General Practice Physicians Research Articles

Reorganización de la especialización médica. Más allá de la Ley de Ordenación de Profesiones Sanitarias

More than 30 years after the creation of postgraduate medical training program in Spain supported by the MIR system, a thorough review of it becomes essential. This was the goal of the LOPS law enacted in 2003.The development of the LOPS is being slow and difficult to enforce, because master lines have to be achieved in order to develop the training of specialists in accordance with internationals standards and, simultaneously, with the reform that is taking place in the undergraduate education. The start up of the medical core will be the cornerstone of this project. The principles of the LOPS provide an opportunity for the training of competent physician in basic general medical practice followed by a progressive specialization supported on a solid foundation. And these principles have to prevail over corporate interests.

Medication use as an outcome variable in environmental (noise) epidemiology

Medication use as an outcome variable in environmental (noise) epidemiology

Irrational prescribing of over-the-counter (OTC) medicines in general practice: testing the feasibility of an educational intervention among physicians in five European countries

BackgroundIrrational prescribing of over-the-counter (OTC) medicines in general practice is common in Southern Europe. Recent findings from a research project funded by the European Commission (FP7), the “OTC SOCIOMED”, conducted in seven European countries, indicate that physicians in countries in the Mediterranean Europe region prescribe medicines to a higher degree in comparison to physicians in other participating European countries. In light of these findings, a feasibility study has been designed to explore the acceptance of a pilot educational intervention targeting physicians in general practice in various settings in the Mediterranean Europe region.MethodsThis feasibility study utilized an educational intervention was designed using the Theory of Planned Behaviour (TPB). It took place in geographically-defined primary care areas in Cyprus, France, Greece, Malta, and Turkey. General Practitioners (GPs) were recruited in each country and randomly assigned into two study groups in each of the participating countries. The intervention included a one-day intensive training programme, a poster presentation, and regular visits of trained professionals to the workplaces of participants. Reminder messages and email messages were, also, sent to participants over a 4-week period. A pre- and post-test evaluation study design with quantitative and qualitative data was employed. The primary outcome of this feasibility pilot intervention was to reduce GPs’ intention to provide medicines following the educational intervention, and its secondary outcomes included a reduction of prescribed medicines following the intervention, as well as an assessment of its practicality and acceptance by the participating GPs.ResultsMedian intention scores in the intervention groups were reduced, following the educational intervention, in comparison to the control group. Descriptive analysis of related questions indicated a high overall acceptance and perceived practicality of the intervention programme by GPs, with median scores above 5 on a 7-point Likert scale.ConclusionsEvidence from this intervention will estimate the parameters required to design a larger study aimed at assessing the effectiveness of such educational interventions. In addition, it could also help inform health policy makers and decision makers regarding the management of behavioural changes in the prescribing patterns of physicians in Mediterranean Europe, particularly in Southern European countries.

Assessment of injection practice in primary health care facilities of Shiraz, Iran

Occupational risk for several bloodborne viruses is attributable to unsafe injection practices. To understand injection frequency and safety, we surveyed injection rates and factors influencing injection prescription in primary health care facilities and associated health clinics in Shiraz, Iran. We used both quantitative and qualitative approaches to study the frequency and safety of injections delivered in 27 primary health care facilities. We used observations and 3 data collecting tools. Patterns of 600 general practice physicians' (GPs) prescriptions were also reviewed. In-depth interviews to elicit the factors contributing to injection prescriptions were conducted. The annual per capita injection rate was 3.12. Corticosteroids were prescribed more frequently than antibiotics (P < .001). Knowledge of participants concerning transmission risks for 3 of the most common bloodborne infections (BBIs) was less than 75%. Factors affecting use of injections by GPs included strong patient preference for injections over oral medications and financial benefit for GPs, especially those in private practice settings. Frequency of therapeutic injections in the participating facilities in Shiraz was high. Sociocultural factors in the patient community and their beliefs in the effectiveness of injections exerted influence on GP prescribing practices. Programs for appropriate and safe injection practices should target GP and injection providers, as well as patients, informing them about alternative treatments and possible complications of unnecessary and unsafe injections.

