Self-employed General Practitioners Research Articles

Comparing GPs according to their model of practice: are multiprofessional group practices associated with more favourable working conditions?

In the generalized context of general practitioner shortages and transitions towards team-based primary care, we investigated how the different practising models relate to general practitioners' labour supply. More precisely, we analysed the association between practice models-solo, groups of general practitioners, and multiprofessional groups-and their reported labour supply and level of satisfaction with work-life balance. We used a French cross-sectional survey from 2018 that surveyed a representative national sample of 3,032 self-employed general practitioners about their working conditions. We found that the model of practice was significantly associated with differences in physician labour supply at the intensive margin and that group practice appeared to be positively associated with general practitioners' reported satisfaction with work-life balance. In terms of weekly working time, only practice in groups of general practitioners was associated with a significantly lower labour supply. However, general practitioners in groups-whether groups of general practitioners or multiprofessional groups-reported more annual leave and seemed more willing to diversify their activity by devoting more time to secondary activities, including salaried activities. Consistently, general practitioners working in groups were also more likely than solo practitioners to report being satisfied with their work-life balance. Although group practice, whether multiprofessionnal or not, seems to be well suited to meeting the new aspirations of general practitioners, those working in multiprofessional groups are associated with a higher level of weekly work supply, which might justify special attention from the public authorities.

Évaluation des échanges professionnels entre médecins généralistes et psychiatres

ObjectivesThere is in France a higher prevalence of psychiatric disorders and higher than average psychotropic consumption in the general population. Considering these elements and the need to involve two complementary medical specialities to manage these disorders, general practice and psychiatry, the necessity for optimal professional exchanges is a major public health concern. In the French public health system, primary care is overseen by self-employed general practitioners. The French psychiatric public sector is said to be “sectorised”, i.e. organised in specific sectors. These sectors include in-patient care entities and out-patient services. The private sector in psychiatry is not sectorised and is mainly composed of self-employed psychiatrists and private clinics. A 2004 law designed to govern who is authorized to refer patients to specialists, stipulated that general practitioners were the only authorized referring doctors for primary care. In the meantime, the number of general practitioners being consulted for cases of depression has doubled between 2005 and 2010. Less than a quarter of these patients were referred to a psychiatrist. Our main objective is to assess the satisfaction with and the efficiency of exchanges between psychiatrists and general practitioners. We also endeavour to identify the main channels through which collaborative care involving these two specialists can be improved. Materials and methodsOur work is an observational, transverse, monocentric and descriptive study carried out using analogous feedback forms mailed by post from June to September 2016. The feedback forms were designed to be analysed both separately and comparatively. Two hundred and ninety nine self-employed general practitioners and 46 psychiatrists employed in the public sector returned the forms. The psychiatric private sector was excluded. All of these doctors worked within three specific geographical treatment zones: Saint-Étienne, Ondaine and Pays de Gier (350,000 inhabitants). The results were treated anonymously via Microsoft Excel® and IBM Corporation SPSS Statistics®. This study was approved by the ethics committee of the university hospital center (CHU) of Saint-Étienne. The doctors’ registers were retrieved via the databases of the Departmental Council of Doctors (CDOM) of the Loire and that of the CHU of Saint-Étienne. ResultsOne hundred and twenty four general practitioners and 30 psychiatrists responded to the feedback form completely. Response rates were 41.4 % for the family physicians and 65.2 % for the psychiatrists. Respectively, 57 % and 70 % knew the identity of their counterpart. A public sector psychiatrist saw 91.9 % of the patients also treated by general practitioners. Of the attending doctors, 79.8 % reported a one third or less return rate of follow-up information from the psychiatrist for the patients they treated together. Similarly, 76.7 % of the psychiatrists reported a return rate of one third or less. One hundred percent (p<0.05) of the general practitioners who did not know the psychiatrists were dissatisfied with their collaboration. Likewise, 98.9% (p<0.05) of the general practitioners who rarely or never received correspondence from the psychiatrists were dissatisfied. Respectively, 77.7% (p>0.05) and 69.5% (p>0.05) of the psychiatrists were dissatisfied. In favor of participating in a standard addressing and return letter process, were 53.4% of the psychiatrists. On the contrary, 64.9% of the general practitioners were against such a process. Willing to receive additional medical training in the psychiatric field were 74.5 % of the family physicians. One out of five psychiatrists considered it a high priority for general practitioners to receive additional training in the psychiatric field. Sharing hospitalisation and consultation reports, along with general practitioners continuous medical training, were considered to be the top priorities for any approach for improving communication. ConclusionsWe observed a high level of dissatisfaction among the participants as a result of the lack of communication. As mentioned above, the field of psychiatry is compartmentalised, psychiatrists are less available for general practitioners. General practitioners are not sufficiently trained but are willing to take more training to improve their practice in the psychiatric field. The results of this study show that first and foremost there is a need to systematise mailings, to simplify phone-based opinion sharing, and to increase the frequency of cross-field training among general practitioners. All of the above could improve exchanges and the management of patients suffering from psychiatric disorders.

