Storylines of family medicine I: framing family medicine - history, values and perspectives

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'I: framing family medicine-history, values, and perspectives', the authors address the following themes: 'Notes on Storylines of Family Medicine', 'Family medicine-the generalist specialty', 'Family medicine's achievements-a glass half full assessment', 'Family medicine's next 50 years-toward filling our glasses', 'Four enduring truths of family medicine', 'Names matter', 'Family medicine at its core' and 'The ecology of medical care.' May readers find much food for thought in these essays.

Education to improve timeliness of shingles diagnosis: Cluster RCT and qualitative study

BACKGROUND

Herpes zoster (shingles) is normally diagnosed clinically. Timely diagnosis is important so antiviral treatment can be started soon after rash onset.

AIM

To assess whether a practice-level educational intervention, aimed at non-clinical patient-facing staff, improves the timely assessment of patients with shingles.

DESIGN AND SETTING

Cluster randomised Study Within A Trial (SWAT) with nested qualitative study in General Practices in England.

METHODS

Practices were cluster randomised 1:1, stratified by centre and minimised by practice list size and index of multiple deprivation score. Intervention practices were sent educational materials, highlighting the common presenting features of shingles and what action to take if suspected. The primary and secondary outcomes were the mean proportion of patients per practice seen within 72 hours and 144 of rash onset, respectively. Comparison between groups was conducted using linear regression, adjusting for randomisation variables. Semi-structured interviews with practice staff in intervention practices explored views and opinions of the intervention.

RESULTS

67 practices were enrolled; 34 randomised to intervention, 33 to control. The mean difference in proportion of patients seen within 72 and 144 hours was -0.132 (95% CI -0.308, 0.043) and -0.039 (95% CI -0.158, 0.080), respectively. In intervention practices, 90.5% reported distributing the educational materials, however engagement with these was suboptimal. 12 participants were interviewed, and the poster component of the intervention was said to be easiest to implement.

CONCLUSION

Our educational intervention did not improve the timely assessment of patients with shingles. This may be the result of poor intervention engagement.

[Present and Future of Scientific Publications in the Field of Family Medicine in Portugal]

N.D.

[Evaluation of the Scientific Production in the Field of General Practice and Family Medicine in Portugal]

INTRODUCTION

The Portuguese publications in the field of General Practice and Family Medicine have not yet been assessed in bibliometric studies. The aim of this study was to analyze that production between 2012 and 2022.

METHODS

The Web of Science Core Collection was used to gather the number of articles, journals and citations obtained; the Journal Citation Reports to obtain the Impact Factor and quartile of journals; and Scimago Journal & Country Rank, for the comparison of data with other European countries. The search was based on the following query: "usf OR unidade de Saude Familiar OR centro de Saude OR ACeS OR medicina geral familiar OR Gen Practice Family SAME Portugal", and a time window between 2012 and 2022 was defined. The study considered the following quantitative indicators: total number of publications, typology, language, affiliation, co-authors, geographical distribution, thematic areas, and the number of publications/inhabitant and publications/physician from European countries; the qualitative indicators selected were the Impact Factor (IF), the quartile and the number of citations.

RESULTS

Between 2012 and 2022, the national scientific production had an average annual growth rate of 36.6%. Of 389 publications, 73.8% were 'Articles' and 11.8% were 'Review Articles', predominantly in English (88.4%). The fields of 'General Internal Medicine' (24.7%) and 'Public Environmental Health' (14.9%) had the highest publication rates among the journals. The 389 publications received 5354 citations, for an average of 13.76 citations per article, and the average yearly citation growth was 115%. According to IF, 22.5% of the 222 journals belonged to Q4, 27.5% to Q3, 29.7% to Q2 and 20.3% to Q1, and therefore no significant bias regarding the journals where Portuguese doctors publish was observed.

CONCLUSION

The bibliometric analysis allowed us to examine the evolution of the scientific production in the field of Portuguese General Practice and Family Medicine by observing an increasing publication trend and with a high potential for publication growth.

[Adolescent Medicine in General Practice: Current Situation and Proposals for Improvement]

N/D.

Patient-Centered Medicine and Self-Care of Patients with Type 2 Diabetes: A Cross-Sectional Study

INTRODUCTION

Even though the prevalence rate of diabetes in Portugal is one of the highest in Europe, no studies on the association between patient centered medicine, diabetes self-care, and glycemic control have been published. Assuming that patient centered medicine increases adherence to treatment through the improvement of the doctor-patient relationship, the aim of this study was to assess the influence of patient-centered medicine on the self-care of patients with type 2 diabetes patients' (T2DM) in two Family Health Units in Central Portugal, according to gender and age.

MATERIAL AND METHODS

A cross-sectional study was conducted in two Family Health Units in Central Portugal between the 25th November 2021 and the 15th January 2022. Patients with type 2 diabetes were invited to fill in the Patient-Centered Medicine questionnaire, for patients (PCM-p) (where higher values represent worse results) and the Summary of Diabetes Self-Care Activities Measure (SDSCAM), (where higher values represent better results), while healthcare professionals filled in the epidemiologic variables on pre-defined days.

RESULTS

A sample of 298 patients with type 2 diabetes was studied. Linear regressions for the association between SDSCAM scale factors and PCM-p showed significant associations for general diet (β = -0.07, p < 0.001), specific diet (β = -0.10, p < 0.001), exercise (β = -0.03, p = 0.008), foot care (β = -0.11, p < 0.001) and medication adherence in general (β = -0.06, p = 0.001). Multiple linear regression including the association between glycated hemoglobin (HbA1c) and the SDSCAM scale dimensions showed that specific diet was associated with lower HbA1c levels (β = -0.01, p = 0.007) and blood sugar testing (β = 0.01, p < 0.001) and that a higher score in PCMp was associated with higher HbA1c levels (β = 0.06, p < 0.001). Male patients (β = -6.93, p = 0.007) and older patients (β = -0.42, p = 0.001) were associated with lower scores in the specific diet. The male gender was associated with higher scores in exercise (β = 7.62, p = 0.029), lower scores in foot care (β = -6.06, p = 0.029) and lower scores in medication adherence to injectable medicines/6.2 (β = -0.73, p = 0.018). Age was associated with a lower score in medication (β = -0.03, p = 0.045) and a higher PCMp total score (β = 0.07, p = 0.030).

CONCLUSION

Patient-centered medicine in type 2 diabetics is associated with better self-care behaviors in patients with type 2 diabetes. Gender and age differences were observed in self-care behaviors and age differences were observed in Patient Centered Medicine.

Identifying depression and its determinants upon initiating treatment: ChatGPT versus primary care physicians

OBJECTIVE

To compare evaluations of depressive episodes and suggested treatment protocols generated by Chat Generative Pretrained Transformer (ChatGPT)-3 and ChatGPT-4 with the recommendations of primary care physicians.

METHODS

Vignettes were input to the ChatGPT interface. These vignettes focused primarily on hypothetical patients with symptoms of depression during initial consultations. The creators of these vignettes meticulously designed eight distinct versions in which they systematically varied patient attributes (sex, socioeconomic status (blue collar worker or white collar worker) and depression severity (mild or severe)). Each variant was subsequently introduced into ChatGPT-3.5 and ChatGPT-4. Each vignette was repeated 10 times to ensure consistency and reliability of the ChatGPT responses.