Emotional disturbances among adult diabetic patients attending diabetic clinic in a Malaysian general hospital

Introduction: Emotional disturbances such as depression, anxiety and stress play an important role in the management of diabetes mellitus since their presence can adversely affect glycemic control, quality of life and compliance with medications. Despite this, emotional disturbances are consistently under-diagnosed and undertreated by physicians in general practice. Objectives: This study aims to determine the prevalence and severity of emotional disturbances among diabetic patients Methodology: This is a cross sectional study conducted on a sample of 200 patients with diabetes mellitus attending the diabetic clinic at the Hospital Tengku Ampuan Afzan, Pahang state, Malaysia. The prevalence and severity of depressive, anxiety and stress symptoms were assessed in those diabetic patients by using the self-rating Bahasa Malaysia version of the Depression, Anxiety and Stress Scales (DASS-42). Results: The prevalence of depression, anxiety, and stress among diabetic patients was 13.5%, 28%, 11% respectively. Most of the patients with emotional disturbances had moderate depression and anxiety symptoms. However, stress symptoms were mild. Although females showed higher prevalence of emotional disturbances, only anxiety was significantly higher than males. Conclusion: Diabetic patients are at risk to develop psychiatric illnesses in the form of depression, anxiety and stress. Anxiety symptoms were more prominent than depression and stress in diabetic patients.

Characteristics of patients consulting their regular primary care physician according to their prescribing preferences for homeopathy and complementary medicine

Homeopathic care has not been well documented in terms of its impact on patients' utilization of drugs or other complementary and alternative medicines (CAM). The objective of this study was to describe and compare patients who visit physicians in general practice (GPs) who prescribe only conventional medicines (GP-CM), regularly prescribe homeopathy within a mixed practice (GP-Mx), or are certified homeopathic GPs (GP-Ho). The EPI3-LASER study was a nationwide observational survey of a representative sample of GPs and their patients from across France. Physicians recorded their diagnoses and prescriptions on participating patients who completed a self-questionnaire on socio-demographics, lifestyle, quality of life Short Form 12 (SF-12) and the complementary and alternative medicine beliefs inventory (CAMBI). A total of 6379 patients (participation rate 73.1%) recruited from 804 GP practices participated in this survey. Patients attending a GP-Ho were slightly more often female with higher education than in the GP-CM group and had markedly healthier lifestyle. They did not differ greatly in their comorbidities or quality of life but exhibited large differences in their beliefs in holistic medicine and natural treatments, and in their attitude toward participating to their own care. Similar but less striking observations were made in patients of the GP-Mx group. Patients seeking care with a homeopathic GP did not differ greatly in their socio-demographic characteristics but more so by their healthier lifestyle and positive attitude toward CAM. Further research is needed to explore the directionality of those associations and to assess the potential economic benefits of homeopathic management in primary care.

Current specific immunotherapy for allergic rhinitis: perspectives from otorhinolaryngologists.

Current specific immunotherapy for allergic rhinitis: perspectives from otorhinolaryngologists.

Rational use of antibiotics for the management of children's respiratory tract infections in the ambulatory setting: an evidence-based consensus by the Italian Society of Preventive and Social Pediatrics

Several guidelines for the management of respiratory tract infections in children are available in Italy, as well as in other European countries and the United States of America. However, poor adherence to guidelines and the sustained inappropriate use of antibiotics have been reported. In the outpatient setting, almost half of antibiotics are prescribed for the treatment of common respiratory tract infections. In Italy the antibiotic prescription rate is significantly higher than in other European countries, such as Denmark or the Netherlands, and also the levels of antibiotic resistance for a large variety of bacteria are higher. Therefore, the Italian Society of Preventive and Social Paediatrics organised a consensus conference for the treatment of respiratory tract infections in children to produce a brief, easily readable, evidence-based document. The conference method was used, according to the National Institute of Health and the National Plan Guidelines. A literature search was performed focusing on the current guidelines for the treatment of airway infections in children aged 1 month-18 years in the ambulatory setting. Recommendations for the treatment of acute pharyngitis, acute otitis media, sinusitis, and pneumonia have been summarized. Conditions for which antibiotic treatment should not be routinely prescribed have been highlighted. This evidence-based document is intended to accessible to primary care pediatricians and general practice physicians in order to make clinical practice uniform, in accordance with the recommendations of the current guidelines.

