Understanding the work of general practitioners: a social science perspective on the context of medical decision making in primary care

Benefits and limitations of the transfer online of Irish College of General Practitioners continuing medical education small group learning during the COVID pandemic: a national Delphi study

BACKGROUND

In Ireland and internationally, small-group learning (SGL) has been shown to be an effective way of delivering continuing medical education (CME) and changing clinical practice.

RESEARCH QUESTION

This study sought to determine the benefits and limitations, as reported by Irish GPs, of the change of CME-SGL from face-to-face to online learning during COVID.

METHODS

GPs were invited to participate via email through their respective CME tutors. The first of three rounds of a survey using the Delphi method gathered demographic information and asked GPs about the benefits and/or limitations of learning online in their established small groups. Subsequent rounds obtained a consensus opinion.

RESULTS

Eighty-eight GPs across Ireland agreed to participate. Response rates varied from 62.5% to 72% in different rounds. These GPs reported that attending their established CME-SGL groups allowed them to discuss the practical implications of applying guidelines in COVID care into practice (92.7% consensus), reviewing new local services and comparing their practice with others (94% consensus); helping them feel less isolated (98% consensus). They reported that online meetings were less social (60% consensus), and informal learning that occurs before and after meetings did not take place (70% consensus). GPs would not like online learning to replace face-to face-CME-SGL after COVID (89% consensus).

CONCLUSION

GPs in established CME-SGL groups benefited from online learning as they could discuss how to adapt to rapidly changing guidelines while feeling supported and less isolated. They report that face-to-face meetings offer more opportunities for informal learning.

Time is money: general practitioners' reflections on the fee-for-service system

BACKGROUND

Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions.

METHODS

We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis.

RESULTS

We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees.

CONCLUSIONS

GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

Systematic development of quality indicators for skin cancer management in primary care: a mixed-methods study protocol

INTRODUCTION

Australia has the highest incidence of skin cancer in the world, with two out of three Australians expected to be diagnosed with skin cancer in their lifetime. Such incidence necessitates large-scale, effective skin cancer management practices. General practitioners (in mainstream practice and in skin cancer clinics) play an important role in skin cancer care provision, making decisions based on relevant evidence-based guidelines, protocols, experience and training. Diversity in these decision-making practices can result in unwarranted variation. Quality indicators are frequently implemented in healthcare contexts to measure performance quality at the level of the clinician and healthcare practice and mitigate unwarranted variation. Such measurements can facilitate performance comparisons between peers and a standard benchmark, often resulting in improved processes and outcomes. A standardised set of quality indicators is yet to be developed in the context of primary care skin cancer management.

AIMS

This research aims to identify, develop and generate expert consensus on a core set of quality indicators for skin cancer management in primary care.

METHODS

This mixed-methods study involves (1) a scoping review of the available evidence on quality indicators in skin cancer management in primary care, (2) identification and development of a core set of quality indicators through interviews/qualitative proforma surveys with participants, and (3) a focus group involving discussion of quality indicators according to Nominal Group Technique. Qualitative and quantitative data will be collected and analysed using thematic and descriptive statistical analytical methods.

ETHICS AND DISSEMINATION

Approval was granted by the university's Research Ethics Committee (HREC no. 520211051532420). Results from this study will be widely disseminated in publications, study presentations, educational events and reports.

Context and general practitioner decision-making - a scoping review of contextual influence on antibiotic prescribing

BACKGROUND

How contextual factors may influence GP decisions in real life practice is poorly understood. The authors have undertaken a scoping review of antibiotic prescribing in primary care, with a focus on the interaction between context and GP decision-making, and what it means for the decisions made.

METHOD

The authors searched Medline, Embase and Cinahl databases for English language articles published between 1946 and 2019, focusing on general practitioner prescribing of antibiotics. Articles discussing decision-making, reasoning, judgement, or uncertainty in relation to antibiotic prescribing were assessed. As no universal definition of context has been agreed, any papers discussing terms synonymous with context were reviewed. Terms encountered included contextual factors, non-medical factors, and non-clinical factors.

RESULTS

Three hundred seventy-seven full text articles were assessed for eligibility, resulting in the inclusion of 47. This article documented the experiences of general practitioners from over 18 countries, collected in 47 papers, over the course of 3 decades. Contextual factors fell under 7 themes that emerged in the process of analysis. These were space and place, time, stress and emotion, patient characteristics, therapeutic relationship, negotiating decisions and practice style, managing uncertainty, and clinical experience. Contextual presence was in every part of the consultation process, was vital to management, and often resulted in prescribing.