RESULTS

For mild depression, ChatGPT-3.5 and ChatGPT-4 recommended psychotherapy in 95.0% and 97.5% of cases, respectively. Primary care physicians, however, recommended psychotherapy in only 4.3% of cases. For severe cases, ChatGPT favoured an approach that combined psychotherapy, while primary care physicians recommended a combined approach. The pharmacological recommendations of ChatGPT-3.5 and ChatGPT-4 showed a preference for exclusive use of antidepressants (74% and 68%, respectively), in contrast with primary care physicians, who typically recommended a mix of antidepressants and anxiolytics/hypnotics (67.4%). Unlike primary care physicians, ChatGPT showed no gender or socioeconomic biases in its recommendations.

CONCLUSION

ChatGPT-3.5 and ChatGPT-4 aligned well with accepted guidelines for managing mild and severe depression, without showing the gender or socioeconomic biases observed among primary care physicians. Despite the suggested potential benefit of using atificial intelligence (AI) chatbots like ChatGPT to enhance clinical decision making, further research is needed to refine AI recommendations for severe cases and to consider potential risks and ethical issues.

Telemedicine in the primary care of older adults: a systematic mixed studies review

BACKGROUND

Family physicians had to deliver care remotely during the COVID-19 pandemic. Their efforts highlighted the importance of developing a primary care telemedicine (TM) model. TM has the potential to provide a high-quality option for primary care delivery. However, it poses unique challenges for older adults. Our aim was therefore to explore the effects of TM and the determinants of its use in primary care for older adults.

METHODS

In this systematic mixed studies review, MEDLINE, PsycINFO, EMBASE, CINHAL, AgeLine, DARE, Cochrane Library, and clinical trials research registers were searched for articles in English, French or Russian. Two reviewers performed study selection, data extraction and assessment of study quality. TM's effects were reported through the tabulation of key variables. TM use determinants were interpreted using thematic analysis based on Chang's framework. All data were integrated using a joint display matrix.

RESULTS

From 3,328 references identified, 20 studies were included. They used either phone (n = 8), videoconference (n = 9) or both (n = 3). Among studies reporting positive outcomes in TM experience, 'user habit or preferences' was the most cited barrier and 'location and travel time' was the most cited facilitator. Only one study reported negative outcomes in TM experience and reported 'comfort with patient communication' and 'user interface, intended use or usability' as barriers, and 'technology skills and knowledge' and 'location and travel time' as facilitators. Among studies reporting positive outcomes in service use and usability, no barrier or facilitator was cited more than once. Only one study reported a positive outcome in health-related and behavioural outcomes.

CONCLUSIONS

TM in older adults' primary care generally led to positive experiences, high satisfaction and generated an interest towards alternative healthcare delivery model. Future research should explore its efficacy on clinical, health-related and healthcare services use.

Influenza presentations and use of neuraminidase inhibitors by Australian general practice registrars: a cross-sectional analysis from the ReCEnT study

OBJECTIVE

This study aims to establish prevalence and associations of (1) influenza and influenza-like illness (IILI) presentations to Australian general practice (GP) registrars (trainees) and (2) the use of neuraminidase inhibitors (NAIs) by GP registrars for new presentations of IILI, for the 10 years leading up to the COVID-19 pandemic in Australia (2010-2019).

DESIGN

This was a cross-sectional analysis of the Registrar Clinical Encounters in Training ongoing inception cohort study of the in-consultation experience and clinical behaviours of GP registrars. Data are collected by individual registrars three times (from 60 consecutive consultations each time) at 6 monthly intervals. Data include diagnoses/problems managed and medicines prescribed, along with multiple other variables. Univariate and multivariable logistic regression was used to establish associations of registrars seeing patients with IILI and of prescribing NAIs for IILI.

SETTING

Teaching practices within the Australian general practitioner specialist vocational training programme. Practices were located in five of the six Australian states (plus one territory).

PARTICIPANTS

GP registrars in each of their three compulsory 6-month GP training terms.

RESULTS

From 2010 to 2019, 0.2% of diagnoses/problems seen by registrars were IILI. 15.4% of new IILI presentations were prescribed an NAI. IILI diagnoses were less likely in younger (0-14) and older (65+) age groups, and more likely in an area of higher socioeconomic advantage. There was considerable variation in NAI prescribing between regions. There was no significant association of prescribing NAIs with age or Aboriginal and/or Torres Strait Islander patients.

CONCLUSIONS

IILI presentations were more likely among working-age adults and not among those groups at higher risk. Similarly, high-risk patient groups who would benefit most were not more likely to receive NAIs. The epidemiology and management of IILI has been distorted by the COVID-19 pandemic, but the burden of influenza in vulnerable populations must not be overlooked. Appropriately targeted antiviral therapy with NAIs influences outcomes for vulnerable patients. General practitioners manage the majority of IILI in Australia, and understanding GP IILI presentation and NAI prescribing patterns is a key first step to enabling sound and rational prescribing decisions for better patient outcomes.

Trust Takes Two…

Research throughout the COVID-19 pandemic, including investigations of resulting pandemic response strategies, evolving public health recommendations, and vaccine development, has highlighted the role of trust between physicians and patients. The focus, however, has largely been on patient trust in physicians. Although the importance of patient trust in physicians has long been recognized, physician trust in patients remains underappreciated. Physician trust in patients is an important factor in the physician-patient relationship. When physicians trust patients, patients can communicate freely, their experiences are validated, and trust may be engendered through reciprocal trust. Thus, a bidirectional approach to trust is necessary that acknowledges the role of physician trust in patients. We posit that shared trust is the dyadic factor that influences positive patient outcomes and is the foundation of shared decision making. Recognizing shared trust as an important outcome of the physician-patient relationship is a necessary step in evaluating how our practice, research, and education can influence or sow distrust of patients. In this commentary, we discuss the importance of attending to shared trust and physician trust in patients, particularly in family medicine.

The Registrar Clinical Encounters in Training (ReCEnT) cohort study: updated protocol

BACKGROUND

During vocational general practice training, the content of each trainee's (in Australia, registrars') in-consultation clinical experience is expected to entail a breadth of conditions that exemplify general practice, enabling registrars to gain competency in managing common clinical conditions and common clinical scenarios. Prior to the Registrar Clinical Encounters in Training (ReCEnT) project there was little research into the content of registrars' consultations despite its importance to quality of training. ReCEnT aims to document the consultation-based clinical and educational experiences of individual Australian registrars.

METHODS

ReCEnT is an inception cohort study. It is comprised of closely interrelated research and educational components. Registrars are recruited by participating general practice regional training organisations. They provide demographic information about themselves, their skills, and their previous training. In each of three 6-month long general practice training terms they provide data about the practice where they work and collect data from 60 consecutive patient encounters using an online portal. Analysis of data uses standard techniques including linear and logistic regression modelling. The ReCEnT project has approval from the University of Newcastle Human Research Ethics Committee, Reference H-2009-0323.

DISCUSSION

Strengths of the study are the granular detail of clinical practice relating to patient demographics, presenting problems/diagnoses, medication decisions, investigations requested, referrals made, procedures undertaken, follow-up arranged, learning goals generated, and in-consultation help sought; the linking of the above variables to the presenting problems/diagnoses to which they pertain; and a very high response rate. The study is limited by not having information regarding severity of illness, medical history of the patient, full medication regimens, or patient compliance to clinical decisions made at the consultation. Data is analysed using standard techniques to answer research questions that can be categorised as: mapping analyses of clinical exposure; exploratory analyses of associations of clinical exposure; mapping and exploratory analyses of educational actions; mapping and exploratory analyses of other outcomes; longitudinal 'within-registrar' analyses; longitudinal 'within-program' analyses; testing efficacy of educational interventions; and analyses of ReCEnT data together with data from other sources. The study enables identification of training needs and translation of subsequent evidence-based educational innovations into specialist training of general practitioners.

