Quality of care in family practice: does residency training make a difference?

As the proportion of physicians who enter residency training in family practice steadily increases, so does the need to evaluate the impact of their training and postgraduate education on the quality of care in their practices. We audited the practices of 120 randomly selected family physicians in Ontario, who were separated into four groups: nonmembers of the College of Family Physicians of Canada (CFPC), members of the CFPC with no certification in family medicine, certificated members without residency training in family medicine and certificated members with residency training in family medicine. The practices were assessed according to predetermined criteria for charting, procedures in periodic health examination, quality of medical care and use of indicator drugs. Generally the scores were significantly higher for CFPC members with residency training in family medicine than for those in the other groups, nonmembers having the lowest scores. Patient questionnaires indicated no difference in satisfaction with specific aspects of care between the four groups. Self-selection into residency training and CFPC membership may account for some of the results; nevertheless, the findings support the contention that residency training in family medicine should be mandatory for family physicians.     

Rural background and clinical rural rotations during medical training: effect on practice location

BACKGROUND: Providing health care services in rural communities in Canada remains a challenge. What affects a family medicine resident's decision concerning practice location? Does the resident's background or exposure to rural practice during clinical rotations affect that decision? METHODS: Cross-sectional mail survey of 159 physicians who graduated from the Family Medicine Program at Queen's University, Kingston, Ont., between 1977 and 1991. The outcome variables of interest were the size of community in which the graduate chose to practise on completion of training (rural [population less than 10,000] v. nonrural [population 10,000 or more]) and the size of community of practice when the survey was conducted (1993). The predictor or independent variables were age, sex, number of years in practice, exposure to rural practice during undergraduate and residency training, and size of hometown. RESULTS: Physicians who were raised in rural communities were 2.3 times more likely than those from nonrural communities to choose to practise in a rural community immediately after graduation (95% confidence interval 1.43-3.69, p = 0.001). They were also 2.5 times more likely to still be in rural practice at the time of the survey (95% confidence interval 1.53-4.01, p = 0.001). There was no association between exposure to rural practice during undergraduate or residency training and choosing to practise in a rural community. INTERPRETATION: Physicians who have roots in rural Canada are more likely to practise in rural Canada than those without such a background.     

A survey of postgraduate training for family practice

The results of a survey of Canadian primary care physicians for the Canadian Medical Association (CMA's) Task Force on Education for the Provision of Primary Care Services are reported. Recent Canadian medical school graduates in primary care practice reported that the three major training routes (rotating and mixed internships and family medicine residencies) each prepared them differently for practice. The graduates of 2-year family medicine residencies were more satisfied with their preparation than were the graduates of the other major training routes. A 2- or 3-year family medicine residency was preferred by 50% of the respondents, although only 33% of them had actually taken one of these routes. There was considerable agreement in the respondents' assessments of the types of postgraduate education needed for primary care practice. The results of this survey were consistent with the recommendations in the final report of the CMA's task force.     

Practice patterns of family physicians with 2-year residency v. 1-year internship training: do both roads lead to Rome?

Are there differences in patterns of practice between actively practising physicians who have been certified after a 2-year family practice residency and matched physicians without certification who have completed the standard 1-year internship? With the use of billing files prepared by the British Columbia Medical Association a group of 65 family practice certificants in active practice in British Columbia was compared with a control group of 130 internship trainees matched by year and school of graduation, category of billing (i.e., solo or group) and region. A wide range of practice features was assessed for the fiscal years 1984-85, 1985-86 and 1986-87. No differences were detected between the groups in 1986-87 for the following practice variables: number of patients (1888 and 1842 respectively), number of personal services billed for (7265 and 7173), number of personal services per patient (3.9), amount of funding for personal services ($140,192 and $140,100) and amount per patient for personal services ($77 and $79). Age-adjusted costs for male and female patients were similar in the two groups. Of six services thought to be influenced by type of training, only maternity care generated a significantly higher number of billings in the study group (341 v. 249). These results suggest that there is no demonstrable effect of training on patterns of practice. However, the question of the effect of training on quality of care and whether the 2-year residency may have a longer effect on practice patterns should be the focus of future research.     