CONCLUSION

Context is essential in real life decision-making, and yet it does not feature in current representations of clinical decision-making. With an incomplete picture of how doctors make decisions in real life practice, we risk missing important opportunities to improve decision-making, such as antibiotic prescribing.

CuS nanoparticles anchored to g-C3N4 nanosheets for photothermal ablation of bacteria

Antibiotic resistance has already been recognized as one of the greatest threats to human beings' health, and thus it is highly desirable to develop new bactericidal approaches. The photothermal antibacterial process based on the photo-to-thermal conversion using semiconducting materials is currently extensively studied owing to its high efficiency, long durability and environmental benignity. In this study, we fabricated copper sulfide (CuS) nanoparticle-decorated graphitic carbon nitride (g-C3N4) nanosheets, denoted as the PEG-CuS@g-C3N4 nanocomposite, via a simple hydrothermal process. Materials characterization showed that CuS nanoparticles were uniformly distributed on the surface of g-C3N4 without agglomeration. Moreover, the nanocomposite exhibited excellent photothermal conversion efficiency (up to 59.64%) due to its strong near-infrared (NIR) absorption characteristics. The antibacterial efficiency evaluation indicated that the PEG-CuS@g-C3N4 nanocomposite could effectively kill the Gram-positive Staphylococcus aureus (S. aureus) and the Gram-negative Escherichia coli (E. coli). We found that up to 99% of both S. aureus and E. coli could be killed in a 200 μg ml-1 PEG-CuS@g-C3N4 suspension within 20 min of NIR irradiation. Moreover, the cytotoxicity of the PEG-CuS@g-C3N4 nanocomposite was evaluated using the mouse skin fibroblast NIH-3T3 cells, and the nanocomposite was found to display acceptable biocompatibility. We believe that the PEG-CuS@g-C3N4 nanocomposite is of significant interest for rapid bacteria-killing, and would gain promising applications for sterilization.

Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis

Objective

To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research.

Materials and Methods

We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research.

Results

The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process.

Discussion

The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations.

Conclusion

The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.

How do general practitioners contribute to preventing long-term work disability of their patients suffering from depressive disorders? A qualitative study

BACKGROUND

Depression is a major cause of work absenteeism that general practitioners (GPs) face directly since they are responsible for sickness certification and for supervising the return to work (RTW). These activities give GPs a key role in preventing long-term work disability, yet their practices in this regard remain poorly documented. The objectives of this study were therefore to describe GPs' practices with people experiencing work disability due to depressive disorders and explore how GPs' work context may impact on their practices.

METHODS

We conducted semi-structured individual interviews with 13 GPs and six mental healthcare professionals in two sub-regions of Quebec. The sub-regions differed in terms of availability of specialized resources offering public mental health services. Data were anonymized and transcribed verbatim. Thematic analysis was performed to identify patterns in the GPs' practices and highlight impacting factors in their work context.

RESULTS

Our results identified a set of practices common to all the GPs and other practices that differentiated them. Two profiles were defined on the basis of the various practices documented. The first is characterized by the integration of the RTW goal into the treatment goal right from sickness certification and by interventions that include the workplace, albeit indirectly. The second is characterized by a lack of early RTW-oriented action and by interventions that include little workplace involvement. Regardless of the practice profile, actions intended to improve collaboration with key stakeholders remain the exception. However, two characteristics of the work context appear to have an impact: the availability of a dedicated mental health nurse and the regular provision of clinical information by psychotherapists. These conditions are rarely present but tend to make a significant difference for the GPs.

CONCLUSIONS

Our results highlight the significant role of GPs in the prevention of long-term work disability and their need for support through the organization of mental health services at the primary care level.

General practitioners' relationship with preventive knowledge: a qualitative study

General practitioners (GPs) do not provide enough preventive care. Nonetheless, without a detailed understanding of the logical processes that underlie their practices, it remains difficult to develop effective means of improvement. Their relationship to knowledge is one of three elements that strongly structure GPs' preventive work (together with the doctor-patient relationship and the organisation of their professional space).The objective of this article was to explore the question of GPs' relationship to knowledge about prevention. In 2010-2011, semi-directive interviews with a diverse sample of 100 GPs practising in the Paris metropolitan area were conducted. These interviews were coded according a reading grid that was developed collectively and analysed in the framework of grounded theory. The cognitive universe of GPs is neither homogeneous nor stable. It is composed of biomedical knowledge (delivered via guidelines, the professional press, opinion leaders and pharmaceutical companies), clinical knowledge (fed by individual situations from their daily experience and often conflicting with epidemiologic reasoning and data) and lay knowledge (from folk culture). Plunged into this complex cognitive universe that is difficult for them to master, doctors construct their own idiosyncratic preventive style by themselves, mostly in isolation. Two types of actions emerged as likely to help GPs better appropriate preventive knowledge: clarification of scientific data (especially from epidemiology and the social sciences) but also development of a collective analysis of the cognitive work required to integrate the different types of knowledge mobilised daily in their preventive practices.