Location dynamics of general practitioners in France

BackgroundFor several years now, the socio-political context in France has widened the territorial divide between metropolitan France and peripheral France. Access to healthcare is part of this divide, which harms small and medium-sized towns as well as rural fringes. This article focuses on these geographic dynamics in access to healthcare, with a focus on self-employed general practitioners (GPs), who are essential links in the care pathway as referring physicians. MethodsThis paper uses data from French public statistics from 2007 to 2017 to build spatial panels and to highlight the territorial factors that explain the dynamics of the locations of GPs. ResultsOver the period under review, the density of GPs has decreased and territorial disparity has increased. There is no trend towards a worsening of this isolation of either the periphery or deprived cantons with regard to the density of GPs in these areas. However, we note a clear trend towards the grouping together of different types of care within cantons, leading to a tendency towards the polarization of the healthcare supply in the territories of mainland France, which implies another type of geographical difficulty. ConclusionThe increase in territorial disparities in accessibility to GPs does not really seem to correspond to the classical divides in France, but rather raises the issue of intra-metropolis and intra-periphery disparities.

Boundary Work in Response to Professionals’ Contextual Constraints: Micro-strategies in Interprofessional Collaboration

Boundary-work research has extensively explored how professionals engage in boundary work to protect or expand their professional boundaries in interprofessional collaboration (IPC). Yet professionals’ contextual constraints in everyday work, such as time pressure or legal restrictions, often result in competing interests of the professionals involved in IPC, prompting them to engage in boundary work to limit—instead of protect or expand—their boundaries. Our empirical analysis uses comprehensive qualitative data on IPC in Germany between self-employed general practitioners (GPs) and registered nurses employed in nursing homes. In this IPC, GPs’ efficiency interests frequently compete with nurses’ safeguarding interests, leading both professionals to engage in boundary-work efforts to limit their boundaries. Our findings provide a comprehensive understanding and framework of professionals’ boundary work, showing that individual GPs and nurses typically hold a portfolio of various defending and accommodating micro-strategies. Based on our first-order findings, we identify how different sources of power enable particular micro-strategies and explore how the choice of micro-strategies depends on different forms of trust in the collaborating partner. Last, we outline interactions of micro-strategies, illustrating how the outcomes of professionals’ bilateral boundary work depend on the sequence of these strategies.