Prenatal care in northwestern Wisconsin

The purposes of this study were to identify the components of prenatal care given by family practice physicians and obstetricians in a rural area and determine whether they were in agreement with standards of care advanced by the American College of Obstetricians and Gynecologists (ACOG). We surveyed 76 physicians (family physicians with and without residency training and obstetricians) and identified 40 components of regular prenatal care; they were consistent with 94% of the ACOG recommendations. Few differences were found in prenatal care practices by type of family practice training. Although the number of obstetricians was small, these specialists appeared more likely to agree with ACOG guidelines. Risk assessment instruments were not routinely used by most physicians, and the services of public health nurses were not generally recommended as part of prenatal care. The findings have implications for continuing medical education programs.     

Which physicians make home visits and why? A survey

BACKGROUND: Recent changes in the North American health care system and certain demographic factors have led to increases in home care services. Little information is available to identify the strategies that could facilitate this transformation in medical practice and ensure that such changes respond adequately to patients' needs. As a first step, the authors attempted to identify the major factors influencing physicians' home care practices in the Quebec City area. METHODS: A self-administered questionnaire was sent by mail to all 696 general practitioners working in the Quebec City area. The questionnaire was intended to gather information on physicians' personal and professional characteristics, as well as their home care practice (practice volume, characteristics of both clients and home visits, and methods of patient assessment and follow-up). RESULTS: A total of 487 physicians (70.0%) responded to the questionnaire, 283 (58.1%) of whom reported making home visits. Of these, 119 (42.0%) made fewer than 5 home visits per week, and 88 (31.1%) dedicated 3 hours or less each week to this activity. Physicians in private practice made more home visits than their counterparts in family medicine units and CLSCs (centres locaux des services communautaires [community centres for social and health services]) (mean 11.5 v. 5.8 visits per week), although the 2 groups reported spending about the same amount of time on this type of work (mean 5.6 v. 5.0 hours per week). The proportion of visits to patients in residential facilities or other private residences was greater for private practitioners than for physicians from family medicine units and CLSCs (29.7% v. 18.9% of visits), as were the proportions of visits made at the patient's request (28.0% v. 14.2% of visits) and resulting from an acute condition (21.4% v. 16.0% of visits). The proportion of physicians making home visits at the request of a CLSC was greater for those in family medicine units and CLSCs than for those in private practice (44.0% v. 11.3% of physicians), as was the proportion of physicians making home visits at the request of a colleague (18.0% v. 4.5%) or at the request of hospitals (30.0% v. 6.8%). Physicians in family medicine units and CLSCs did more follow-ups at a frequency of less than once per month than private practitioners (50.9% v. 37.1% of patients), and they treated a greater proportion of patients with cognitive disorders (17.2% v. 12.6% of patients) and palliative care needs (13.7% v. 8.6% of patients). Private practitioners made less use of CLSC resources to assess home patients or follow them. Male private practitioners made more home visits than their female counterparts (mean 12.8 v. 8.3 per week), although they spent an almost equal amount of time on this activity (mean 5.7 v. 5.2 hours per week). INTERPRETATION: These results suggest that practice patterns for home care vary according to the physician's practice setting and sex. Because of foreseeable increases in the numbers of patients needing home care, further research is required to evaluate how physicians' practices can be adapted to patients' needs in this area.     

Private physicians in ambulatory care training in U.S. medical schools

The contribution of private physicians to medical student education in ambulatory care was determined by a questionnaire directed to departments of family practice, internal medicine, and pediatrics in 124 U.S. medical schools and their branch campuses. The response rate was 84 percent. Of the responding departments, 82 percent offered an ambulatory care course in curricular years three and/or four, and 56 percent utilized private physicians in their courses. Departments of internal medicine were least likely to offer such a course, and their courses less frequently included teaching by private physicians (p less than 0.0001). When offered, internal medicine courses in ambulatory care were least likely to be required for graduation and involved the fewer students. Departments of family practice were most likely to offer ambulatory care courses and were most likely to utilize private physicians in their courses.     