'We can do only what we have the means for' general practitioners' views of primary care for older people with complex health problems

Background

Due to demographic change, general practitioners (GPs) are increasingly required to care for older people with complex health problems. Little is known about the subjective appraisals of GPs concerning the demanded changes. Our objective is to explore how general practitioners view their professional mandates and capacities to provide comprehensive care for older people with complex health problems. Do geriatric training or experience influence viewpoints? Can barriers for the implementation of changes in primary care for older people with complex health problems be detected?

Methods

Preceding a controlled intervention study on case management for older patients in the primary care setting (OMAHA II), this qualitative study included 10 GPs with differing degrees of geriatric qualification. Semi structured interviews were conducted and audio-taped. Full interview transcripts were analyzed starting with open coding on a case basis and case descriptions. The emerging thematic structure was enriched with comparative dimensions through reiterated inter-case comparison and developed into a multidimensional typology of views.

Results

Based on the themes emerging from the data and their presentation by the interviewed general practitioners we could identify three different types of views on primary care for older people with complex health problems: ‘maneuvering along competence limits’, ‘Herculean task’, and ‘cooperation and networking’. The types of views differ in regard to role-perception, perception of their own professional domain, and action patterns in regard to cooperation. One type shows strong correspondence with a geriatrician. Across all groups, there is a shared concern with the availability of sufficient resources to meet the challenges of primary care for older people with complex health problems.

Conclusions

Limited financial resources, lack of cooperational networks, and attitudes appear to be barriers to assuring better primary care for older people with complex health problems. To overcome these barriers, geriatric training is likely to have a positive impact but needs to be supplemented by regulations regarding reimbursement. Most of all, general practitioners’ care for older people with complex health problems needs a conceptual framework that provides guidance regarding their specific role and contribution and assisting networks. For example, it is essential that general practice guidelines become more explicit with respect to managing older people with complex health problems.

Predictors of physician performance on competence assessment: Findings from CPEP, the Center for Personalized Education for Physicians

PURPOSE

To identify factors associated with physician performance in a comprehensive competence assessment.

METHOD

The authors conducted a retrospective analysis of 683 physicians referred for assessment at the Center for Personalized Education for Physicians from 2000 to 2010, who were evaluated as either safe or unsafe to return to practice. Multivariate logistic regression was used to determine factors predictive of unsafe assessment outcome. Covariates included personal characteristics (e.g., age), practice context (e.g., solo practice), and referral information (e.g., previous board license action).

RESULTS

Older physicians were more likely to have unsafe assessment outcomes (odds ratio [OR] = 1.07; P < .001). Board-certified individuals were less likely to have poor assessment outcomes (OR = 0.40; P = .003) than uncertified individuals. Physicians in solo practice were more likely (OR = 2.15; P = .037) to be deemed unsafe than physicians in other settings. Physicians with a practice scope that matched their training were less likely (OR = 0.29; P = .023) to have unsafe assessment outcomes than those whose did not. Physicians with current or previous board action (suspension, revocation, limitation, or stipulation) were more likely to be deemed unsafe (OR = 2.47; P = .003) than those without.

CONCLUSIONS

Findings suggest that important predictors of physician performance on competence assessment include personal characteristics, practice context, and reasons for assessment referral. These findings have implications for development of policies and programs designed to assess risk of poor physician performance and quality of care improvement efforts through organizational/practice design or remedial education.

Primary care practice characteristics associated with the quality of care received by patients with depression and comorbid chronic conditions

OBJECTIVE

This study aimed to identify primary care practice characteristics associated with the quality of depression care in patients with comorbid chronic medical and/or psychiatric conditions.

METHOD

Using data from cross-sectional organizational and patient surveys conducted within 61 primary care clinics in Quebec, Canada, the relationships between primary care practice characteristics, comorbidity profile, and the recognition and minimally adequate treatment of depression were assessed using multilevel logistic regression analysis with 824 adults with past-year depression and comorbid chronic conditions.