[Knowledge of PrevenIMSS Programs in users of a primary health care clinic]

BACKGROUND

The PrevenIMSS programs are a strategy to promote health self-care at the three levels of prevention, with special emphasis on primary health care. One of its objectives is to have an impact on the morbidity and mortality of chronic non-communicable diseases such as obesity, diabetes and hypertension, the prevention of these illnesses requires knowledge for health self-care contained in these guidelines.

OBJECTIVE

To identify the information that the IMSS beneficiaries have on self-care of health contained in the PrevenIMSS guidelines.

MATERIAL AND METHODS

Descriptive cross-sectional study. After signing the informed consent, one thousand beneficiaries of a UMF were interviewed, 200 for each PrevenIMSS age group. Questions were asked about: 1. Health promotion, 2. Prevention and control of diseases, 3. Detection of diseases, 4. Nutrition, 5. Sexual and reproductive health, and an open question, to identify their needs for self-care of health.

RESULTS

The respondents answered having knowledge about the PrevenIMSS components in: Health promotion: 62%. Nutrition: 43%. Disease prevention: 55.3%. Detection and control of diseases: 51.9%. Sexual and reproductive health: 49.9%. The total score obtained by age group was: 0-9 years 46.35 ± 14.36; 10-19 years 46.02 ± 12.06; women from 20 to 59 years old 46.79 ± 8.19, men from 20 to 59 years old 52.19 ± 14.58; adults aged 60 and over 46.65 ± 13.34.

CONCLUSIONS

The least information is in nutrition. The group of adolescents was the most affected.

How does postgraduate diploma in Family Medicine impact on primary care doctors?

BACKGROUND

Over the last decade, the emphasis on improving the education and training of family physicians has increased. World Health Organization has also emphasized the importance of a trained primary care workforce. In 2017, Khyber Medical University (KMU) Peshawar initiated a one-year Postgraduate Diploma in Family Medicine for doctors working in primary care, to upgrade their skills and knowledge as Family Physicians. To justify the allocation of resources, there is a need for research on the impact of such programs. This study explores the impact of Diploma in Family Medicine (DFM) on primary care doctors in Khyber Pakhtunkhwa. It also identifies the barriers associated with learning and its translation to practice.

METHODS

A mixed-method explanatory study was conducted from February 2019-2020. Forty-five graduates from the DFM program at KMU were invited to participate in this study. The quantitative data was collected through questionnaires (n=30) and the results were then explained further through qualitative focus group interviews (n=24). Descriptive statistics were calculated for the quantitative data and thematic analysis was performed for the qualitative data.

RESULTS

The respondents (n=30/45) were satisfied from the course content and delivery. They agreed that the course is useful (93.3%), relevant to their learning needs (86.7%) and they were able apply it to their clinical practice (100%). The qualitative findings also corroborated that the course improved both the clinical and consultation skills of the participants. The learning environment encouraged them to identify their learning needs and attain new competencies. They reported being more patient-centered and evidence-based, which increased patients' satisfaction. The program also resulted in increased career opportunities and other monetary benefits. Despite the blended nature of the program, the participants found it challenging to balance training with the provision of services.

CONCLUSION

One-year Postgraduate Diploma in Family Medicine is focused, practical and relevant to the learning needs of primary healthcare physicians. The policymakers should consider provision of such training opportunities in both public and private-sector. Future research should explore the long-term impact of such programs on healthcare outcomes.

Detection and follow-up of chronic health conditions in Rio de Janeiro - the impact of residency training in family medicine

BACKGROUND

There is a need for evidence that residency training in family medicine can benefit the care of patients in primary care in low- and middle-income countries. We tested the hypothesis that two years of residency training in family medicine enables doctors to better detect chronic health conditions while requesting fewer laboratory tests and providing more follow-up visits.

METHODS

We performed a retrospective longitudinal observational analysis of medical consultations from 2013 to 2018 in primary care in Rio de Janeiro, comparing doctors without residency training in family medicine (Generalists) versus family physicians (FPs). Multivariate multilevel binomial regression models estimated the risks of patients being diagnosed for a list of 31 chronic health conditions, having a follow-up visit for these conditions, and having laboratory tests ordered from a list of 30 exams.

RESULTS

569.289 patients had 2.908.864 medical consultations performed by 734 generalists and 231 FPs. Patients seen by FPs were at a higher risk of being detected for most of the chronic health conditions, at a lower risk of having any of the 30 laboratory tests requested, and at a higher risk of having a follow-up visit in primary care.

CONCLUSIONS

Residency training in family medicine can make physicians more skilled to work in primary care. Policymakers must prioritize investments in capacity building of healthcare workforce to make primary care truly comprehensive.

Accuracy of Signs, Symptoms, and Hematologic Parameters for the Diagnosis of Infectious Mononucleosis: A Systematic Review and Meta-Analysis

BACKGROUND

The accuracy of individual symptoms, signs, and several easily obtainable hematologic parameters for diagnosing infectious mononucleosis (IM) still needs to be confirmed. Improving the diagnosis of IM based on the clinical findings could prompt physicians to identify better which patients need a diagnostic test for IM. This study performed a systematic review to determine the accuracy of symptoms, signs, and hematologic parameters in patients with suspected IM that used heterophile antibody test or viral capsid antigen tests as the reference standard.

METHODS

The PubMed database was searched for all relevant articles. Two reviewers reviewed all studies in parallel and assessed the quality of the selected studies using the quality assessment of diagnostic accuracy studies 2 (QUADAS-2) criteria. The pooled measures of diagnostic performance were calculated by bivariate meta-analysis for each clinical finding, which included sensitivity, specificity, likelihood ratios, the diagnostic odds ratios, and the area under the receiver operating characteristic curve.

RESULTS

Seventeen studies were included in our final analysis. The prevalence of IM ranged from 2.1% to 80% among prospective cohort studies. The presence of splenomegaly (positive likelihood ratio [LR+], 2.39; 95% confidence interval [CI], 1.11-5.51), palatal petechiae (LR+, 1.32-11.40), posterior cervical lymphadenopathy (LR+, 3.16; 95% CI, 1.45-5.20), and axillary or inguinal cervical lymphadenopathy (LR+, 3.05; 95 CI, 1.85-4.70) were moderately useful for ruling in IM. The most helpful hematologic parameters for ruling in IM include lymphocytes greater than 4 × 10⁹/L and greater than 40% to 50%, or atypical lymphocytes greater than 40%. A combination of lymphocytes greater than 50% and atypical lymphocytes greater than 10% (LR+, 50.40; 95% CI, 8.43-162) was also found to be helpful to rule in disease. Most of the clinical findings have limited diagnostic value in ruling out the disease when absent.

CONCLUSIONS

Although most symptoms and signs were unhelpful, the likelihood of IM is appreciably increased by several examination findings. Hematologic parameters were more accurate than symptoms and signs. Since most clinical findings have limited diagnostic value in ruling out the disease, physicians should not rely on the absence of any individual symptom or clinical sign for ruling out IM.

Implementation of targeted screening for poverty in a large primary care team in Toronto, Canada: a feasibility study

Background

Poverty has a significant influence on health. Efforts to optimize income and reduce poverty could make a difference to the lives of patients and their families. Routine screening for poverty in primary care is an important first step but rarely occurs in Canada. We aimed to implement a targeted screening and referral process in a large, distributed primary care team in Toronto, Ontario, Canada. The main outcome was the proportion of targeted patients screened.