Head and Neck Cancer Mortality, Socioeconomic Status, and Distribution of Otolaryngologists

Objectives: Assess the relationship between distribution of otolaryngologists and head and neck cancer mortality rates, taking into account measures of socioeconomic status. Methods: We used the number of deaths from head and neck cancer in each U.S. county during 2002-2009 reported by National Center for Health Statistics. Due to low numbers in many counties, we aggregated counties into the 949 Health Service Areas (HSAs), which reflect hospital referral patterns. We used the Area Resource File to obtain numbers of otolaryngologists, general practice physicians, and dentists, as well as urban/rural designation, poverty rate, educational attainment, median household income, and racial minority proportion for each HSA. The impact of these covariates was evaluated on mortality rates adjusted for age and sex distribution. Results: The crude mortality rate was 4.1/100,000. There were no otolaryngologists in 274 HSAs (median 2, range 0-351). There were no significant relationships between number of otolaryngologists, general practitioners, or dentists, as continuous variables, and mortality rate. However, HSAs with no otolaryngologists had a higher mortality rate (by 0.32/100,000) than those with one or more otolaryngologist (p=.005). Mortality rates were significantly higher in HSAs with lower median income and greater poverty rate, non-white population, and proportion of adults without high school education, and also in entirely rural HSAs ( P &lt; .0001). On multivariate analysis, adverse socioeconomic factors and rural status were independently associated with higher mortality ( p &lt; .0001), but presence of an otolaryngologist was not ( P = .23). Conclusions: Socioeconomic factors are stronger independent predictors of head and neck cancer mortality than otolaryngologist distribution.

Attitudes and knowledge about obstructive sleep apnea among Latin American primary care physicians

ObjectivesWe aimed to evaluate Latin American primary care physicians’ knowledge and attitudes about obstructive sleep apnea (OSA) using a Spanish-language version of the OSA Knowledge and Attitudes (OSAKA) questionnaire and to evaluate its psychometric properties. MethodsWe used a cross-sectional survey of general practice physicians in Ecuador, Peru, and Venezuela who completed the Spanish-language version OSAKA questionnaire. ResultsOf 684 primary care physicians surveyed, 367 (65%) responded (mean age, 45years; range, 21–75years). Mean total knowledge (proportion of 18 items correctly answered) was 60% (range, 0–100%). Less than half of physicians correctly answered the questions about the association between OSA and hypertension. We found no significant differences in overall knowledge in gender or time since graduation (⩽5years vs >5years). Although 73.5% of the physicians felt confident in identifying patients at risk for OSA, only 35.4% felt confident in managing those patients and 22.1% felt confident in managing patients with continuous positive airway pressure (CPAP) therapy. The Spanish-language version of the OSAKA questionnaire had comparable psychometric properties to the English-language version. ConclusionsThis Spanish-language version of the OSAKA yielded considerable variance in Spanish-speaking physicians’ knowledge about OSA and confidence in identifying and managing patients with OSA. Focused OSA education for Latin American general physicians is needed.

Ultrasound-guided pain interventions in shoulder region

Shoulder pain is one of the common complaints to physicians in general practice. Among therapeutic measures used to treat this pain, invasive techniques, such as joints and periarticular injection, as well as suprascapular and axillary nerve block, play a crucial role. Ultrasound guidance is a safe alternative to blind techniques, increasing the safety and accuracy of the procedure and reducing complications. A good understanding of the anatomy and sonoanatomy is of paramount importance in performing the ultrasound-guided injections.