RESULTS

Likelihood of depression recognition was higher in clinics where accessibility of mental health professionals was not viewed to be a major barrier to depression care [odds ratio (OR)=1.61; 95% confidence interval (CI) 1.13-2.30]. Four practice characteristics were associated with minimal treatment adequacy: greater use of treatment algorithms for depression (OR=1.77; 95% CI=1.18-2.65), high value given to teamwork (OR=2.48; 95% CI=1.40-4.38), having at least one general practitioner at the clinic devote significant time in practice to mental health (OR=1.54; 95% CI=1.07-2.21) and low perceived barriers to depression care due to inadequate payment models (OR=2.12; 95% CI=1.30-3.46).

CONCLUSIONS

Several primary care practice characteristics significantly influence the quality of care provided to patients with depression and comorbid chronic conditions and should be targeted in quality improvement efforts.

An analysis of actions to promote health in underprivileged urban areas: a case in Brazil

BACKGROUND

Two policies stood out in the 2000s geared towards changing the care model adopted in Brazil: The National Policy on Primary Health Care, based on a family health care model, and the National Policy on Health Promotion.The aim of this study was to analyze health promotion actions developed by family health care teams in the municipality of Belford Roxo. This town was chosen by virtue of its "below average" level of primary health care services offered in relation to other municipalities in Rio de Janeiro state.

METHODS

The following methodological strategies were employed: analysis of health systems, document analysis (2010 Annual Health Schedule and 2010 Annual Management Report), participant observation and interviews with nine health care professionals in the region of study, namely: the manager of the Regional Health Polyclinic (responsible for health care actions in the region), and nurses belonging to the eight family health teams. Giddens' Theory of Structuration was used for analysis of the results.

RESULTS

Varying levels of health care activity were found, indicating that the managers have been either unable or lacked the commitment to perform the proposed actions. From a structural point of view, 87.5% of the teams were incomplete. Also of particular note was the lack of any physicians in the teams, which, despite its detrimental effect, was regarded by the interviewees as "natural".Strong political party influence in the area hindered relations between the team and the local population. Health education, especially through lectures was the main health promotion activity picked up in this study.No cross-sectorial or public participation actions were identified. Connections between the teams for sharing responsibilities were found to be very weak.

CONCLUSION

In addition to political factors, there are also structural limitations such as a lack of human resources that overburdens the teams' daily activities. From this point of view, the political context and lack of professionals were restrictive factors for health promotion.Belford Roxo is not necessarily representative of other experiences in Brazil. However, problems such as patronage, political manipulation, poverty and incipient cross-sectorial actions are common to other Brazilian towns and cities.

Clinical supervision among family physicians: prevalence, needs, and attitudes

BACKGROUND

Clinical supervision (CS) is not an established support system among physicians. Family physicians (FPs) have used Balint groups as a form of clinical supervision. In all, not much is known about the prevalence of physicians' attendance to or needs for CS.

OBJECTIVE

We studied what proportion of FPs compared with other physicians have attended or report they would need CS and whether having patients who request certain tests or medicines is associated with FPs' attendance to or need for CS.

DESIGN

A postal survey for all working-aged Finnish physicians was performed in 2008. Special questions concerning CS (eg, Balint) and patients' requests were included.

RESULTS

Response rate for the survey was 74% (N = 13 708). Special questions were responded by 10 559 physicians of whom 1252 were FPs. FPs had attended CS more often than other physicians (42% vs 29%, P < .001). Of FPs, 25% reported a need for CS with no availability of it. FPs experienced with or needing for CS were more often than other FPs females, had participated in continuing medical education, and reported that patients with requests have increased in recent years.

CONCLUSION

Both experience of CS and a need for CS with no availability are common among Finnish FPs. Experiences of patients with requests may reflect a need for CS among FPs. Studies on the content, significance and effectiveness CS among FPs are needed.

Quality of care for major depression and its determinants: a multilevel analysis

BACKGROUND

Numerous studies highlight an important gap in the quality of care for depression in primary care. However, basic indicators were often used. Few of these studies examined factors associated with receiving adequate treatment, particularly with a simultaneous consideration of individual and organizational characteristics. The purpose of this study was to estimate the proportion of primary care patients with a major depressive episode (MDE) who receive adequate treatment and to examine the individual and organizational (i.e., clinic-level) characteristics associated with the receipt of at least one minimally adequate treatment for depression.