Methods

This implementation evaluation was conducted with a large community-based primary care team in north Toronto. The primary care team serves relatively wealthy neighborhoods with pockets of poverty. Physicians were invited to participate. We implemented targeted screening by combining census information on neighborhood-level deprivation with postal codes in patient records. For physicians agreeing to participate, we added prompts to screen for poverty to the charts of adult patients living in the most deprived areas. Standardized electronic medical record templates recommended a referral to a team case worker for income optimization, for those patients screening positive. We recorded the number and percentages of participants at each stage, from screening to receiving advice on income optimization.

Results

128 targeted patients with at least one visit (25%) were screened. The primary care team included 86 physicians distributed across 19 clinical locations. Thirty-four physicians (39%) participated. Their practices provided care for 27,290 patients aged 18 or older; 852 patients (3%) were found to be living in the most deprived neighborhoods. 509 (60%) had at least one office visit over the 6 months of follow up. 25 patients (20%) screened positive for poverty, and 13 (52%) were referred. Eight patients (62% of those referred) were ultimately seen by a caseworker for income optimization.

Conclusions

We implemented a targeted poverty screening program combined with resources to optimize income for patients in a large, distributed community-based primary care team. Screening was feasible; however, only a small number of patients were linked to the intervention Further efforts to scale and spread screening and mitigation of poverty are warranted; these should include broadening the targeted population beyond those living in the most deprived areas.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01514-9.

PRESSS: A New Patient-Centered Name for an Old Problem

There are many words for what physicians commonly refer to as Somatoform Disorder. However, none is particularly patient-centered; to greater or lesser extent, they are all framed by medical jargon. Based on his experience as a seasoned clinician, the author suggests family physicians consider adopting the word PRESSS-an acronym for "Physical Reaction to Emotional Stress of Some Sort"-when describing and explaining to patients with Somatoform Disorder the cause of their suffering. Using examples from practice, the author notes how PRESSS combines simplicity, ambiguity, and directness in one non-stigmatizing, patient-focused word. Combined with a patient-centered manner of communication, the use of PRESSS can help create the kind of shared therapeutic presence that is so important when attending to patients who experience the bothersome, unrelenting symptoms these conditions suggest.

Effect of Patient Empowerment Model on Smoking Cessation: Randomized Controlled Trial

BACKGROUND

Smoking is a preventable cause of chronic morbidity. Patient empowerment is a process through which people establish greater control over their health-related decisions and actions. To assess the effect of patient empowerment versus health education on the nicotine dependence score and progress of patients under different stages of smoking cessation.

METHODS

This was a single-blinded randomized controlled clinical trial that included 76 smokers attending family medicine clinics. Participants were divided into two groups: empowerment and health education groups. Their nicotine-dependence score and smoking cessation stage were identified. All study participants were subjected to five health education sessions with a 3-month follow-up period.

RESULTS

The mean nicotine-dependence score decreased significantly in both groups after the intervention. This decrease was slightly higher in the empowerment group; however, the difference was not statistically significant. After the intervention, 16.7% of the health education and 30.0% of the empowerment group transitioned from stage 1 to stages 2-4 of smoking cessation, with the change being statistically significant only in the empowerment group. There was no statistically significant difference in the number of study participants who stopped smoking between the health education and empowerment groups.

CONCLUSION

Both the empowerment model and traditional health education have similar positive effects on decreasing the nicotine-dependence level. There was a significant improvement in the stage of change for patients under the empowerment model, although there was no statistically significant difference between the groups regarding the number of participants who stopped smoking.

Advance care planning conversations in primary care: a quality improvement project using the Serious Illness Care Program

Background

Advance care planning (ACP) conversations are associated with improved end-of-life healthcare outcomes and patients want to engage in ACP with their healthcare providers. Despite this, ACP conversations rarely occur in primary care settings. The objective of this study was to implement ACP through adapted Serious Illness Care Program (SICP) training sessions, and to understand primary care provider (PCP) perceptions of implementing ACP into practice.

Methods

We conducted a quality improvement project guided by the Normalization Process Theory (NPT), in an interprofessional academic family medicine group in Hamilton, Ontario, Canada. NPT is an explanatory model that delineates the processes by which organizations implement and integrate new work. PCPs (physicians, family medicine residents, and allied health care providers), completed pre- and post-SICP self-assessments evaluating training effectiveness, a survey evaluating program implementability and sustainability, and semi-structured qualitative interviews to elaborate on barriers, facilitators, and suggestions for successful implementation. Descriptive statistics and pre-post differences (Wilcoxon Sign-Rank test) were used to analyze surveys and thematic analysis was used to analyze qualitative interviews.

Results

30 PCPs participated in SICP training and completed self-assessments, 14 completed NoMAD surveys, and 7 were interviewed. There were reported improvements in ACP confidence and skills. NoMAD surveys reported mixed opinions towards ACP implementation, specifically concerning colleagues’ abilities to conduct ACP and patients’ abilities to participate in ACP. Physicians discussed busy clinical schedules, lack of patient preparedness, and continued discomfort or lack of confidence in having ACP conversations. Allied health professionals discussed difficulty sharing patient prognosis and identification of appropriate patients as barriers.

Conclusions

Training in ACP conversations improved PCPs’ individual perceived abilities, but discomfort and other barriers were identified. Future iterations will require a more systematic process to support the implementation of ACP into regular practice, in addition to addressing knowledge and skill gaps.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00817-z.

Family Issues in Japanese Clinics: Concordance between Patients' and Physicians' Views

Introduction:

The objectives of the present study were to clarify the frequency and content of family issues for patients in Japanese clinics, and the concordance between physicians’ and patients’ views of family issues.

Methods:

In this study, we used a cross-sectional design with a questionnaire survey. Participants were outpatients and their physicians in charge (four family physicians) at four Japanese clinics. The main body of research was conducted between April 5 and May 15, 2004. After obtaining oral informed consent, the physician in charge distributed questionnaires to participating patients to complete at home. The questionnaire comprised three items: 1) Do you have any worries about your family? 2) Are you comfortable consulting a physician regarding your family issue?, and 3) If possible, could you tell us why you feel like that?

Participants provided written informed consent and answered the questionnaire before sealing it in an envelope and posting it back to the research center. Physicians in charge completed their version of the questionnaire and independently sent the data to the center.

Results:

Of the 272 participating patients, 118 (45.6%) had family issues. “Health problems with family members” (28%) and “family life cycle issues” (19.5%) were the main content of these issues. Physicians indicated that 45.7% of patients had family issues. The rate of concordance between physicians’ and patients’ perspectives regarding family issues was 46.6%.

Conclusions:

Family issues can therefore be regarded as a common health problem due to the frequency. There was some inconsistency between physicians’ and patients’ views, but much of this discrepancy may be resolved by developing the specialty of family practice.

Changes in Opioid Therapy Use by an Interprofessional Primary Care Team: A Descriptive Study of Opioid Prescription Data

OBJECTIVE

The purpose of this study was to describe changes in opioid-therapy prescription rates after a family medicine practice included on-site chiropractic services.

METHODS

The study design was a retrospective analysis of opioid prescription data. The database included opioid prescriptions written for patients seeking care at the family medicine practice from April 2015 to September 2018. In June 2016, the practice reviewed and changed its opioid medication practices. In April 2017, the practice included on-site chiropractic services. Opiod-therapy use was defined as the average rate of opioid prescriptions over all medical providers at the practice.