Sanctions against sexual abuse of patients by doctors: sex differences in attitudes among young family physicians.

OBJECTIVE: To explore attitudes of new-to-practice certified family physicians in Ontario concerning sanctions against sexual abuse of patients by physicians and to assess the importance of concern about accusations of sexual abuse in influencing clinical decisions. DESIGN: Qualitative study and cross-sectional survey. SETTING: Ontario. PARTICIPANTS: Focus groups: 34 physicians who completed family medicine residency training between 1984 and 1989 participated in seven focus groups between June and October 1992. Survey: all certificants of the College of Family Physicians of Canada who received certification between 1989 and 1991 and were currently practising in Ontario. Of the 564 eligible physicians 395 (184 men and 211 women) responded, for an overall response rate of 70.0%. The response rates among the male and female physicians were 70.5% and 69.6% respectively. OUTCOME MEASURES: Physicians' attitudes toward restricting physical examinations done by physicians to same-sex patients, mandatory reporting of sexual impropriety and loss of licence in cases of sexual violation and the perceived importance of concern about accusations of sexual abuse as an influence on clinical decisions. RESULTS: During the focus groups male physicians in particular expressed concerns about the effect on their practice patterns of the current climate regarding sexual abuse of patients. Female physicians were less concerned about possible accusations of sexual abuse but expressed concerns regarding possible sexualization of the clinical encounter by male patients. In the survey equal proportions of men (163 [93.7%]) and women (191 [92.3%]) disagreed with restricting examinations to same-sex patients. The women were more likely than the men to agree that all suspected cases of sexual impropriety committed by other physicians should be reported (121 [58.7%] v. 86 [50.0%]), whereas the men were more likely to disagree (48 [27.9%] v. 32 [15.5%]) (p = 0.008). The women were also more likely than the men to agree that physicians should lose their licence permanently if they were found guilty of sexual violation (125 [62.2%] v. 73 [43.5%]), whereas the men were more likely to disagree (61 [36.3%] v. 37 [18.4%]) (p < 0.001). Almost half of the men (80 [46.5%]) but only 28 women (14.1%) reported that concerns about accusations of sexual abuse were of importance in their clinical decisions (p < 0.001). CONCLUSIONS: Young female family physicians practising in Ontario are much more likely than their male counterparts to endorse permanent loss of licence for physicians who sexually abuse patients and are significantly less concerned about accusations against themselves. Neither sex endorses only same-sex examinations by physicians. Educational approaches to protect patients while ensuring that appropriate care continues to be delivered are essential.     

Career choice of 'fifth pathway' graduates from New York state medical schools

Graduates of "fifth pathway" programs at medical schools in New York state between 1976 and 1978 were studied to determine their professional careers and choice of medical specialties. Of the 545 physicians participating in the program, 510 were able to be located. Of this latter cohort, 177 (34.7 percent) had entered primary care fields as of 1981. Of the physicians no longer in residency training, 19.1 percent had full-time salaried positions in academic institutions, and the remaining physicians were engaged in various clinical medical activities. Of the 545 fifth pathway graduates, 74 (13.6 percent) had not been able to pass the licensing examinations as of 1981, and an additional 54 (9.9 percent) had not taken those examinations. Comparisons with regular students graduating from a medical school in New York state showed that fifth pathway graduates were more likely to select nonprimary care specialties than primary care specialties (p less than 0.001). These data suggest that although a majority of graduates of fifth pathway programs in New York state are involved in the provision of health care, a small number are still unable to engage in the practice of medicine.     

