To examine the practice patterns and clinical and academic roles of family physicians who have care of the elderly training.
Family medicine practices or specialized geriatric services programs.
Fifty-two family physicians, surveyed in 2005 and 2006, identified as having 6 or 12 months' care of the elderly training.
Self-reported practice type and description of clinical and academic roles.
Surveys were sent to 103 physicians; the response rate was 50.5% (N = 52). Respondents were relatively young, with a mean age of 42 years. Slightly more respondents had completed 6 months of training than had completed a full year of training (54.9% vs 45.1%). More than half (55.8%) described their medical practice areas as "general family medicine." The remainder worked in "restricted practices" (25.0%) or provided "specialist care" (17.3%); 1 physician was no longer practising medicine. Many provided some care within specialized geriatric service areas, most commonly in-hospital consultation and rehabilitation. More than half (51.9%) provided active hospital care, and a substantial number worked in long-term care facilities as physicians or medical directors. More than 20% provided newborn care, although only a small percentage (7.7%) performed obstetric services. Respondents were actively involved in teaching and other academic activities, including resident supervision.
Care of the elderly physicians provide comprehensive family medicine services, but also often provide care in other areas currently facing physician shortages. Care of the elderly physicians play relevant clinical and academic roles in both family medicine training and specialized geriatric services.
Our primary objective in this study was to measure family physicians' knowledge of the key elements that go into assessing the validity and interpreting the results in three different types of studies: i) a randomized controlled trial (RCT); ii) a study evaluating a diagnostic test; and iii) a systematic review (SR). Our secondary objectives were to determine the relationship between the above skills and age, gender, and type of practice.
We obtained a random sample of 1000 family physicians in Ontario from the College of Family Physicians of Canada database. These physicians were sent a questionnaire in the mail with follow-up mailings to non-responders at 3 and 8 weeks. The questionnaire was designed to measure knowledge and understanding of the basic concepts of critical appraisal skills. Based on the responses to the questions an Evidence Based Medicine (EBM) Knowledge Score was determined for each physician.
A response rate of 30.2% was achieved. The respondents were younger and more likely to be recent graduates than the population of Ontario Family Physicians as a whole. This was an expected outcome. Just over 50% of respondents were able to answer questions concerning the critical appraisal of methods and the interpretation of results of research articles satisfactorily. The average score on the 12-point EBM Knowledge Scale was 6.4. The younger physicians scored higher than the older physicians, and academic physicians scored higher than community-based physicians. Scores of male and female physicians did not differ.
We have shown that in a population of physicians which is younger than the general population of physicians, about 50% have reasonable knowledge regarding the critical appraisal of the methods and the interpretation of results of a research article. In general, younger physicians were more knowledgeable than were older physicians. EBM principles were felt to be important to the practice of medicine by 95% of respondents.
Cites: Med Educ. 2000 Feb;34(2):120-510652064
Cites: Fam Pract. 1999 Dec;16(6):627-3210625142
Cites: Acad Med. 2002 Nov;77(11):1157-812431934
Cites: BMJ. 2002 Dec 7;325(7376):1338-4112468485
Cites: Ann Intern Med. 1986 Jul;105(1):149-533717805
Cites: Ann Intern Med. 1986 Aug;105(2):309-123729227
Cites: Ann Intern Med. 1986 Sep;105(3):474-83527017
Cites: CMAJ. 1988 Apr 15;138(8):697-7033355948
Cites: JAMA. 1988 Nov 4;260(17):2537-413050179
Cites: JAMA. 1993 Dec 1;270(21):2598-6018230645
Cites: JAMA. 1994 Jan 5;271(1):59-638258890
Cites: JAMA. 1994 Feb 2;271(5):389-918283589
Cites: JAMA. 1994 Mar 2;271(9):703-78309035
Cites: JAMA. 1994 Nov 2;272(17):1367-717933399
Cites: CMAJ. 1998 Jan 27;158(2):177-819469138
Cites: Med Educ. 1998 Sep;32(5):486-9110211289
Cites: J Gen Intern Med. 2000 Oct;15(10):710-511089714
A discordance exists between the proportion of Canadian family physicians that we expect should be able to perform minor office procedures and the actual provision of care. This pattern has not been extensively studied. The objective of this study was to determine the current patterns and obstacles relating to the provision of four minor office procedures by GP/FPs in a small city in Ontario, Canada. An additional goal was to determine the impact of the remuneration method on the provision of such services.
A survey was mailed to all GP/FPs practising in Kingston, Ontario. The main outcomes measured in the study were work setting and remuneration method, current procedural practices with respect to four procedures, reasons for not performing procedures, current skill levels, and desire to upgrade.
Surveys were mailed to all 108 GP/FPs in the City of Kingston. Completed surveys were collected for 82 percent (89/108) and 10 were excluded leaving 79 eligible participants. The percentages of GP/FPs who reported performing the procedure were as follows: dermatological excision (63.3%), endometrial biopsy (35.4%), shoulder injection (31.6%), and knee injection (43.0%). The majority of GP/FPs who would not do the procedure themselves would refer to a specialist colleague rather than to another GP/FP. The top reason cited for not performing a specific procedure was "lack of up to date skills" followed by "lack of time". The latter was the only statistically significant difference reported between GP/FPs working in Family Health Networks and GP/FPs working in fee for service settings (26.7% vs 47.0%, chi2 = 4.191 p = 0.041).