RESULTS

There was a significant decrease of 22% in the average monthly rate of opioid prescriptions after the inclusion of chiropractic services (F_1,40 = 10.69; P < .05). There was a significant decrease of 32% in the prescribing rate of schedule II opioids after the inclusion of chiropractic services (F_2,80 = 6.07 for the Group × Schedule interaction; P < .05). The likelihood of writing schedule II opioid prescriptions decreased by 27% after the inclusion of chiropractic services (odds ratio, 0.73; 95% confidence interval, 0.59-0.90). Changes in opioid medication practices by the medical providers included prescribing a schedule III or IV opioid rather than a schedule II opioid (F_6,76 = 29.81; P < .05) and a 30% decrease in the daily doses of opioid prescriptions (odds ratio, 0.70; 95% confidence interval, 0.50-0.98).

CONCLUSION

This study demonstrates that there were decreases in opioid-therapy prescribing rates after a family medicine practice included on-site chiropractic services. This suggests that inclusion of chiropractic services may have had a positive effect on prescribing behaviors of medical physicians, as they may have been able to offer their patients additional nonpharmaceutical options for pain management.

Developing National Functional Accreditation Model for Primary Healthcares with Emphasis on Family Practice in Iran

BACKGROUND

Accreditation is an approach toward quality improvement which has been increasingly implemented in healthcare. This study aimed at developing a national functional accreditation model for primary healthcare with emphasis on family practice in Iran.

METHODS

This mixed-method study utilizes a set of research methods purposefully. Initially, the reference models were used for benchmarking accreditation standards through a systematic review. Then, the primary accreditation standards were developed and then they were assessed and approved by the experts of the field via Delphi technique. In the following and after developing essential parts of the standards, the necessary changes in developed model were done according to the pilot test results.

RESULTS

The results of systematic review suggested the superiority of accreditation models of the United States, Australia, Canada, and the United Kingdom globally; and the models of Jordan, Saudi Arabia, Lebanon, and Egypt in Eastern-Mediterranean region. Then, the primary standards including 39 functional standards with 231 measures were developed according to the benchmarked models, and were approved by the experts in Delphi-based study. In pilot test step, the compliance rate of developed standards by primary healthcare centers was calculated 61.61% and 26.37% for self-evaluation and external evaluation phases, respectively.

CONCLUSION

Regarding the comprehensiveness of developed accreditation model due to its focus on all functional dimensions and the consensus over the developed standards by the experts, it can be an underlying ground for the establishment and evaluation of functional improvement programs in Iranian primary healthcare system.

[Criteria for Requesting 'Routine' Laboratory Tests in Family Practice]

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Factors Associated with Choice of Career in Family Medicine Among Junior Doctors in Oman

Objectives

The number of family physicians in Oman is far below that recommended by the World Health Organization. This study aimed to determine factors influencing junior doctors’ choice of a career in family medicine.

Methods

This cross-sectional study was conducted between March and June 2018 and targeted applicants to Oman Medical Specialty Board residency programmes during the 2018–2019 academic year. Applicants were grouped according to their choice of either family medicine (n = 64) or other specialities (n = 81). A self-administered questionnaire was utilised to compare the applicants’ sociodemographic characteristics, factors influencing their choice of career and their Myers-Briggs Type Indicator^® (MBTI) personality traits.

Results

A total of 52 family medicine and 43 other residency applicants participated in the study (response rates: 81.3% and 53.1%, respectively). Most family medicine applicants were female (86.5%), married (65.4%) and resided in rural areas (73.1%); moreover, 19.2% were ≥30 years of age. Overall, emphasis on continuity of care, opportunity to deal with a variety of medical problems, the ability to use a wide range of skills and knowledge, early exposure to the discipline, opportunity to teach and perform research and the influence of family or friends were important factors in determining choice of a career in family medicine. Moreover, the MBTI analysis revealed that family medicine applicants were commonly extroverted-sensing-thinking-judging personality types.

Conclusion

Knowledge of the factors influencing career choice among junior doctors may be useful in determining future admission policies in order to increase the number of family physicians in Oman.

["Routine" Laboratory Test Requests in Family Medicine: A Cross-Sectional Study Based on Clinical Practice in Portugal]

INTRODUCTION

In Portugal, patients still believe they should perform a periodic check-up. The present study was designed to study the prescription pattern of "routine" laboratory tests in the Family practice in Portugal.

MATERIAL AND METHODS

We performed a cross-sectional study in the Portuguese primary healthcare setting. We surveyed physicians on their "routine" laboratory test request pattern and the reasons for requesting or not requesting laboratory tests. The questions were based on the panel of the most prescribed tests in the of Central Lisbon health centre group.

RESULTS

Most of the inquired doctors said they requested "routine" laboratory tests (51.4%). There is a significant difference in the request of "routine" laboratory tests performed by trainees or specialists (p = 0.013). The most requested laboratory tests in adults are total cholesterol (92.2%) and blood glucose while the most requested laboratory tests in children are blood glucose, total cholesterol and full blood count. Many doctors (79.4%) that request "routine" laboratory tests do so to perform screening and the doctors that do not request routine" laboratory tests do so mainly (80.8%) because there's lack of scientific evidence.

DISCUSSION

We found differences in the prescription pattern of Family Physicians in Portugal, namely regarding the request of "routine" laboratory tests by doctors from different regions, degrees of specialization and age. We found that there is an association between prescribing "routine" laboratory tests and their request for screening. These physicians aparently want to track different types of pathology, even though patients have no symptoms or risks that could justify it. Most doctors, who do not prescribe "routine" laboratory tests, do not agree with screening for asymptomatic individuals, which is consistent with the evidence.

CONCLUSION

Our results suggest that there is an excessive request of laboratory tests which can lead to overdiagnosis and overtreatment that requires global Social Marketing strategies to change the prevailing culture.

"GENOGRAM Physician Involvement Model" New Approach for Indonesian Physician Involvement with Family

Background

The family, as the smallest social institution, has responsibilities across many functions, including maintaining family health. Increases in chronic diseases and life expectancy require more family support to prevent disease and implement treatment for family members with chronic diseases. Therefore, physician involvement in not only the treatment of diseases but also their prevention and rehabilitation is required In Indonesia. Hence, a new approach for physician involvement with families is required, especially with regard to comprehensiveness. This study aimed to develop a physician involvement program with the family model for primary healthcare in Indonesia.

Methods

A two-round Delphi method with family medicine experts from 17 of the highest accredited medical faculties in Indonesia as participants was conducted, and factor analysis performed thereafter. The items were considered relevant at ≤0.8 validity content ratio. The second step of this research is survey using e-questionnaire involving 101 primary care physician from all over Indonesia. They live scattered in several provinces in the main islands of Indonesia such Sumatra, Java, Kalimantan, Sulawesi dan Bali.

Results

Results showed an adequately measured sample and correlation for all items (Kaiser-Meyer-Olkin of sampling=0.821; Bartlett’s test <0.001). Seven dimensions were derived from results with eigenvalue of >1, and 25 items were filtered after determining the loading factor of >0.5. The Cronbach’s α for each factor varied from 0.602 to 0.829, and that for the total 25 items was 0.913, with a total variation documented as high as 66%.

Conclusion

A new physician involvement model with the family approach model, known as the “GENOGRAM model,” was developed, which consisted of seven dimensions and 25 items.

[The Choice of Medical Specialty: Can University Professors Influence The Decision?]

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Audit of diabetic care in family practice center in Abha City, Aseer region: CBAHI standards application

OBJECTIVE

The objectives of this study is to assess the quality of diabetic care at AlManhal PHCC based on CBAHI standards.