德国全科医生培养体系对我国社区全科医生临床教育的启示

德国家庭医生以诊所经营为主,实行自我管理,提供基本医疗服务;德国医生自由执业的基础是德国的同质化医学教育;医学教育改革强调理论和实践教学贯穿医学教育全过程;毕业后教育按照全科医学专科特点设置轮转方案和考核标准,强调在诊所的临床实践时间并注重心身医学的教育;通过医疗保险的给付制度督促医生的继续教育。本文借鉴德国全科医生培养模式,提出加强本科院校教育期间的全科医学教育启蒙,并在加强全科医生的临床实践环节、全科医学培训基地建设以及社区带教师资能力提升等方面提出建议,以期对我国的全科医生培养提供参考。     

Variability in physicians' decisions on caring for chronically ill elderly patients: an international study.

OBJECTIVES: To determine what treatment decisions physicians will make when faced with an incompetent elderly patient with life-threatening gastrointestinal bleeding and to identify the factors that affect their decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. OUTCOME MEASURE: A self-administered questionnaire containing three case vignettes. Each provided the same details on an incompetent elderly patient; however, one gave no information about the wishes of the patient and his family (no directive), the second provided a do-not-resuscitate (DNR) request, and the third included a detailed therapeutic and resuscitative effort chart (DTREC) requesting maximum therapeutic care without admission to the intensive care unit (ICU). The four treatment options were supportive care only, limited therapeutic care, maximum therapeutic care without admission to the ICU and maximum care with admission to the ICU. MAIN RESULTS: Treatment decisions varied and were systematically related to age, level of training and country (p less than 0.001). The older physicians and those in family medicine were less likely than the others to choose aggressive treatment options. Brazilian and US physicians were the most aggressive; Australian physicians were the most conservative. The DNR request resulted in a significant decrease in the number of physicians choosing aggressive options (p less than 0.001). The DTREC resulted in a move toward more aggressive treatment, as outlined in the directive (p less than 0.001). Overall, however, about 40% of the physicians chose a level of care different from what had been requested. Furthermore, over 10% would have tried cardiopulmonary resuscitation despite the DNR request. CONCLUSION: Treatment of incompetent elderly patients with life-threatening illness varies widely within and between countries. Uniform standards should be developed on the basis of societal values and be communicated to physicians.     

Specific clinical competencies for managing care: views of residency directors and managed care medical directors

CONTEXT: Although medical educators recognize the need to prepare physicians to work effectively in managed care environments, managed care is often perceived negatively by academic physicians. Curricular reform has been hampered by a failure to seek agreement about specific clinical competencies that are important to both managed care directors and medical educators. OBJECTIVES: To identify specific clinical competencies in the managed care setting and to assess agreement between residency directors and managed care medical directors on the importance of these competencies. DESIGN, SETTING, AND PARTICIPANTS: Surveys (1998-1999) of a national sample of 59 residency directors involved in managed care training programs (response rate, 94%); a sample of 186 residents in these programs and 258 matched control residents (response rate, 77%); and national samples of 147 managed care organization (MCO) medical directors (response rate, 67%) and 140 primary care residency program directors in areas of high MCO penetration (response rate, 73%). MAIN OUTCOME MEASURES: Specific clinical managed care tasks as defined by residency directors; self-reported confidence in performing these tasks by sample residents vs control residents; and importance of these tasks as rated by MCO medical directors and residency program directors. RESULTS: Twenty-six specific clinical managed care tasks were identified by the residency directors. Residents who participated in managed care training were significantly more confident than their counterparts in performing 20 of the 26 tasks (P<.01 for all). Residency directors and MCO medical directors viewed 65% of these tasks as important to patient care during the next 5 years. Of the 10 tasks most highly rated by residency directors and MCO medical directors, 9 were the same, addressing time management, ethics, case management, practice guidelines, cost-effective clinical decision making, referral management, disease management, patient satisfaction, and clinical epidemiology. CONCLUSIONS: Our data indicate that residency directors and managed care medical directors value mastery of many of the same specific clinical competencies in managed care. Previously documented negative attitudes toward managed care among academic physicians may obscure an underlying concordance about the skills essential to managing the health of populations. JAMA. 2000;284:1093-1098     