Chlamydia screening practices among physicians and community nurses in Yukon, Canada

BackgroundYukon, a territory in northern Canada, has one of the highest reported sexually transmitted chlamydia infection rates in the country.ObjectiveWe examined screening practices among physicians and community nurses to elucidate factors that may be contributing to the high rates.DesignCross-sectional survey.MethodsA questionnaire was distributed to all physicians in Yukon and all community nurses in Yukon's communities. We surveyed sexual health assessment frequency, chlamydia testing frequency and barriers to screening. Comparison of physician testing practices was performed to another Canadian jurisdiction, which previously undertook a similar survey. Survey results were compared to the available laboratory data in Yukon.ResultsEligible physicians and nurses, 79% and 77%, respectively, participated in the survey. Physicians tested 15 to 24-year-old females more frequently than 15 to 24-year-old males for chlamydia (p=0.007). Physicians who asked sexual health assessment questions were more likely to test for chlamydia in both females (p<0.001) and males (p=0.032). More physicians screened females based on risk factors compared to males. General practice physicians in Yukon were more likely to test females for chlamydia than general practice physicians in Toronto, Canada (p<0.001). Community nurses had different testing patterns than physicians, with a lower overall frequency of testing, equal frequency of testing males and females, and in applying risk factor-based screening to both males and females. Barriers to screening included testing causing patient discomfort, patients reluctant to discuss screening, health provider uncomfortable conducting sexually transmitted infection tests and sexual health assessments, among others. Laboratory data in Yukon appear to confirm provider screening patterns.ConclusionsThis survey provides valuable information on health provider screening patterns. We have some evidence which suggests that chlamydia testing rates may be higher among patients seen by physicians in Yukon in comparison to another Canadian jurisdiction. However, more consistent application of optimal screening methods with support to “start the conversation” around sexual health may assist in overcoming barriers to screening and in addressing Yukon's high rate of chlamydia.

General practitioners’ hypertension knowledge and training needs: a survey in Xuhui district, Shanghai

BackgroundHypertension prevalence is high in China, while patients’ levels of hypertension awareness, treatment and control are low. General practitioners’ knowledge and training relating to hypertension prevention may be an important related factor. We aimed to investigate general practitioners’ knowledge of hypertension prevention and potential training needs.MethodsA questionnaire survey was conducted among all general practitioners at five community health service centers selected by convenience sampling. A total of 160 questionnaires were distributed and 147 were returned (response rate 91.9%) The questionnaire included general information; 12 subjective questions on health promotion, education and training needs; and 19 objective questions in 5 domains (epidemiology, diagnosis, treatment, referral and community management) measuring knowledge of hypertension prevention and treatment.ResultsThe major difficulties in health education practice for general practitioners were poor patient compliance (77.6%) and lack of medical consultation time (49.0%). The average accuracy rate of hypertension prevention knowledge was 49.2%, ranging from 10.5% to 94.7%. The factors associated with accuracy rate were physician’s education level (medical university vs. professional school, β = 13.3, P = 0.003), and type of center (training base vs. community healthcare center, β = 12.3, P < 0.0001). Most physicians (87.8%) reported being willing to attend training courses regularly and the preferred frequency was once every 2 ~ 3 months (53.5%). The preferred course was medical treatment of hypertension (82.3%) and the most favored training approach was expert lectures (80.3%).ConclusionsThe knowledge level of hypertension prevention is low among general practitioners in urban settings. Physicians working in community clinics where they participate in a series of teaching, assessing and evaluating systems for hypertension prevention perform better than those in general healthcare centers who lack specific training. Continuing hypertension education is urgently needed to ensure that physicians in general practice are aware of and adhere to the national hypertension prevention guidelines.

Gynybinė medicina Lietuvos sveikatos apsaugoje: gydytojų gynybinių reakcijų formavimasis