METHODS

This audit was conducted during 2018 at Al_Manhal PHCC through assessment all aspects of DM care ( structures, processes and outcomes) using CBAHI standards . Data entry and analysis were managed used SPSS.

RESULTS

Most of DM structures were available at the PHCC , however, health educational program , lab relevant facilities were partially met the standards. Records of 429 patients were assessed for process of care which were satisfactory except for laboratory investigations and eye examination which were partially met . Good DM metabolic control was (28%) , HTN control (71%) and lipid control( 54%), good compliance with appointment was 85% . The most common documented complications were retinopathy( 14%), nephropathy (4.5%) and CHD( 4%).

CONCLUSION AND RECOMMENDATIONS

This audit revealed that using of CBAHI standards for DM care at PHCC is simple and practical and could help to identify the weak areas that needs improvement. The present care of DM in our PHCC has acceptable infrastructures except for health education program , laboratory and referral system which should be scaled up to improve the processes and outcomes. DM control is still a big challenge and needs more collaborative effort between health care providers and patients.

Exploring learning needs for general practice based pharmacist: Are behavioural and influencing skills needed?

Background

Embedding pharmacists in general practice has been shown to create cost efficiencies, improve patient care and free general practitioner capacity. Consequently, there is a drive to recruit additional pharmacists to work within general practices. However, equipping pharmacists with behaviour and influencing skills may further optimise their impact. Key elements which may enhance behaviour and influencing skills include self-efficacy and resilience.

Objective

This study aimed to: 1) Assess general practice pharmacists' self-efficacy and resilience. 2) Explore differences primarily between pharmacists reporting lower and higher self-efficacy, secondarily for those reporting lower and higher scores for resilience.

Methods

All 159 NHS Greater Glasgow and Clyde general practice pharmacists were invited to complete an online survey in May 2019. The survey captured anonymised data covering: demographics; professional experience; qualifications, prescribing status and preferred learning styles. Unconscious learning needs for behavioural and influencing skills were assessed using validated tools: the new general self-efficacy scale (GSES) and short general resilience scale (GRIT). Participants' responses were differentiated by the lowest quartile and higher quartiles of GSES and GRIT scores, and analysed to identify differences.

Results

The survey was completed by 57% (91/159) of eligible pharmacists; mean age 38 (range 24-60) years; 91% were of white ethnicity and 89% female. The median time qualified was 14 (1-38) years and 3 (1-22) years working in general practices. Overall pharmacists scored well on the GSES, mean 25 (SD 3; 95%CI 24.4-25.6), and GRIT, mean 30 (SD 4; 95%CI 29.6-30.4), out of a maximum 32 and 40 respectively. A significant positive correlation between GSES and GRIT scores was found (Pearson's r=0.284, p=0.006). However, no significant differences were identified between pharmacists scoring in the lower and upper quartiles by GSES or GRIT. Overall respondents reported their preferred learning styles were activists (46%) or pragmatists (29%). The majority (91%) preferred blended learning methods as opposed to 38% or less for a range of online methods.

Conclusions

General practice pharmacists on average scored highly for self-efficacy and resilience. Higher scores did not appear to be associated with demographic, years of practice, professional or educational experience. Prospective interventions to support those with lower scores may enhance and optimise pharmacists' effectiveness in general practice.

[Switching to Another Family Physician: The Reality of a Health Unit]

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Educational expectations of professionals who teach in primary health care in Chile

With more emphasis on primary health care (PHC) both in the undergraduate and postgraduate curriculum, there is an increasing demand for high quality teaching in PHC centres. Professionals in low- and middle-income countries often have little training in teaching. Countries where family medicine is more highly developed may play an important role in supporting training the trainers in low and mid development countries. However, the needs of these PHC teachers may differ. We explored the needs of professionals who teach in PHC in Chile through an online survey and focus groups.All the domains of competence of a clinical educator were considered to be important for training by >83% of the questionnaire respondents. Ninety percent of the respondents agreed that PHC professionals should be permitted to attend courses about teaching; 79% preferred blended learning: a combination of face-to-face training and online education.Three themes emerged in the focus groups. 1) The specific role of the teacher in PHC. 2) The challenges faced by teachers in PHC. 3) Intuitive teaching. This was an unexpected emergent theme that reflected the desire of the teachers to analyse and reflect on their teaching.There are enthusiastic and dedicated professionals in PHC in Chile with a strong felt-need for teacher training.

[Radio-diagnostic congruence improvement in a first-level unit]

BACKGROUND

Radiology is a fundamental tool on outpatient Family Medicine practice. Its adverse effects include its abuse, given that the patient is exposed to unnecessary radiation, and health care costs increase.

OBJECTIVE

To evaluate the implementation of a radio-diagnostic congruence strategy (RDCS) in a first-level unit in Mexico City.

MATERIAL AND METHODS

It was carried out an experimental, longitudinal study that covered both a previous period of time and another one after implementing the RDCS. It was evaluated the congruence between the diagnosis and the appropriateness of the imaging studies on the basis of the correspondent clinical practice guidelines. It was applied as well a bivariate statistical analysis that associated the diagnosis, the anatomical region and the patients' sex.

RESULTS

The number of imaging studies diminished substantially, while the congruence increased; this was associated to the anatomical region and the diagnosis; sex was not a decisive variable.

CONCLUSIONS

Implementing the RDCS shows positive effects, since the number of requests for imaging diminished (in 43.7%), and the radio-diagnostic congruence increased (8.5%) after implementing the RDCS. The reduction of requests for imaging could have been influenced by the fact that the medical staff could have been inhibited after been monitored, which could have led them to dispatch only the necessary requests for imaging. Our findings concur with the literature in the number of imaging studies requested in the first level of care, and the necessity to check out its appropriateness in order to increase its effectivity.

[Cost to ambulatory care for schizophrenia in Family Medicine]

BACKGROUND

The groups related to ambulatory care (GRAA, according to its initials in Spanish) are a classification of clinical diagnoses performed on patients receiving medical care in primary care; it is a comprehensive treatment for one year.

OBJECTIVE

To determine the costs of ambulatory care and sociodemographic characteristics of patients with schizophrenia attended in Family Medicine (FM).

MATERIAL AND METHODS

Cross-sectional study which included adult patients with complete electronic clinical record, who had confirmed diagnosis of schizophrenia and received medical attention in a FM unit from January to December 2017. The variables were: age, sex, sociodemographic data, drug addiction and employment status. To determine the annual cost of schizophrenia based on GRAA, the economic medical card was applied, which includes family medicine consultations, inter-consultations, medications, medical supplies, and the time of use of installed capacity for one year.

RESULTS

Out of all patients, 56.2% were men (n = 172). Age was 48.42 ± 14.4 years. Of women, 21.2% were married and 21.2% homemakers, 4.2% smokers, and 1.3% alcohol drinkers. Of men, 30.4% were unmarried, 15% unemployed, 13.1% smokers, and 6.9% alcohol drinkers. The total annual cost of schizophrenia for FGRAA-MH for men was $ 7 613 236.00.

CONCLUSIONS

The use of FGRAA-MH revealed the total annual cost for the care of schizophrenia in the medical unit, which provides important information for better understanding the magnitude of this health problem in that area, and will improve planning and economic medical management.