A large number of Kingston, Ontario GP/FPs refer patients who require one of four minor office-based procedures for specialist consultation. Referral to other GP/FP colleagues appears underutilized. A perceived lack of up to date skills and a lack of time appear to be concerns. GP/FPs working in Family Health Networks were more likely to perform these procedures themselves. Further studies would clarify the role of changes in medical education, the role of continuing education, and the impact of different remuneration models.
Cites: Fam Pract Res J. 1992 Sep;12(3):297-3031414434
Cites: Br J Gen Pract. 1994 Aug;44(385):364-58068396
Cites: Fam Med. 1996 Sep;28(8):565-98884253
Cites: Can Fam Physician. 1997 Apr;43:715-89111988
Cites: Br J Gen Pract. 1997 Apr;47(417):205-109196961
Cites: Can Fam Physician. 1998 Mar;44:521-99559192
Cites: Fam Med. 2005 Jul-Aug;37(7):491-515988634
Cites: Can Fam Physician. 2005 Oct;51:1364-516926970
There continues be a problem with the proportion of treated hypertension patients who are actually at recommended blood pressure targets.
Is an intensive protocol-based strategy for achieving blood pressure control effective in family practice and will family physicians and their hypertensive patients adhere to such a protocol.
Design of the study is a cluster randomized controlled trial at the Centre for Studies in Primary Care, Queen's University, Kingston, Ontario. Participants were 19 family physicians and 156 (98 intervention group and 58 control group) of their patients in and around the Kingston area. Patients were eligible if they had a diagnosis of hypertension and had not yet achieved their target blood pressure. Patients in the intervention group were managed according to a protocol that involved seeing their family doctor every 2 weeks over a 16-week period and having their antihypertensive medication regimen adjusted at each visit if target was not achieved. This was compared to usual care. Main outcomes were primary effectiveness outcome measured at 12 months was the differences in blood pressure between baseline and 12 months in the two groups. Secondary effectiveness outcomes included rates of achieving BP target and compliance with protocol by physicians and patients. Adherence outcomes were assessed by determining the number of visits made during the 16-week intervention period and the increase in the number of drugs being used.
Of the patients enrolled, 72 (74%) from the intervention group and 41 (71%) in the control group were available for analysis. Improvement between baseline and 12-month follow-up was significantly better for the intervention group than the control for diastolic mean daytime BP on 24 hours ambulatory blood pressure monitoring (4.5 mmHg reduction versus 0.5 mmHg reduction) and for both systolic (14.7 mmHg reduction versus 2.7 mmHg reduction) and diastolic (7.4 mmHg reduction versus 0.6 mmHg increase) blood pressure on BpTRU. Of the 98 patients in the intervention, 80% attended four or more of the eight visits and 25% attended all eight visits; physicians increased the number or dosage of drugs the patient was taking in 52% of the visits. Conclusions. An intensive, protocol-based, management approach to achieving blood pressure control in hypertensive patients in family practice is effective and works even when there is flexibility built into the algorithm to allow family physicians to use their judgement in individual patients.
To compare e-mail with regular mail for conducting surveys of physicians.
Randomized controlled trial.
A random sample of physicians listed in the College of Family Physicians of Canada's membership database.
Survey delivered by e-mail and by post.
Response rates and times, and completeness and characteristics of responses to the survey.
Overall response rate was 44.7% (33.6% of e-mail recipients, 52.7% of post recipients who have e-mail, and 47.8% of post recipients without e-mail). While the e-mail rate was significantly lower than for both post groups, e-mail responses were received much faster. There was no significant difference among groups as to completeness of responses, but e-mail responses had more frequent and longer comments.
E-mail provides faster but fewer responses to surveys. Content of structured-response questions was similar in all groups, but e-mail provided more and longer responses to open-ended questions. Where a quick response to a survey is required, e-mail is superior.
Cites: Eval Health Prof. 1998 Sep;21(3):395-40810350958
To examine the views of faculty and residents about teaching and evaluating health advocacy, one of the more difficult CanMEDS roles to integrate into postgraduate medical education.
In 2002, two focus groups of faculty and two of residents at Queen's University, Kingston, Ontario, Canada, were asked standardized questions to elicit their answers to what was a health care advocate as understood and reported by teachers and residents, and what were the reported barriers and enhancers to teaching and evaluating the role of residents as health care advocates.
The study found that faculty and residents knew little about how to teach and evaluate the role of the health advocate. There was consensus between the two types of groups with congruity between residents and faculty about the key issues. The one exception to this was the disconnect between the faculty members' belief that advocacy was an aspect of their daily work and the residents' apparent lack of awareness of this. The majority of participants were not familiar with the Royal College's description of the role of health advocate and were very keen to receive further guidance on teaching tools and methods of evaluation.