METHODS

The sample used for this study included 915 adults consulting a general practitioner (GP), regardless of the motive of consultation, meeting DSM-IV criteria for MDE during the 12 months preceding the survey (T1), and nested within 65 primary care clinics. Data reported in this study were obtained from the "Dialogue" project. Adherence rates for 27 quality indicators selected to cover the most important components of depression treatment were estimated. Multilevel analyses were conducted.

RESULTS

Adherence to guidelines was high (>75%) for one third of the quality indicators that were measured but was low (<60%) for nearly half of the measures. Just over half of the sample (52.2%) received at least one minimally adequate treatment for depression. At the individual level, determinants of receipt of minimally adequate care included age, having a family physician, a supplementary insurance coverage, a comorbid anxiety disorder and the severity of depression. At the clinic level, determinants included the availability of psychotherapy on-site, the use of treatment algorithms, and the mode of remuneration.

CONCLUSIONS

Our findings suggest that interventions are needed to increase the extent to which primary mental health care conforms to evidence-based recommendations. These interventions should target specific populations (i.e. the younger adults and the elderly), enhance accessibility to psychotherapy and to a regular family physician, and support primary care physicians in their clinical practice with patients suffering from depression in different ways such as developing knowledge to treat depression and adapting mode of remuneration.

General practitioners' management of mental disorders: a rewarding practice with considerable obstacles

Background

Primary care improvement is the cornerstone of current reforms. Mental disorders (MDs) are a leading cause of morbidity worldwide and widespread in industrialised countries. MDs are treated mainly in primary care by general practitioners (GPs), even though the latter ability to detect, diagnose, and treat patients with MDs is often considered unsatisfactory. This article examines GPs' management of MDs in an effort to acquire more information regarding means by which GPs deal with MD cases, impact of such cases on their practices, factors that enable or hinder MD management, and patient-management strategies.

Methods

This study employs a mixed-method approach with emphasis on qualitative investigation. Based on a previous survey of 398 GPs in Quebec, Canada, 60 GPs representing a variety of practice settings were selected for further study. A 10-minute-long questionnaire comprising 27 items was administered, and 70-minute-long interviews were conducted. Quantitative (SPSS) and qualitative (NVivo) analyses were performed.

Results

At least 20% of GP visits were MD-related. GPs were comfortable managing common MDs, but not serious MDs. GPs' based their treatment of MDs on pharmacotherapy, support therapy, and psycho-education. They used clinical intuition with few clinical tools, and closely followed their patients with MDs. Practice features (salary or hourly fees payment; psycho-social teams on-site; strong informal networks), and GPs' individual characteristics (continuing medical education; exposure and interest in MDs; traits like empathy) favoured MD management. Collaboration with psychologists and psychiatrists was considered key to good MD management. Limited access to specialists, system fragmentation, and underdeveloped group practice and shared-care models were impediments. MD management was seen as burdensome because it required more time, flexibility, and emotional investment. Strategies exist to reduce the burden (one-problem-per-visit rule; longer time slots). GPs found MD practice rewarding as patients were seen as grateful and more complying with medical recommendations compared to other patients, generally leading to positive outcomes.

Conclusions

To improve MD management, this study highlights the importance of extending multidisciplinary GP practice settings with salary or hourly fee payment; access to psychotherapeutic and psychiatric expertise; and case-discussion training involving local networks of GPs and MD specialists that encourage both knowledge transfer and shared care.

Influence of patient payment on antibiotic prescribing in Irish general practice: a cohort study

BACKGROUND

Antibiotics are widely believed to be overused and misused. Approximately 80% of all prescriptions for antibiotics are written by GPs. There are many external factors that influence a GP's decision to prescribe, including patient pressure. Access to primary care services operates on a two-tier system in the Republic of Ireland: General Medical Service (GMS) card holders have free access to GPs and medications; and non-card holders (private patients) must pay a non-subsidised fee to visit their GP.

AIM

To ascertain whether there was a difference in antibiotic prescribing practice between those who pay a fee for their GP consultation and those who attend free of charge.

DESIGN AND SETTING

Cohort study in Irish general practice.

METHOD

All GPs attending continuing medical education (CME) groups nationwide were invited to participate from October 2008 until April 2010. GPs gathered data on 100 consecutive consultations including diagnosis and patient characteristics.