[Adolescent medical care: A priority in family medicine]

Today’s adolescents are, undoubtedly, very different from those attended by the family doctor in the past. Currently, we are facing young people full of ideas, with a lot of personality, who show novel interactions with the world. It is a fact that the care of adolescent patient by family physicians it is performed more frequently and will be further increased by the recent incorporation of the care of adolescent patient to the Instituto Mexicano del Seguro Social (Mexican Institute of Social Security: IMSS). Among the most frequent medical problems of adolescents, the most important are: early pregnancy, depression, violence, use and abuse of alcohol and drugs, and nutrition and eating disorders. It is required an approach to this very complex population. For this reason, family doctors should be open to facilitate dialogue, without making judgments, and with too much empathy. To that end, it is necessary to be updated in all issues that are emerging day by day concerning adolescents.

GPs' perspectives on colorectal cancer screening and their potential influence on FIT-positive patients: an exploratory qualitative study from a Dutch context

Background

In the Dutch colorectal cancer (CRC) screening programme, individuals receive a faecal immunochemical test (FIT) to do at home. After a positive FIT result, a follow-up colonoscopy is recommended to identify CRC or advanced adenomas (AA). GPs may influence their patients’ decisions on adherence to follow-up by colonoscopy.

Aim

To explore GPs’ perspectives on the CRC screening programme and their potential influence on FIT-positive patients to follow up with the recommended colonoscopy.

Design & setting

Semi-structured interviews among GPs in Amsterdam, the Netherlands.

Method

GPs were approached using purposive sampling. Analysis was performed on 11 interviews using open coding and constant comparison.

Results

All interviewed GPs would recommend FIT-positive patients without obvious contraindications to adhere to a follow-up colonoscopy. If patients were likely to be distressed by a positive FIT result, most GPs described using reassurance strategies emphasising a low cancer probability. Most GPs stressed the probability of false-positive FIT results. Some described taking a positive screening result in CRC screening less seriously than one in breast cancer screening. Most GPs underestimated CRC and AA probabilities after a positive FIT result. When told the actual probabilities, some stated that this knowledge might change the way they would inform patients.

Conclusion

These results imply that some of the interviewed GPs have too low a perception of the risk associated with a positive FIT result, which might influence their patients’ decision-making. Simply informing GPs about the actual rates of CRC and AA found in the screening programme might improve this risk perception.

[Referral and consultation process between family medicine and continuous medical attention]

The process of sending patients between the outpatient service of family medicine and the continuous medical care service at the IMSS is well established in the various internal systems as well as in the applicable mexican official standards, but it is necessary for the personnel involved to know it well in order to avoid setbacks during the reference and counter-reference process within the unit.

[Proportionate Universalism in Family Medicine - Comment on "Are Socioeconomic Inequalities in the Process of Registration with Family Physicians Decreasing in Portugal?"]

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[Usefulness and reliabitlity of musculoskeletal point of care ultrasound in family practice (2): Muscle injuries, osteoarthritis, rheumatological diseases and eco-guided procedures]

This article is a continuation of the review initiated in the previous issue about the usefulness of musculoskeletal point of care ultrasound in Primary Care, completing the scenarios of muscle injuries, osteoarthritis, rheumatological diseases and eco-guided procedures.

[Are Socioeconomic Inequalities in the Process of Registration with Family Physicians Decreasing in Portugal?]

INTRODUCTION

The percentage of citizens who were not registered with a family physician in Portugal reached 16.6% in 2011. In 2012 the Ministry of Health implemented several measures aiming at improving access to family physicians. One clear objective was that all individuals would be registered with a family physician by 2014. We evaluate the evolution of the socioeconomic inequalities regarding registration with family physicians in Portugal between 2009 and 2014.

MATERIAL AND METHODS

We use data at the primary health care unit level on the number of individuals who are not registered with a family physician and the purchasing power of the population served by each unit. The analysis is done using concentration measures.

RESULTS

We find a higher concentration of individuals not registered with a family physician among units serving populations with higher socioeconomic status, although this has been decreasing over the years analyzed. Amongst units serving the most disadvantaged populations, we find a situation close to perfect equality.

DISCUSSION

Our results may reflect the fact that populations with higher economic status live in urban areas where there is greater shortage of family physicians. Alternatively, it may be that these populations choose not to have a family physician within the public system, thus relying on private providers.

CONCLUSION

Our findings convey a reduction in existing socioeconomic inequalities in terms of registration with a primary care physician, during the period under analysis. This reduction took place among the populations which experienced more inequality.

[Evaluation of Primary Care Accessibility and Longitudinality in Granada Using Primary Care Assessment Tools]

OBJECTIVE

To assess accessibility and longitudinality performance in Primary Care Teams of Granada from the point of view of Clinical Team Leaders. Any differences will also be determined in the performance of these 2functions depending on the environment of the Primary Care Centres (urban, rural or suburban).

METHOD

A cross-sectional descriptive study using the "Primary Care Assessment Tool" (PCAT) questionnaire on all Primary Care Team managers from "Granada-Metropolitan" Primary Health Care District (n = 35). The Objective functions were described using the mean numerical scores obtained through the questionnaire. A mean score of ≥3 shows good performance. A bivariate analysis by Prevalence ORs was performed to study the factors related to a good performance.

RESULTS

Granada-Metropolitan Primary Health District achieved a good accessibility performance (3.03). Differences were found depending on the Primary Care Team environment (OR rural/urban=32). Only Primary Care Centres with emergency services had a good accessibility scores. A good longitudinality performance was assessed by 94% of Clinical Team Leaders, with a better performance in the urban areas (OR urban/rural = 7.5). Primary Care Teams with trainees in Family and Community Medicine achieved better longitudinality results.

CONCLUSIONS

Primary Care Teams from Granada Primary Health Care District achieved a good performance in Accessibility and Longitudinality in the PCAT Facilities questionnaire, from the point of view of their Clinical Team Leaders. However, it would be interesting to check these items from a user and provider perspective. According to this study, good accessibility was related to the availability of emergency services.

Barriers Faced by Family Medicine Graduates Interested in Performing Obstetric Deliveries

Fewer family physicians are providing deliveries, which raises concern for access to obstetric care. We found that among recent family medicine graduates who would like to do deliveries, difficulty finding a position that supports including deliveries was a major barrier.

[Reorganization and clinical management for hypertension control at primary healthcare]

BACKGROUND

In Mexico, 40% of hypertensive patients see their blood pressure under control. The evidence to keep hypertension (HT) under control is scarce, particularly in older adults who have the highest prevalence and require more health services. The objective was to determine the impact of a double intervention to increase the percentage of hypertensive patients with blood pressure levels under control and estimate differences among adults and older adults.

METHODS

Quasi-experimental design including reorganization and training to physicians using clinical guidelines in four primary healthcare units at the Instituto Mexicano del Seguro Social (IMSS). We included adults who participated whether in the intervention group (IG) or in the control group without equivalence (CGNE). We used regression models for longitudinal data for systolic pressure (SP) and diastolic pressure (DP) variables and proportion of patients with hypertension under control.

RESULTS

530 participants, 272 in the IG; 57.5% were ≥ 60 years. In the IG decreased the SP, β= −5.93 (95%CI −9.59, −2.28) and increased the proportion with blood pressure under control in young adults (OR 1.48, 95%CI 1.02, 2.14). In the elderly the intervention decreased the DP among those with HT and other comorbidities, β= −3.57(95%CI −6.72, −0.41), p < 0.05.

CONCLUSION

The interventions reduced SP among adults and DP among older adults with hypertension and other comorbidities. Actions of secondary prevention addressed to each group of age are needed to achieve the control of hypertension at IMSS.