Determinants of Setting up a General Practice - a Qualitative Study

In recent years, the motivation of the new generation of general practitioners to set up their own practice is decreasing. Knowledge of factors that promote and inhibit the process of setting up a practice can enable developing strategies to support this process. The aim of this study was to explore these determinants. Between April and October 2016, self-employed general practitioners from Baden-Württemberg were invited to participate in a qualitative interview study. Stratification of 553 physicians, who participated in a general practice support program between 2008 and 2011 and set up a practice in 2008 to 2014, was based on the agglomeration in rural areas, the peripheral zones around the agglomeration and the urban agglomerations themselves. The transcripts of the interviews were analyzed by two authors with the content analysis according to Mayring and summarized. In a second step, a consensus version was elaborated. A total of 23 general practitioners were recruited, 57% female and 42 years on average, and mostly working in group practices. The main motivation to set up a practice was the desire to improve the situation in relation to the daily clinical routine. These included a lower duty load and more family-friendly working hours. Relevant supportive factors during setting up a practice were family support, participation in a postgraduate training rotation network program and professional counseling. Inhibiting factors were fears of recourse and indebtedness, a complicated accounting system and a bureaucratic process of admission. On the one hand, the study shows that the many advantages of working as a general practitioner, such as its being family friendly, need to be better communicated to the doctors and their financial concerns alleviated. On the other hand, the need for courses on management of one's practice has also become clear. A standardized and optimized process of setting up a practice with an improved overview and a collegial contact person can facilitate the decision for and implementing the setting up a medical practice as a general practitioner.

Community orientation of general practitioners in 34 countries

General practitioners (GPs) are frontline health workers. They should be sensitive to the health needs of the community in addition to caring for patients that visit their practice. Due to changes in demography, epidemiology, ecology and healthcare policy, a community orientation becomes more important. Our research question is: to what extent does community orientation of GPs vary between countries and GPs and how can this variation be explained? We use cross-sectional survey data from the QUALICOPC study, conducted among over 7000 GPs in 34 countries. Community orientation was measured through a scale constructed from three survey questions on whether GPs would take action when confronted with: repeated accidents in an industrial setting, frequent respiratory problems in patients living near a certain industry, and repeated cases of food poisoning in the local community. Independent variables are at healthcare system level and GP or practice level. Data were analysed using linear multilevel regression analysis. Community orientation varies between GPs and countries. Community orientation is more frequent in healthcare systems with a list system, among self-employed GPs, those using medical records to make overviews, and those more active in prevention and multidisciplinary cooperation. GPs in rural areas and areas with more people from ethnic minorities are more community oriented. Based on the variation between countries and GPs, we would like to raise awareness and underline the importance of multidisciplinary cooperation.

Telementoring with project ECHO: a pilot study in Europe

The Extension of Community Healthcare Outcomes (ECHO) project is a novel educational intervention designed in New Mexico to transfer subspecialty knowledge about hepatitis C virus (HCV) to primary care providers,...

Einschätzung der Weiterbildung im Fach Allgemeinmedizin in Bayern – eine Online-Befragung von Ärzten in Weiterbildung

Statistical projections suggest that by 2020 the number of general practitioners (GPs) in Germany will have decreased by about 13%, which will lead to a risk of medical undersupply, especially in rural areas. This study was conducted on behalf of the Bavarian Ministry of Environment and Health in order to answer the following questions: How satisfied are young Bavarian physicians in GP specialty training with their training situation? To what extent are they willing to start a private practice, in general and, in particular, in rural areas? The study's online questionnaire contained items concerning the context of GP specialty training and the willingness to set up a private practice. In addition, the "Heidelberger Niederlassungsbarometer", a structured questionnaire illustrating self-assessment of competencies of GPs in training, was included in the survey. We asked GP specialty trainees to participate by e-maiI, directly or via their GP trainers. In total, 99 questionnaires were returned, whereof 95 fulfilled the criteria for analysis. In 76% of the cases participants were female, 63% working in practice and 37% in a structured training programme. The majority of participants (58%) preferred to work in a practice with more than one GP, followed by those preferring to work as a salaried GP (26%). Their disposition to work in rural areas after having passed their specialty certificate examination was high or very high (59%). Feedback on a regular basis was given to 29% of the study participants. Almost every second participant received a structured initial training programme. Most of the participating GP trainees (59%) were satisfied or very satisfied with their training. In general, there is a high level of motivation among study participants to become an independent and self-employed GP, also in rural areas. Despite the fact that not even every second received central training elements like individual feedback and structured initial training, the participants were mostly satisfied with their GP specialty training.

