remedies
+        and
+        access to services). Introduced widely and rapidly, these services each potentially provide
+        significant features of primary care&#x2014;namely, quick access to skilled health advice
+        and
+        first line treatment.</p>
+    </sec>
+    <sec>
+      <title>Loss of interpersonal continuity</title>
+      <p>If a patient has to consult several different professionals, particularly over a short
+        period of time, there is inevitable duplication of stories, risk of naive diagnoses,
+        potential for conflicting advice, and perhaps loss of trust. Trust is essential if patients
+        are to accept the &#x201C;wait and see&#x201D; management policy which is, or should be, an
+        important part of the management of self limiting conditions, which are often on the
+        boundary between illness and non-illness.<xref ref-type="bibr" rid="B17">17</xref> Such
+        duplication again increases pressure for more extra (unscheduled) consultations resulting in
+        late running and professional frustration.<xref ref-type="bibr" rid="B18">18</xref>
+      </p>
+      <p>Mechanic described how loss of longitudinal (and perhaps personal and relational<xref
+          ref-type="bibr" rid="B19">19</xref>) continuity influences the perception and use of time
+        through an inability to build on previous consultations.<xref ref-type="bibr" rid="B2">2</xref>
+        Knowing the doctor well, particularly in smaller practices, is associated with enhanced
+        patient enablement in shorter time.<xref ref-type="bibr" rid="B4">4</xref> Though Mechanic
+        pointed out that three quarters of UK patients have been registered with their general
+        practitioner five years or more, this may be misleading. Practices are growing, with larger
+        teams and more registered patients. Being registered with a doctor in a larger practice is
+        usually no guarantee that the patient will be able to see the same doctor or the doctor of
+        his or her choice, who may be different. Thus the system does not encourage adequate
+        personal continuity. This adds to pressure on time and reduces both patient and professional
+        satisfaction.</p>
+    </sec>
+    <sec>
+      <title>Health service reforms</title>
+      <p>Finally, for the past 15 years the NHS has experienced unprecedented change with a
+        succession
+        of major administrative reforms. Recent reforms have focused on an NHS led by primary care,
+        including the aim of shifting care from the secondary specialist sector to primary care. One
+        consequence is increased demand for primary care of patients with more serious and less
+        stable
+        problems. With the limited piloting of reforms we do not know whether such major redirection
+        can
+        be achieved without greatly altering the delicate balance between expectations (of both
+        patients
+        and staff) and what is delivered.</p>
+    </sec>
+    <sec>
+      <title>The future</title>
+      <p>We think that the way ahead must embrace both longer mean consultation times and more
+        flexibility. More time is needed for high quality consultations with patients with major and
+        complex problems of all kinds. But patients also need access to simpler services and advice.
+        This should be more appropriate (and cost less) when it is given by professionals who know
+        the patient and his or her medical history and social circumstances. For doctors, the higher
+        quality associated with longer consultations may lead to greater professional satisfaction
+        and, if these longer consultations are combined with more realistic scheduling, to reduced
+        levels of stress.<xref ref-type="bibr" rid="B20">20</xref> They will also find it easier to
+        develop further the care of chronic disease.</p>
+      <p>The challenge posed to general practice by walk-in centres and NHS Direct is considerable,
+        and the diversion of funding from primary care is large. The risk of waste and duplication
+        increases as more layers of complexity are added to a primary care service that started out
+        as something familiar, simple, and local and which is still envied in other developed
+        countries.<xref
+          ref-type="bibr" rid="B21">21</xref> Access needs to be simple, and the advantages of
+        personal knowledge and trust in minimising duplication and overmedicalisation need to be
+        exploited.</p>
+      <p>We must ensure better communication and access so that patients can more easily deal with
+        minor issues and queries with someone they know and trust and avoid the formality and
+        inconvenience of a full face to face consultation. Too often this has to be with a different
+        professional, unfamiliar with the nuances of the case. There should be far more managerial
+        emphasis on helping patients to interact with their chosen practitioner<xref ref-type="bibr"
+          rid="B22">22</xref>; such a programme has been described.<xref ref-type="bibr" rid="B23"
+        >23</xref>
+        Modern information systems make it much easier to record which doctor(s) a patient prefers
+        to see and to monitor how often this is achieved. The telephone is hardly modern but is
+        underused. Email avoids the problems inherent in arranging simultaneous availability
+        necessary for telephone consultations but at the cost of reducing the communication of
+        emotions. There is a place for both.<xref ref-type="bibr" rid="B2">2</xref> Access without
+        prior appointment is a valued feature of primary care, and we need to know more about the
+        right balance between planned and ad hoc consulting.</p>
+    </sec>
+    <sec>
+      <title>Next steps</title>
+      <p>General practitioners do not behave in a uniform way. They can be categorised as slow,
+        medium, and fast and react in different ways to changes in consulting speed.<xref
+          ref-type="bibr"
+          rid="B18">18</xref> They are likely to have differing views about a widespread move to
+        lengthen consultation time. We do not need further confirmation that longer consultations
+        are desirable and necessary, but research could show us the best way to learn how to
+        introduce them with minimal disruption to the way in which patients and practices like
+        primary care to be provided.<xref ref-type="bibr" rid="B24">24</xref> We also need to learn
+        how to make the most of available time in complex consultations.</p>
+      <p>Devising appropriate incentives and helping practices move beyond just reacting to demand
+        in
+        the traditional way by working harder and faster is perhaps our greatest challenge in the
+        United
+        Kingdom. The new primary are trusts need to work together with the growing primary care
+        research
+        networks to carry out the necessary development work. In particular, research is needed on
+        how a
+        primary care team can best provide the right balance of quick access and interpersonal
+        knowledge
+        and trust.</p>
+    </sec>
+  </body>
+  <back>
+    <ack>
+      <p>We thank the other members of the working group: Susan Childs, Paul Freeling, Iona Heath,
+        Marshall Marinker, and Bonnie Sibbald. We also thank Fenny Green of the Royal College of
+        General
+        Practitioners for administrative help.</p>
+    </ack>
+    <ref-list>
+      <ref id="B1">
+        <label>1</label>
+        <element-citation publication-type="journal" publication-format="print">
+          <person-group person-group-type="author">
+            <name>
+              <surname>Shah</surname>
+              <given-names>NC</given-names>
+            </name>
+          </person-group>
+          <article-title>Viewpoint: Consultation time&#x2014;time for a
+            change? Still the &#x201C;perfunctory work of perfunctory men!&#x201D;</article-title>
+          <source>Br J Gen Pract</source>
+          <year iso-8601-date="1999">1999</year>
+          <volume>49</volume>
+          <fpage>497</fpage>
+        </element-citation>
+      </ref>
+
+      <ref id="B2">
+        <label>2</label>
+        <element-citation publication-type="journal" publication-format="print">
+          <person-group person-group-type="author">
+            <name>
+              <surname>Mechanic</surname>
+              <given-names>D</given-names>
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