Knowledge, Current Status, and Barriers toward Healthcare Worker Vaccination among Family Medicine Resident Participants in a Web-Based Survey in Korea

Background

We investigated the knowledge, status, and barriers toward healthcare workers receiving vaccinations among Korean family medicine residents. To date, a systematic study has not been conducted among medical practitioners examining these variables.

Methods

A web-based, anonymous, self-administered questionnaire was distributed to all 942 family medicine residents working in 123 training hospitals in Korea. A multiple logistic regression analysis was performed to investigate factors affecting vaccination completion.

Results

Korean family medicine residents (N=242, 25.7%) from 54 training hospitals (43.9%) participated in the survey. Only 24 respondents (9.9%) had correct knowledge on all the recommended vaccinations by the Korean Society of Infectious Diseases. The complete vaccination rates against hepatitis B virus and influenza were relatively high (69.4% and 83.0%, respectively), whereas they were relatively low against other infections (e.g., 16.5%– 53.1%). The most common reason for not receiving a vaccination was the belief that there was little possibility of infection from the vaccine-preventable diseases.

Conclusion

Knowledge and vaccination coverage were poor among family medicine residents in Korea. Medical schools should provide vaccination information to healthcare workers as part of their mandatory curriculum. Further research should confirm these findings among primary care physicians and other healthcare workers.

Physician Cost Consciousness and Use of Low-Value Clinical Services

PURPOSE

Choosing Wisely^TM engaged medical specialties, creating "top 5 lists" of low-value services. We describe primary care physicians' (PCPs') self-reported use of these services and perceived barriers to guideline adherence. We quantify physician cost consciousness and determine associations with use.

METHODS

PCP attendees of a continuing medical education conference completed a survey. For each Family Medicine Choosing Wisely behavior, participants reported clinical adherence. Likert scale items assessed perceived barriers. Low-value service frequency was the dependent variable. A validated Cost Consciousness Scale created the predictor variable. We hypothesized that participants with greater cost consciousness would report less frequent use of low-value services.

RESULTS

Of 199 PCP attendees, 143 (72%) participated. Papanicolaou test after hysterectomy was performed least (0.2 mean services performed/10 patients). Provider knowledge of sinusitis treatment guidelines was greatest but provided most frequently (3.9 mean services performed/10 patients). Practice related barriers were perceived most frequently for adhering to sinusitis treatment guidelines. Attitudinal barriers were greatest for avoiding osteoporosis screening in low risk patients. Greater cost consciousness was associated with less use of low-value services (P = .03), greater knowledge of guidelines (P = .001), and fewer perceived attitudinal and practice behavior-related barriers (P < .001 for each). Greater knowledge of guidelines was not associated with less use of low-value services (P = .58). Familiarity with Choosing Wisely was associated with both greater cost consciousness (P = .004) and less use of low-value services (P = .03).

CONCLUSIONS

Greater PCP cost consciousness was associated with less use of low-value services. Interventions to decrease perceived barriers and increase cost consciousness, perhaps by increasing awareness of Choosing Wisely, may translate into improved performance.

"A Paradox Persists When the Paradigm Is Wrong": Pisacano Scholars' Reflections from the Inaugural Starfield Summit

The inaugural Starfield Summit was hosted in April 2016 by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care with additional partners and sponsors, including the Pisacano Leadership Foundation (PLF). The Summit addressed critical topics in primary care and health care delivery, including payment, measurement, and team-based care. Invited participants included an interdisciplinary group of pediatricians, family physicians, internists, behaviorists, trainees, researchers, and advocates. Among the family physicians invited were both current and past PLF (Pisacano) scholars. After the Summit, a small group of current and past Pisacano scholars formed a writing group to reflect on and summarize key lessons and conclusions from the Summit. A Summit participant's statement, "a paradox persists when the paradigm is wrong," became a repeated theme regarding the paradox of primary care within the context of the health care system in the United States. The Summit energized participants to renew their commitment to Dr. Starfield's 4 C's of Primary Care (first contact access, continuity, comprehensiveness, and care coordination) and to the Quadruple Aim (quality, value, and patient and physician satisfaction) and to continue to explore how primary care can best shape the future of the nation's health care system.

Care Coordination and Population Management Services Are More Prevalent in Large Practices and Patient-centered Medical Homes

Despite efforts to better coordinate health care and improve population health, primary care practices may face difficulty dedicating an individual to provide these services. Using data from the American Board of Family Medicine, we found that the presence of care coordinators or population health managers was higher in larger practices and those with patient-centered medical home certification.

Patients' Perceived Quality of Family Physicians' Primary Care with or without 'Family Medicine' in the Clinic Name

BACKGROUND

Patients' perspectives of family medicine according to the physician's identity and role as a primary-care specialist need to be investigated. This study was conducted to investigate the perceived quality of the primary care of family medicine clinics as assessed by patients in a community setting.

METHODS

Patients (or their guardians) visiting nine community family medicine clinics were surveyed using the Korean Primary Care Assessment Tool from April 2014 to June 2014. The scores of the Korean Primary Care Assessment Tool domains were compared according to the clinics' designation (or not) as 'family medicine' and the patients' recognition (or not) of the physicians as board-certified family medicine specialists.

RESULTS

A total of 196 subjects responded to the questionnaire. They assessed the community clinics' quality of primary care as moderate to high. Of the clinics, those that were not designated as family medicine scored higher than those that were designated as family medicine (P<0.05). The group of patients that recognized a clinic as that of a board-certified family medicine specialist awarded higher scores than the non-recognition group in the domains of coordination function and personalized care (P<0.05).

CONCLUSION

The moderate to high scores for the community family medicine clinics' quality of primary care are encouraging. It seems that patients' recognition of the family physician's role and of the physician-patient relationship has a significant influence on their assessment of the quality of primary care.

Lost in Translation: NIH Funding for Family Medicine Research Remains Limited

Departments of Family Medicine (DFMs) in the United States consistently received around 0.2% of total research funding dollars and 0.3% of all awards awarded by the National Institutes of Health (NIH) across the years 2002 to 2014. We used the NIH Reporter tool to quantify the amount of funding and the number of grants received by DFMs from the NIH from 2002 to 2014, using criteria similar to those applied by previous researchers. NIH funding to DFMs as remained fairly consistent across the time period, at roughly 0.2% of total NIH funding and 0.3% of total grants awarded. Changing these proportions will likely require considerable effort to build research capacity within DFMs and their frontline practice research networks, and to shift policymaker and funder perceptions of the value of the FM research enterprise.

Federal Research Funding for Family Medicine: Highly Concentrated, with Decreasing New Investigator Awards

A small proportion of National Institutes of Health and other federal research funding is received by university departments of family medicine, the largest primary care specialty. That limited funding is also concentrated, with roughly a quarter of all National Institutes of Health, Centers for Disease Control and Prevention, and Agency for Healthcare Research and Quality funding awarded to 3 departments, almost half of that funding coming from 3 agencies, and a recent trend away from funding for new investigators.

Practice-based Research Networks (PBRNs) Bridging the Gaps between Communities, Funders, and Policymakers

In this commentary, we propose that practice-based research networks (PBRNs) engage with funders and policymakers by applying the same engagement strategies they have successfully used to build relationships with community stakeholders. A community engagement approach to achieve new funding streams for PBRNs should include a strategy to engage key stakeholders from the communities of funders, thought leaders, and policymakers using collaborative principles and methods. PBRNs that implement this strategy would build a robust network of engaged partners at the community level, across networks, and would reach state and federal policymakers, academic family medicine departments, funding bodies, and national thought leaders in the redesign of health care delivery.