Defensive medicine is a flawed health care phenomenon, when the main doctor’s priority becomes the striving to protect himself against possible legal prosecution for possible errors in diagnosis and treatment. The article analyses sources of doctors’ defensive responses in a given clinical situation.The article continues the presentation of the results of 2440 Lithuanian doctors’ study (2011–2012). The previous article introduced its general results, whereas the current one discusses differences of defensive reactions in different medical specialties and further differences that are caused by individual characteristics of a physician, patient and a clinical situation. Examining differences in defensive reactions in different specialties, it was found that a high level of defensive reactions were inherent in all medical specialties investigated. Therefore, in Lithuanian health care, there do not exist any ‘safe’ specialties, which do not use defensive medicine to protect themselves from prosecution actions. The study also identifies the most sensitive (insecure) medical specialties (general practice physicians, internal medicine specialists, pediatricians, neurologists). An important result of the study was large differences (variance) of defense reactions within each specialty. It turned out that even within a single specialty physicians may react very differently depending on the features of an individual doctor, patient and a clinical situation. In order to clarify the interaction between these characteristics, factor analysis (principal component method with Oblimin rotation) has been carried out.This analysis made it possible to discover two fundamental factors responsible for the interaction between different traits of a doctor, patient and a clinical situation and play the crucial role in the development of defensive reactions of doctors.The outcomes of the study showed a highly important role of grass-root psychological, ethical and cultural relations between doctor and patient in both arising and depressing of defensive medicine. The study showed that some doctors were quite successful in solving patient’s confidence problems and this way is ‘immune’ from factors and effects causing defense medicine. A doctor who is able to understand patient’s feelings (also his distrust) has incomparably better conditions to overcome this distrust. On the contrary, a doctor who sees patient’s distrust as an expression of his hostility has no other option than to defend and to use defensive medicine methods.This provided the basis for the concept of the ‘double-aetiology’ of defense medicine with legal and social factors acting on the societal level and quite different psychological ones prevailing on the interpersonal doctor-patient level.

The Evolutionary Role of Physician Assistants across the United States, Canada, and the United Kingdom

With physician shortages looming ominously on the horizon, healthcare systems across the globe are awaiting a surge of eager young doctors to enter the field. Much to the dismay of these systems, it does not appear that there will be a collective sigh of relief in the coming years. Fortunately there still remains a promising position to fill the gaps and potentially overcome the growing inundation of patients, shortage of general practice physicians, and ever growing underserved rural populations: the position of physician assistant (PA). Through this review, the evolution of the PA position will be discussed from the perspective of healthcare systems in the United States, Canada, and the United Kingdom. Further, an outline of the educational requirements, projected student debt-to-income ratios, and position availability will be touched upon.

Where have all the GPs gone--where will they go? Study of Finnish GPs.

BackgroundIn this paper a specialist in general practice is referred to as a general practitioner (GP). In Finland only half of all GPs work as a health centre physician. The present aim was to establish what the working places of specializing and specialized physicians in general practice are, and where they assume they will work in the future.MethodsThe study population comprised 5,357 physicians licensed in Finland during the years 1977–1996. Altogether 2,956 questionnaires were returned, a response rate of 55.2%. Those either specializing (GP trainees, n=133) or already having specialized (GPs, n=426) in general practice were included in the study. Respondents were asked what kind of physician’s work they would most preferably do. They were further asked what work they assumed they would be doing in the year 2020.ResultsAltogether 72% were working in public primary health centres and 14% in the private sector. Of GPs 53% and of GP trainees 70% would most preferably work in health centres. Of GPs 14% would most preferably work as private practitioners and 9% as occupational health physicians. Sixteen per cent assumed they would be working as private practitioners and 35% assumed they would be retired in the year 2020. Of GP trainees 57% assumed they would be working as health centre physicians in 2020.ConclusionsAccording to the present findings many experienced GPs will leave their work as a health centre physician. Moreover, several GP trainees do not consider health centre physician’s work as a long-term career option. These trends may in the future reflect a recruiting problem in many primary health centres.

Translation of an evidence-based asthma intervention: Physician Asthma Care Education (PACE) in the United States and Australia