The teaching of liberal arts in internal medicine residency training

Forty-four members of the Association of Program Directors in Internal Medicine and 58 members of the Society for Research and Education in Primary Care Internal Medicine completed questionnaires on the teaching of liberal arts in internal medicine residency programs and the importance of liberal arts to the practice of medicine. They rated economics of medical care and bioethics as essential to residency training. Law and organization of the health care system as well as economics and bioethics were rated as essential to medical practice. Although there was great variability in the curricula represented, over 40 percent of the respondents reported having formal lecture and/or seminar exposure to these topics in their programs. Problems encountered in implementing liberal arts programs included lack of curriculum time, limited-faculty members, and a lack of interest on the part of residents. There is a need both to arrive at a consensus among residency directors and to explore means of developing interdisciplinary faculties if the liberal arts are to form an established part of internal medicine residency training.     

近观美国全科医生规范化培训有感

目的 实地了解美国全科医生规范化培训项目,为我国的全科医生培养提供参考。 方法 赴美国内布拉斯加大学医学中心(University of nebraska medical center,UNMC)参加全科医学师资培训,实地接触了解美国全科医生的规范化培训项目。 结果 美国全科医生的规范化培训项目发展比较成熟,培训效果较好,以下几点令人印象深刻:①培训项目设计严谨实用,确保经过培训的全科医生能够为居民提供安全、高质量、综合性、连续性的医疗照护。美国全科医生规范化培训项目专业设置全面,重视在社区诊所的培训和解决社区常见健康问题的能力,强调对临床实用技能的掌握,充分体现全科医学综合性、连续性的特点,不断强化全科医生的全科意识。②美国的全科医生以诊所服务、医院服务和护理院服务为主导,服务内容涵盖预防、保健、治疗、康复、健康教育等多个方面,并对慢性病患者和康复期患者进行持续追踪管理,真正实现为个人和家庭提供全面、连续的健康和医疗照顾。③注重医患沟通、提高人文修养是全科医生的必备技能,沟通技巧和人文关怀贯穿美国全科医生培训全过程和临床实践。以上几点可为我国的全科医生培养提供参考借鉴。 结论 标准化、规范化的住院医师培训项目是美国全科医生培养的基石,是美国高质量初级医疗卫生保健服务的关键。      

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.     

Women in pediatrics: the experience in Quebec.

OBJECTIVES: To compare the practice patterns of female pediatricians in Quebec with those of their male counterparts and to identify specific factors influencing these practice patterns. DESIGN: Matched cohort questionnaire survey. SETTING: Primary, secondary and tertiary care pediatric practices in Quebec. PARTICIPANTS: All 146 female pediatricians and 133 of the 298 male pediatricians, matched for age as well as type and site of practice; 119 (82%) of the female and 115 (86%) of the male pediatricians responded. MAIN OUTCOME MEASURES: Demographic and family data as well as detailed information about the practice profile. RESULTS: The two groups were comparable regarding demographic data, professional work and patient care. Compared with the male respondents, the female pediatricians were younger and saw more outpatients. The mean number of hours worked per week, excluding on-call duty, was 40.5 (standard deviation [SD] 12.4) for the women and 48.9 (SD 12.0) for the men (p < 0.001). The female pediatricians were more likely than their male counterparts to have spouses who were also physicians (40%) or in another profession (45%). The female pediatricians without children worked significantly fewer hours than the male pediatricians with or without children (p < 0.001). Children (p = 0.006), but not the number of children (p = 0.452), had a significant effect on the number of hours worked by the female pediatricians. CONCLUSION: The duality of the role of female physicians as mothers and professional caregivers must be considered during workload evaluations. If the same style of practice and the increase in the proportion of female pediatricians continue, about 20% more pediatricians will be needed in 10 years to accomplish the same workload.     