The authors' hypothesis was that little is known about how to teach and evaluate the role of the health advocate. The results confirmed this and identified important areas upon which to build an educational framework. The definition of the health advocate and the expectations require clarity and direction. Academic programs would benefit from clear objectives.
To elicit the opinions of family physician anesthetists (FPAs) and hospital Chief Executive Officers (CEOs) regarding the structure of their organizations and the importance of family medicine anesthesia.
The CEOs of Ontario hospitals and family physicians who provide anesthetic services in Ontario hospitals.
Demographics, practices, and opinions of FPAs and CEOs regarding family medicine anesthesia.
Responses were received from 159 of 195 practising FPAs (82%). Of the 128 hospitals in Ontario that offered anesthesia services, 59% used at least one FPA; in 39% of these hospitals, all services were provided by FPAs. Both FPAs and CEOs thought that FPAs were competent to meet the anesthesia needs of small community hospitals. Most FPAs and CEOs supported certification and maintenance of competence programs coordinated by a national body, such as the College of Family Physicians of Canada. Both FPAs and CEOs thought there should be support for additional training programs in family medicine anesthesia.
Small community hospitals rely completely on FPAs to provide essential anesthesia services. Additional training programs and a national structure to coordinate certification and maintenance of competence programs are important to maintain and enhance this essential service.
Cites: CMAJ. 2002 Feb 19;166(4):429-3411876170
Cites: Can Fam Physician. 2002 Feb;48:324, 33311889892
Cites: Can Fam Physician. 1998 Oct;44:2117-249805166
Cites: Can J Anaesth. 1999 Oct;46(10):962-910522584
Research is not perceived as an integral part of family practice by most family physicians working in community practices. OBJECTIVE OF THE PROGRAM To assist community-based practitioners in answering research questions that emerge from their practices in order for them to gain a better understanding of research and its value.
The Ontario College of Family Physicians developed a program consisting of 5 sets of weekend workshops, each 2 months apart. Two pilots of the 5-weekend program occurred between 2000 and 2003. After the pilots, thirteen 5-weekend programs were held in 2 waves by 20 facilitators, who were trained in one of two 1-day seminars.
This 5-weekend program, developed and tested in Ontario, stimulates community practitioners to learn how to answer research questions emerging from their practices. A 1-day seminar is adequate to train facilitators to successfully run these programs. Evaluations by both facilitators and program participants were very positive, with many participants stating that their clinical practices were improved as a result of the program. The program has been adapted for residency training, and it has already been used internationally.
Cites: Ann Fam Med. 2004 May 26;2 Suppl 2:S60-415655092
Cites: Public Health. 2005 Mar;119(3):174-8315661126
Cites: Ann Fam Med. 2006 Jul-Aug;4(4):373-416868243
Cites: CMAJ. 2002 May 28;166(11):1419-2012054410
Cites: Can Fam Physician. 1997 Dec;43:2151-79426934
Cites: Ann Fam Med. 2004 May 26;2 Suppl 2:S17-2215655082
Cites: Fam Med. 1994 Oct;26(9):579-827843508
Cites: J Fam Pract. 2002 Jul;51(7):59312160486
Cites: Aust Fam Physician. 2002 Dec;31(12):1139-4212516520
Cites: Eur J Gen Pract. 2003 Jun;9(2):41-714611015
Cites: Ann Fam Med. 2004 Mar-Apr;2 Suppl 1:S3-3215080220
Cites: Acad Med. 2004 Nov;79(11):1095-10215504779
Cites: Fam Med. 1994 May;26(5):303-88050649
Comment In: Can Fam Physician. 2010 May;56(5):41220463267
Automated blood pressure (BP) devices are commonly used in doctor's offices. How BP measured on these devices relates to ambulatory BP monitoring is not clear.
To assess how well office-based manual and automated BP predicts ambulatory BP.
Using data on 654 patients, we assessed how well sphygmomanometer measurements and measurements taken with an automated device (BpTRU) predicted results on ambulatory BP monitoring. We assess positive and negative predictive values and overall accuracy. We look at different cut-points for systolic (130, 135 and 140 mmHg) and diastolic (80, 85 and 90 mmHg) BP.
A single automated office BP (AOBP) assessment provides superior predictive values and overall accuracy compared to three manual office BP assessments. For systolic BP, the predictive values are =69% for any of the cut-points while the positive predictive values for the single automated measurement is between 80.0% and 86.9% and the overall accuracy gets as high as 74% for the 130 mmHg cut-point. For diastolic BP, the automated readings are also more predictive but in this case, it is the negative predictive values that are better, as well as the overall accuracy.
Based on the results, we suggest that 135/85 mmHg continue to be used as the cut-point defining high BP with the BpTRU device. However, future research might suggests that values in a grey zone between 130-139 mmHg systolic and 80-89 mmHg diastolic be confirmed using ambulatory BP monitoring. As well, three AOBP assessments might produce much greater accuracy than the single AOBP assessment used in the study.