Missionary Medicine of Canadian Presbytery and Korean Doctors under Japanese Occupation--focusing Sung-jin and Ham-heung

In East Asia during the second half of the 19th century, overseas mission work by Protestant churches thrived. Missionaries built schools and hospitals and effectively used them for evangelism. In the 20th century when Social Gospel Movement was expanding, medical work has been recognized as a significant mission service in and by itself. This article reviewed the construction and characteristics of missions work conducted by Canadian Presbytery; missionary doctors and Korean doctors who worked at the mission hospitals; why the missionary medical work had to stop; and career paths taken by Korean doctors upon liberation from Japanese occupation. The Canadian Presbytery missionaries, unlike other denomination missionaries, were rather critical of Imperial Japan, but supportive towards Koreans. This could have stemmed from the reflection of their own experience of once a colony of British Empire and also their value system that promotes egalitarian, democratic and progressive theology. The Sung-jin and Ham-heung Mission Bases were a community, interacting organically as a 'Triangle of Church, School and Hospital.' The missionaries mobilized the graduates from Christian schools and organized a Young Men's Christian Association (YMCA). Some of the graduates were trained to become medical doctors or assistants and worked at mission hospitals. Missionary doctors' approaches to balancing evangelism and medical practice varied. For example, Robert Grieson went through confusion and struggled to balance conflicting roles as a pastor for evangelism and also as a physician. Kate McMillan, on the other hand, had less burden for evangelism than Grieson, and focused on medical work by taking advantage of the opportunity that, as a woman, she can easily approach Korean women. Still another case was Florence Murray who practised evangelism within the hospital setting, and successfully carried out the role as a hospital administrator, going beyond 'women's work' as McMillan did. Korean doctors and assistants who worked at the mission hospitals had seen the spread of Protestantism in their youth; had received modern education; had experienced the fall of own country in 1910 and nationwide protest against Japan in 1919. The majority of them were graduates of Severance Medical College, the hub of missionary medicine at the time. After the resignation from the mission hospitals, 80 percent of them became self-employed general practitioners. The operations of the mission hospitals began to contract in 1930 due to tightened control by Imperial Japan. Shrine worship imposed on Christians caused internal conflict and division among missionaries and brought about changes in the form and contents of the mission organization. The incidence of the assault of Dr. Grieson brought about the dissolution of Sung-jin mission base and the interruption of the operation of Je-dong Hospital. As the Pacific War expanded, missionaries were driven out of Korea and returned home. In conclusion, the missions work by Canadian Presbytery missionaries had greatly impacted Protestantism in Korea. The characteristics of Canadian Presbytery were manifested in their support of Korean nationalism movement, openness for Social Gospel, and maintaining equal footing with Korean Christians. Specifically we note the influence of these characteristics in Chosun doctors who had worked in the mission hospitals. They operated their own hospitals or clinics in a manner similar to the mission hospitals by providing treatment for poor patients free of charge or for a nominal fee and treating the patients in a kind and humanistic way. After the 1945 Liberation, Korean doctors'career paths split into two directions. most of them defected to South Korea and chose the path to work as general practitioners. A few of them remained in North Korea and became educator of new doctors. It is meaningful that former doctors of Canadian missionary hosptal became dean of 2 medical colleges among 3 of all in early North Korea. This article does not cover the comparative analysis of the medical work by the missionaries of Canadian Presbytery and other denominations. It is desirable to include this analysis of the contents and the comparison in a future study of Korean doctors who participated in the mission hospitals, by denomination and by geographical region.