Physician Asthma Care Education (PACE) is a programme developed in the USA to improve paediatric asthma outcomes. To examine translation of PACE to Australia. The RE-AIM framework was used to assess translation. Demographic characteristics and findings regarding clinical asthma outcomes from PACE randomised clinical trials in both countries were examined. Qualitative content analysis was used to examine fidelity to intervention components. Both iterations of PACE reached similar target audiences (general practice physicians and paediatric patients with asthma); however, in the USA, more children with persistent disease were enrolled. In both countries, participation comprised approximately 10% of eligible physicians and 25% of patients. In both countries, PACE deployed well-known local physicians and behavioural scientists as facilitators. Sponsorship of the programme was provided by professional associations and government agencies. Fidelity to essential programme elements was observed, but PACE Australia workshops included additional components. Similar outcomes included improvements in clinician confidence in developing short-term and long-term care plans, prescribing inhaled corticosteroids, and providing written management instructions to patients. No additional time was spent in the patient visit compared with controls. US PACE realised reductions in symptoms and healthcare use, results that could not be confirmed in Australia because of limitations in follow-up time and sample sizes. US PACE is maintained through a National Heart, Lung, and Blood Institute website. Development of maintenance strategies for PACE Australia is underway. Based on criteria of the RE-AIM framework, the US version of PACE has been successfully translated for use in Australia.

Healthcare providers and teen driving safety: topics discussed and communication products used in practice

BackgroundTraffic crashes are the leading cause of death among US teens. Healthcare providers who care for adolescents have an opportunity to address the issue and discuss what works to keep...

Variation in primary care physicians' colorectal cancer screening recommendations by patient age and comorbidity.

Screening patterns among primary care physicians (PCPs) may be influenced by patient age and comorbidity. Colorectal cancer (CRC) screening has little benefit among patients with limited life expectancy. To characterize the extent to which PCPs modify their recommendations for CRC screening based upon patients' increasing age and/or worsening comorbidity Cross-sectional, nationally representative survey. The study comprised primary care physicians (n = 1,266) including general internal medicine, family practice, and obstetrics-gynecology physicians. Physician CRC screening recommendations among patients of varying age and comorbidity were measured based upon clinical vignettes. Independent variables in adjusted models included physician and practice characteristics. For an 80-year-old patient with unresectable non-small cell lung cancer (NSCLC), 25 % of PCPs recommended CRC screening. For an 80-year-old patient with ischemic cardiomyopathy (New York Heart Association, Class II), 71 % of PCPs recommended CRC screening. PCPs were more likely to recommend fecal occult blood testing than colonoscopy as the preferred screening modality for a healthy 80-year-old, compared to healthy 50- or 65-year-old patients (19 % vs. 5 % vs. 2 % p < 0.001). For an 80-year-old with unresectable NSCLC, PCPs who were an obstetrics-gynecology physician were more likely to recommend CRC screening, while those with a full electronic medical record were less likely to recommend screening. PCPs consider comorbidity when screening older patients for CRC and may change the screening modality from colonoscopy to FOBT. However, a sizable proportion of PCPs would recommend screening for patients with advanced cancer who would not benefit. Understanding the mechanisms underlying these patterns will facilitate the design of future medical education and policy interventions to reduce unnecessary care.

Perception of oral and maxillofacial surgery by medical and dental health care professionals in Kuwait

Oral and Maxillofacial Surgery (OMFS) is a recently established specialty in Kuwait. The aim of this study was to assess the level of awareness regarding OMFS among dentists and physicians in general practice. One hundred dentists and 100 physicians were randomly selected to complete a self-administered questionnaire. The questionnaire was designed to assess the referral patterns of certain clinical scenarios of four different categories: reconstruction, trauma, pathology, and cosmetics. Referral patterns were either to a plastic surgeon, ENT, OMF surgeon, General Surgeon, or other specialty. Both medical and dental professionals agreed on referring most cases involving the maxillofacial region to OMFS (p>0.05), however in cases like cleft lip, cleft palate, or cleft lip and palate, the results varied widely, with dentists leaning towards referral to OMFS and physicians towards plastic surgeons (p<0.001). Trauma cases in the maxillofacial region were generally referred to OMFS with some differences between the professionals regarding some midface fractures. Regarding oral and maxillofacial pathology both categories preferred referring to OMFS however in cases such as malignancies of the tongue, cancer of the lip, lump in the neck and salivary gland removal referral to medical specialist was preferred (p<0.001). There was agreement that cosmetic procedures should be treated by plastic surgeons except for dentofacial deformities. In conclusion, although a recently introduced specialty, OMFS has already established itself well in the Kuwaiti society. However there are areas for improvement to provide optimal referral and treatment.