Management of the early and late presentations of rheumatoid arthritis: a survey of Ontario primary care physicians.

OBJECTIVE: To examine primary care physicians' management of rheumatoid arthritis, ascertain the determinants of management and compare management with that recommended by a current practice panel. DESIGN: Mail survey (self-administered questionnaire). SETTING: Ontario. PARTICIPANTS: A stratified computer-generated random sample of 798 members of the College of Family Physicians of Canada. OUTCOME MEASURES: Proportions of respondents who chose various items in the management of two hypothetical patients, one with early rheumatoid arthritis and one with late rheumatoid arthritis. Scores for investigations, interventions and referrals for each scenario were generated by summing the recommended items chosen by respondents and then dividing by the total number of items recommended in that category. The scores were examined for their association with physician and practice characteristics and physician attitudes. RESULTS: The response rate was 68.3% (529/775 eligible physicians). Recommended investigations were chosen by more than two thirds of the respondents for both scenarios. Referrals to physiotherapy, occupational therapy and rheumatology, all recommended by the panel, were chosen by 206 (38.9%), 72 (13.6%) and 309 (58.4%) physicians respectively for early rheumatoid arthritis. These proportions were significantly higher for late rheumatoid arthritis (p < 0.01). In multiple regression analysis, for early rheumatoid arthritis, internship or residency training in rheumatology was associated with higher investigation and intervention scores, for late rheumatoid arthritis, older physicians had higher intervention scores and female physicians had higher referral scores. CONCLUSIONS: Primary care physicians' investigation of rheumatoid arthritis was in accord with panel recommendations. However, rates of referral to rheumatologists and other health care professionals were very low, especially for the early presentation of rheumatoid arthritis. More exposure to rheumatology and to the role of physiotherapy, occupational therapy and social work during primary care training is strongly recommended.     

国外农村基层医师医学培养项目实施现状、成效及评价的系统综述

背景　2010年我国农村订单定向医学生免费培养工作启动，旨在为农村地区培养具备本科学历的全科医生，缓解农村地区基层医师匮乏的现状。本研究通过系统综述了解国外类似项目的实施现状、成效及评价，为我国农村订单定向医学生培养工作评价和改善提供理论参考。目的　了解国外农村基层医师医学培养项目实施现状、成效及评价指标方法等。方法　2019年2-7月，采用系统综述的方法，以“医学教育”“医学教育+医学本科生”“医学院校教育”“医学生”“住院医师规范化培训”“医学专业+人力资源”“农村地区”“农村基层医疗服务”“医师执业地点”“农村基层医师”“农村基层医师培养”“农村医学实习”“农村临床见习”为检索词，检索Ovid MEDLINE、PubMed、Cochrane及Google Scholar主要英文数据库，获取2000-01-01至2019-01-01发表的关于全球农村基层医师院校教育及住院医师培训等项目的实施现状、成效及评价的英文文献。结果　最终纳入53篇文献，分别来自美国、加拿大、澳大利亚、日本、泰国及南非6个国家，包括20个院校教育项目和6个住院医师培训项目。文献显示各国农村基层医师培养项目均具有指向性招生策略、面向农村卫生和全科医学的临床课程体系、以农村执业的家庭医生为临床导师及农村地区临床实践基地等要素；培养项目学生选择家庭医学为执业专业、农村地区执业率和长期农村保留率均明显高于非培养项目学生，两者国家医疗执照考试成绩和通过率无明显差异。长期农村地区临床实践培训、招生策略倾斜农村成长背景学生及农村执业的家庭医生导师是影响项目最终效果的关键因素。结论　医学教育是解决农村基层医师匮乏的有效途径。国外农村基层医师培养项目的招生策略、临床课程体系设置、导师指导及评价可为我国农村订单定向医学生培养工作提供有益参考。     

Factors associated with the decision of family physicians to provide intrapartum care.

