Background There is limited evidence about the impact of specific patterns of multi-morbidity on health-related quality of life (HRQoL) from large samples of adult subjects. Methods We used data from the English General Practice Patient Survey 2011-2012. We defined multi-morbidity as the presence of two or more of 12 self-reported conditions or another (unspecified) long-term health problem. We investigated differences in HRQoL (EQ-5D scores) associated with combinations of these conditions after adjusting for age, gender, ethnicity, socio-economic deprivation and the presence of a recent illness or injury. Analyses were based on 831,537 responses from patients aged 18 years or older in 8,254 primary care practices in England.Results Of respondents, 23 % reported two or more chronic conditions (ranging from 7 % of those under 45 years of age to 51 % of those 65 years or older). Multimorbidity was more common among women, White individuals and respondents from socio-economically deprived areas. Neurological problems, mental health problems, arthritis and long-term back problem were associated with the greatest HRQoL deficits. The presence of three or more conditions was commonly associated with greater reduction in quality of life than that implied by the sum of the differences associated with the individual conditions. The decline in quality of life associated with an additional condition in people with two and three physical conditions was less for older people than for younger people. Multimorbidity was associated with a substantially worse HRQoL in diabetes than in other long-term conditions. With the exception of neurological conditions, the presence of a comorbid mental health problem had a more adverse effect on HRQoL than any single comorbid physical condition. Conclusion Patients with multi-morbid diabetes, arthritis, neurological, or long-term mental health problems have significantly lower quality of life than other people. People with long-term health conditions require integrated mental and physical healthcare services.

Abstract:The practice of medicine involves inherent ambiguity, arising from limitations of knowledge, diagnostic problems, complexities of treatment and outcome and unpredictability of patient response. Research into doctors' tolerance of ambiguity is hampered by poor conceptual clarity and inadequate measurement scales. We aimed to create and pilot a measurement scale for tolerance of ambiguity in medical students and junior doctors that addresses the limitations of existing scales. After defining tolerance of ambiguity, scale items were generated by literature review and expert consultation. Feedback on the draft scale was sought and incorporated. 411 medical students and 75 Foundation doctors in Exeter, UK were asked to complete the scale. Psychometric analysis enabled further scale refinement and comparison of scale scores across subgroups. The pilot study achieved a 64% response rate. The final 29 item version of the Tolerance of Ambiguity in Medical Students and Doctors (TAMSAD) scale had good internal reliability (Cronbach's alpha 0.80). Tolerance of ambiguity was higher in Foundation Year 2 doctors than first, third and fourth year medical students (-5.23,P = 0.012; -5.98, P = 0.013; -4.62, P = 0.035, for each year group respectively). The TAMSAD scale offers a valid and reliable alternative to existing scales. Further work is required in different settings and in longitudinal studies but this study offers intriguing provisional insights.Response to Reviewers: Dear Sir, Thank you for your email providing further feedback on our second draft manuscript.We have now responded to your comments (see table below).We have included a new manuscript both with and without tracked changes. In the tracked changes version we have accepted all format changes and so tracked changes indicate changes to text and tables.We look forward to hearing from you in due course. Yours faithfully, Powered by Editorial Manager® and ProduXion Manager® from Aries Systems CorporationJason Hancock (corresponding author) AbstractThe practice of medicine involves inherent ambiguity, arising from limitations of knowledge, diagnostic problems, complexities of treatment and outcome and unpredictability of patient response.Research into doctors' tolerance of ambiguity is hampered by poor conceptual clarity and inadequate measurement scales. We aimed to create and pilot a measurement scale for tolerance of ambiguity in medical students and junior doctors that addresses the limitations of existing scales. After defining tolerance of ambiguity, scale items were generated by literature review and expert consultation.

ObjectivesPatients’ trust in general practitioners (GPs) is fundamental to effective clinical encounters. Associations between patients’ trust and their perceptions of communication within the consultation have been identified, but the influence of patients’ demographic characteristics on these associations is unknown. We aimed to investigate the relative contribution of the patient's age, gender and ethnicity in any association between patients’ ratings of interpersonal aspects of the consultation and their confidence and trust in the doctor.DesignSecondary analysis of English national GP patient survey data (2009).SettingPrimary Care, England, UK.ParticipantsData from year 3 of the GP patient survey: 5 660 217 questionnaires sent to patients aged 18 and over, registered with a GP in England for at least 6 months; overall response rate was 42% after adjustment for sampling design.Outcome measuresWe used binary logistic regression analysis to investigate patients’ reported confidence and trust in the GP, analysing ratings of 7 interpersonal aspects of the consultation, controlling for patients’ sociodemographic characteristics. Further modelling examined moderating effects of age, gender and ethnicity on the relative importance of these 7 predictors.ResultsAmong 1.5 million respondents (adjusted response rate 42%), the sense of ‘being taken seriously’ had the strongest association with confidence and trust. The relative importance of the 7 interpersonal aspects of care was similar for men and women. Non-white patients accorded higher priority to being given enough time than did white patients. Involvement in decisions regarding their care was more strongly associated with reports of confidence and trust for older patients than for younger patients.ConclusionsAssociations between patients’ ratings of interpersonal aspects of care and their confidence and trust in their GP are influenced by patients’ demographic characteristics. Taking account of these findings could inform patient-centred service design and delivery and potentially enhance patients’ confidence and trust in their doctor.

. Both auditory and phonetic processes have been implicated by previous results from selective adaptation experiments using speech stimuli. It has proved difficult to dissociate their individual contributions because the auditory and phonetic structure of conventional acoustical stimuli are mutually predictive. In the present experiment, the necessary dissociation was achieved by using an audiovisualadaptor consisting of an acoustical [bE] synchronized to a video recording of a talker uttering the syllable [gEl. This stimulus was generallyidentifiedas oneof the dentals [dE] or [a E]. It producedan adaptation effect,measuredwith an acoustical[be-ds] test continuum, identical in size and direction to that produced by an acoustical [bEl-an adaptor sharing its acoustical structure-and opposite in direction to that produced by an acoustical [dEl-an adaptor sharing its perceived phonetic identity. Thus, the result strongly suggests that auditory rather than phonetic levels of processing are influenced in selective adaptation.Since the introduction of the selective adaptation paradigm to research on speech perception (Eimas & Corbit, 1973), many questions have been raised concerning the nature and loci of the processes underlying the effects obtained. The paradigm is straightforward. A series of speech sounds varying in some distinctive acoustic parameter is created, usually spanning two phonetic categories. These test syllables are randomized and presented for identification under two conditions. In the baseline condition, the individual syllables are presented for identification in isolation. In the adaptation condition, each test syllable is presented following a number of repetitions of an adapting syllable. In each condition, an ogive is fitted to the identification functions from several presentations of each syllable in a series. The point of response equiprobability, the phoneme boundary, is determined. The position of the boundary in the series usually changes following adaptation, and the size of the change provides a measure of the adaptation effect. When the adaptor is an unambiguous syllablecorrespondingto one or the other of the endpoints of the test continuum, the boundary usually moves toward that syllable. If, for instance, the test series embraces a phonetic contrast in voicing (e.g., [ba-pha]), following adaptation with [ba] a greater proportion of test syllables, particularly in the boundary region, are identified as [phal, and the phoneme boundary shifts toward the [ba] end of the series.Originally, it was proposed (Cooper, 1974;