RESULTS

Data were collected from 171 GPs (distributed throughout Ireland), which resulted in 16 899 consultations. Antibiotics were prescribed at 3407 (20.16%) consultations. Nearly half of the prescriptions were for GMS card holders (n = 1669; 48.99%) and 1526 (44.79%) were for private patients; for 212 (6.22%) the payment status of the patient was unknown. Private patients were more likely to receive a prescription for antibiotics (odds ratio 1.23, 95% confidence interval = 1.14 to 1.33).

CONCLUSION

These results demonstrate that a GP's decision to provide a prescription for antibiotics may be influenced by whether or not the patient pays for their consultation at the GP interface. Private patients are more likely than GMS card holders to receive a prescription for antibiotics.

The profile of general practitioners (GPs) who publish in selected family practice journals

Background

Providing support for research is one of the key issues in the ongoing attempts to improve Primary Care. However, when patient care takes up a significant part of a GP's time, conducting research is difficult. In this study we examine the working conditions and profile of GPs who publish in three leading medical journals and propose possible remedial policy actions.

Findings

The authors of all articles published in 2006 and 2007 in three international Family Medicine journals - Annals of Family Medicine, Family Practice, and Journal of Family Practice - were contacted by E-mail. They were asked to complete a questionnaire investigating the following variables: availability of specific time for research, time devoted to research, number of patients attended, and university affiliation. Only GPs were included in the study. Three hundred and ten relevant articles published between 2006 and 2007 were identified and the authors contacted using a survey tool. 124 researchers responded to our questionnaire; 45% of respondents who were not GPs were excluded. On average GPs spent 2.52 days per week and 6.9 hours per day on patient care, seeing 45 patients per week. Seventy-five per cent of GPs had specific time assigned to research, on average 13 hours per week; 79% were affiliated to a university and 69% held teaching positions.

Conclusions

Most GPs who publish original articles in leading journals have time specifically assigned to research as part of their normal working schedule. They see a relatively small number of patients. Improving the working conditions of family physicians who intend to investigate is likely to lead to better research results.

Factors affecting physician performance: implications for performance improvement and governance

BACKGROUND

A physician's personal and professional characteristics constitute only one, and not necessarily the most important, determining factor of clinical performance. Our study assessed how physician, organizational and systemic factors affect family physicians' performance.

METHOD

Our study examined 532 family practitioners who were randomly selected for peer assessment by the College of Physicians and Surgeons of Ontario. A series of multivariate regression analyses examined the impact of physician factors (e.g., demographics, certification) on performance scores in five clinical areas: acute care, chronic conditions, continuity of care and referrals, well care and records. A second series of regressions examined the simultaneous effects of physician, organizational (e.g., practice volume, hours worked, solo practice) and systemic factors (e.g., northern practice location, community size, physician-to-population ratio).

RESULTS

OUR STUDY HAD THREE KEY FINDINGS: (a) physician factors significantly influence performance but do not appear to be nearly as important as previously thought; (b) organizational and systemic factors have significant effects on performance after the effects of physician factors are controlled; and (c) physician, organizational and systemic factors have varying effects across different dimensions of clinical performance.

CONCLUSIONS

We discuss the implications of our results for performance improvement and physician governance insofar as both need to consider the broader environmental context of medical practice.

Family physicians and dementia in Canada: Part 2. Understanding the challenges of dementia care

OBJECTIVE

To explore the challenges Canadian family physicians face in providing dementia care.

DESIGN

Qualitative study using focus groups.

SETTING

Academic family practice clinics in Calgary, Alta, Ottawa, Ont, and Toronto, Ont.

PARTICIPANTS

Eighteen family physicians.

METHODS

We conducted 4 qualitative focus groups of 4 to 6 family physicians whose practices we had audited in a previous study. Focus group transcripts were analyzed using the principles of thematic analysis.

MAIN FINDINGS

Five major themes related to the provision of dementia care by family physicians emerged: 1) diagnostic uncertainty; 2) the complexity of dementia; 3) time as a paradox in the provision of dementia care; 4) the importance of patients' families; 5) and familiarity with patients. Participants expressed uncertainty about diagnosing dementia and a strong need for expert verification of diagnoses owing to the complexity of dementia. Time, patients' family members, and familiarity with patients were seen as both barriers and enablers in the provision of dementia care.

CONCLUSION

Family physicians face many challenges in providing dementia care. The results of this study and the views of family physicians should be considered in the development and dissemination of future dementia guidelines, as well as by specialist colleagues, policy makers, and those involved in developing continuing physician education about dementia.