OBJECTIVE: To investigate which characteristics and beliefs of family physicians determine their decision to provide intrapartum care. DESIGN: Confidential survey questionnaire mailed in spring 1993. SETTING: Alberta and Ontario. SUBJECTS: Random selection of 207 physicians who had graduated from medical school between 1953 and 1990 and were thought to be in family or general practice. Of 178 eligible physicians, usable replies were received from 104 (58.4%). OUTCOME MEASURES: Beliefs (measured on a 7-point Likert scale) about the relevance of 16 primary factors to the type of obstetric care provided; demographic, training and practice characteristics. RESULTS: The respondents who provided intrapartum care differed from those who did not in their beliefs about the availability of a local hospital suitable for intrapartum care (p < 0.001), their practice partners' views on the role of family physicians in providing obstetric care (p < 0.002), their own concept of the role of family physicians in providing obstetric care (p < 0.001) and women's views on the type of obstetric care they want (p < 0.002). They also differed, although less significantly, in their beliefs about the adequacy of their obstetric training before entering family practice (p < 0.04), the expected effects of providing obstetric care on their free time (p < 0.006), their fear of malpractice litigation (p < 0.028) and their perceived competence in performing practical obstetric procedures (p < 0.05). Logistic regression analysis revealed that certain secondary factors were particularly relevant to the respondents' provision of intrapartum care at present. These included the physician's perceived competence at managing postpartum maternal hemorrhage (odds ratio [OR] 48.90, 90% confidence interval [CI] 4.70 to 509), the belief that medical insurance premiums should not be affected by the type of obstetric care provided (OR 3.55, 90% CI 1.67 to 7.57]) and the number of practice partners who provided intrapartum care (OR 10.08, 90% CI 2.31 to 44.10). CONCLUSION: Several factors appear to influence family physicians in their decision to provide intrapartum care. This information will help to focus efforts to provide appropriate obstetric training for family practice residents and to retain involvement of family physicians in intrapartum care.     

Provision of preventive care to unannounced standardized patients

OBJECTIVE: To examine the relation between physician, training and practice characteristics and the provision of preventive care as described in the guidelines of the Canadian Task Force on the Periodic Health Examination. DESIGN: Cross-sectional study. SETTING: Family practices open to new patients within 1 hour's drive of Hamilton, Ont. PARTICIPANTS: A total of 125 family physicians were randomly selected from respondents to an earlier preventive care survey. Of the 125, 44 (35.2%) declined to participate, and an additional 19 (15.2%) initially consented but later withdrew when they closed their practices to new patients. Sixty-two physicians thus participated in the study. INTERVENTION: Unannounced standardized patients posing as new patients to the practice visited study physicians' practices between September 1994 and August 1995, portraying 4 scenarios: 48-year-old man, 70-year-old man, 28-year-old woman and 52-year-old woman. OUTCOME MEASURES: Proportion of preventive care manoeuvres carrying grade A, B, C, D and E recommendations from the Canadian Task Force on the Periodic Health Examination that were performed, offered or advised. A standard score was computed based on the performance of grade A and B manoeuvres (good or fair evidence for inclusion in the periodic health examination) and the non-performance of grade D and E manoeuvres (fair or good evidence for exclusion from the periodic health examination). RESULTS: Study physicians performed or offered 65.6% of applicable grade A manoeuvres, 31.0% of grade B manoeuvres, 22.4% of grade C manoeuvres, 21.8% of grade D manoeuvres and 4.9% of grade E manoeuvres. The provision of evidence-based preventive care was associated with solo (v. group) practice and capitation or salary (v. fee-for-service) payment method. Preventive care performance was unrelated to physician's sex, certification in family medicine or problem-based (v. traditional) medical school curriculum. CONCLUSIONS: Preventive care guidelines of the Canadian Task Force on the Periodic Health Examination have been incompletely integrated into clinical practice. Research is needed to identify and reduce barriers to the provision of preventive care and to develop and apply effective processes for the creation, dissemination and implementation of clinical practice guidelines.