Factors associated with the use of rapid antigen diagnostic tests in children presenting with acute pharyngitis among French general practitioners

In this investigation, we wanted: (i) to describe the attitudes and declared practices of a representative sample of French general practitioners (GPs) regarding rapid antigen diagnostic tests (RADTs) for acute pharyngitis and (ii) to identify the GPs' characteristics associated with the use of an RADT in the last paediatric patient with pharyngitis. We performed a cross-sectional survey conducted in 2012 among a representative sample of 1,126 self-employed GPs in France. 60.1 % of GPs declared that they used an RADT in their last patient aged between 3 and 16 years presenting with acute pharyngitis; 29.6 % of these tests were positive. Among the GPs who did not use an RADT, 50.2 % prescribed an antibiotic, compared to 30.5 % of prescriptions among GPs who performed an RADT, whatever its result. In a multivariate analysis, GPs' age between 45 and 54 years and having attended Continuing Medical Education (CME) sessions on infectious diseases in the past year were significantly associated with an increased use of an RADT in the last patient with pharyngitis, whereas a low volume of activity, occasionally practising alternative medicine, receiving pharmaceutical representatives at the practice and declaring a consultation duration <15 min were factors associated with a decreased use of RADTs. The use of RADTs by GPs must be promoted; our findings could help define interventions to improve practice.

Indicators show differences in antibiotic use between general practitioners and paediatricians

The purpose of this investigation was to adapt to an individual physician level and to the paediatric context a set of drug-specific indicators of outpatient antibiotic use developed by the European Surveillance of Antimicrobial Consumption (ESAC) project, and to describe the differences in antibiotic prescriptions between general practitioners (GPs) and paediatricians. We conducted a retrospective cross-sectional study analysing antibiotic prescriptions in 2009 for children below 16 years of age in south-eastern France, using the National Health Insurance (NHI) outpatient reimbursement database. A generalised linear model adjusted on physicians' characteristics and patient population characteristics was used to compare indicators between GPs and paediatricians. We included 4,921 self-employed GPs and 301 paediatricians. Penicillins accounted for 47% and 45% of all antibiotics prescribed by GPs and paediatricians, respectively, followed by cephalosporins (33% and 39%) and macrolides (14% and 9%). In both specialties, there were around 70% more antibiotic prescriptions during the winter quarters compared to the summer quarters. The 13 indicators we calculated showed wide variations in antibiotic prescriptions among GPs, among paediatricians, and between GPs and paediatricians. In an adjusted econometric model, GPs were found to issue 54% more antibiotic prescriptions than paediatricians, whereas paediatricians used a significantly higher proportion of co-amoxiclav (18% vs. 12%) and cephalosporins (39% vs. 33%) and a significantly lower proportion of macrolides (9% vs. 14%) compared to GPs. A set of 13 indicators may be calculated using reimbursement data to describe outpatient antibiotic use at the physician level. We observed very different prescribing profiles between GPs and paediatricians.

Le cycle de vie des motivations professionnelles en médecine générale : une étude dans le champ de la prévention

Background The analysis of “professional motivations”, mainly through the possible crowding-out effects between extrinsic and intrinsic motivations, has become an issue of great concern in the economic literature. This paper aims at applying this topic to the healthcare professions where the proper scaling up of pay-for-performance (P4P) policies by public authorities is at stake. Methods We used a panel of 528 self-employed general practitioners in the “Provence-Alpes-Côte d’Azur” region in France to provide an interpersonal statistical decomposition between extrinsic and intrinsic motivations with regard to preventive actions. Then, we applied a Tobit model in order to specify the main explicative variables of the share of intrinsic motivations entering into physicians’ total motivations. Results The relative share of intrinsic motivations was quite high among physicians paid with fixed fees. We found a significant effect of age on intrinsic motivations describing a U-shaped curve which can be interpreted as being the result of a “life cycle of medical motivations” or a generational effect. Conclusion The cross-sectional nature of the data does not allow us to draw any conclusions concerning the predominance of the generational effect or the “life cycle effect” on the evolution of the relative share of physician's intrinsic motivations. Nevertheless, the U-shaped relation between intrinsic motivations and age questions the suitability of using uniformly P4P mechanisms. The generations or age groups of self-employed physicians who seem to be less responsive to extrinsic motivations are more likely to favour the introduction of other types of payment schemes (capitation or salary systems) or regulation tools such as clinical practice guidelines.