The evolution of the general practice workforce in Australia, 1991-2003

OBJECTIVE: To examine changes between 1991 and 2003 in the characteristics of active recognised general practitioners in Australia. DESIGN: We compared self-reported GP characteristics from the 1990-91 Australian Morbidity and Treatment Survey (AMTS) with those from the 1999 and 2003 Bettering the Evaluation and Care of Health (BEACH) surveys, after standardisation for age and sex to the respective sample frames. AMTS and BEACH are cross-sectional, paper-based, national surveys. PARTICIPANTS: Three random samples of 473 (1990-91), 980 (1998-99) and 1008 (2002-03) GPs who had claimed at least 1500 A1 (ie, general practice) Medicare items in the preceding year (in the AMTS) or 375 general practice Medicare items in the preceding 3 months (in the BEACH surveys). MAIN OUTCOME MEASURES: Changes in distribution of GP sex, GP age, number of sessions per week, practice size and location, country of graduation, and postgraduate training. RESULTS: Between 1991 and 2003, the proportion of female GPs rose from 19.3% to 35.2%; GPs aged < 35 years dropped from 22.3% to 10.0%, and those aged >or= 55 years increased from 21.4% to 31.6%. Between 1999 and 2003, the proportion of male GPs working < 6 sessions/week increased from 6.1% to 11.4%, while the proportion working >or= 11 sessions/week fell from 23.8% to 17.1%. Between 1991 and 2003, the proportion of solo practitioners nearly halved (25.5% v 13.7%); the proportion of GPs in practices of >or= 4 partners increased from 34.3% to 59.8%; the proportion of Australian graduates fell from 81.4% to 72.2%; and the proportion of graduates from Asia and Africa increased. Over the same period, the proportion of GPs with Fellowship of the Royal Australian College of General Practitioners more than doubled (17.8% v 36.4%). All of these differences were statistically significant (P < 0.001). CONCLUSION: Changes in characteristics of the practising GP population will affect consultative services and the balance between supply and demand for these services. These changes should be considered in future workforce planning.     

General practitioner consultations at residential aged-care facilities

OBJECTIVES: To describe the patients seen and the clinical activity undertaken by general practitioners during encounters at residential aged-care facilities (RACFs), and to ascertain how these differ from all GP encounters in Australia as a whole. DESIGN AND PARTICIPANTS: A secondary analysis of encounter data from the Bettering the Evaluation and Care of Health (BEACH) study, April 2004 to March 2006, comparing RACF consultations (identified by Medicare item numbers) with all BEACH study encounters in Australia. Participants were a random sample of GPs who had claimed at least 375 general practice Medicare items in the 3 months prior to the study. MAIN OUTCOME MEASURES: Differences in the characteristics of GPs and patients at RACF consultations, morbidities managed, and treatments provided to patients. RESULTS: Over the study period there were 2310 RACF encounters out of a total of 197 000 BEACH encounters; 360/1970 GPs (18.4%) recorded at least one RACF consultation. GPs aged > or = 45 years were more likely to record at least one RACF consultation than those aged < 45 years. Patients were predominantly women (70.7%), and 83.4% were aged > or = 75 years. At RACF consultations, problems managed significantly more often included chronic problems, as well as psychological, neurological, urological, circulatory, eye and musculoskeletal problems. Dementia was the most common problem managed, at 33 times the usual management rate in everyday practice. Significantly fewer medications, non-pharmacological treatments, referrals, pathology and imaging tests were recorded at RACF consultations. CONCLUSION: GP encounters at RACFs involve the management of chronic and complex conditions, including some not frequently seen in everyday general practice. The provision of additional education and resources where required may assist with workforce shortages in this setting.     

Gold Coast general practitioners' recommendations of health websites to their patients

OBJECTIVE: To identify trends associated with health website recommendations by selected general practitioners to their patients. DESIGN AND SETTING: Quantitative data collection using a prepaid postal survey, consisting of 17 questions, mailed to 250 of 410 GPs (61%) on the Gold Coast, Queensland. The survey was conducted between 9 October and 11 December 2006. MAIN OUTCOME MEASURES: GPs' website recommendations to patients; associated GP demographic variables (age, sex and years of practice). RESULTS: 59% (64/108) of participating GPs recommend health websites to their patients during consultations. Male GPs (63%, 45/72), those aged 41-50 years (55%, 35/64), and those practising for < 10 years (60%, 12/20) are more inclined to recommend a health website to a patient. The majority of GPs (69%, 44/64) reported that they most often recommended websites to patients 26-45 years old. 53% of GPs (34/64) recommended websites to 1%-20% of their male patients, while 47% (30/64) recommended websites to 21%-40% of their female patients. A greater proportion of participating female GPs (47%, 17/36) do not recommend health websites, compared with male GPs (38%, 27/72). CONCLUSIONS: More than half the surveyed GPs actively recommend websites to their patients, with a GP's sex, age and years of experience influencing his or her recommendation decisions. Web-based continuing medical education courses or programs in medical schools may help doctors develop the skills necessary for the delivery of effective e-health care.     

Medical services provided by general practitioners in residential aged-care facilities in Australia

We conducted a literature review to assess the current status of general practitioner services in residential aged-care facilities (RACFs) in Australia and the impact of recent initiatives to enhance access by RACF residents to these services. Of 400 publications identified, 22 were selected as relevant to our study. We also analysed publicly available statistical data on GP services in RACFs. Recent initiatives to improve quality of care and facilitate access to GP services for RACF residents include the Aged Care GP Panels Initiative, the Enhanced Primary Care program, and an expanded role of palliative care. Despite these initiatives, many GPs still find RACF services unappealing due to a perceived poor level of remuneration for the effort involved. Further improvements in access to and quality of GP services to RACFs may require new models of care delivery and financing.     

Trends in the use of hospital beds by older people in Australia: 1993-2002

OBJECTIVE: To determine trends in use of Australian acute hospital inpatient services by older patients. DESIGN AND DATA SOURCES: Secondary analysis of hospital data from the Australian Institute of Health and Welfare in the period 1993-94 to 2001-02, with population data for this period from the Australian Bureau of Statistics. OUTCOME MEASURES: Population-based rates of hospital separations and bed utilisation. RESULTS: The Australian aged population (65 years and older) increased by 18% compared with total population growth of 10%, yet the proportion of hospital beds occupied by older patients remained stable at 47%. The most substantial changes were observed in the population aged 75 years and older, with separations increasing by 89%, length of stay reducing by 35% and bed utilisation increasing by 23%. However, rates of bed utilisation (in relation to population) declined among older groups (10% decline in per capita use in population 75 years and older), but increased in the younger population (1% increase in per capita use in people younger than 65 years). CONCLUSION: Important trends in use of inpatient services were identified in this study. These trends are contrary to common perception. Ageing of the Australian population was not associated with an increase in the proportion of hospital beds used by older patients.     

基层全科医生的工作胜任度及满意度研究

背景　全科医生是居民健康和控制医疗费用支出的“守门人”,在基本医疗卫生服务中发挥着重要作用,其服务能力、激励机制及队伍稳定性对于推进家庭医生签约服务、建立分级诊疗制度具有重要意义。目的　了解基层全科医生的工作胜任度及满意度。方法　于2016年7月,采用分层整群抽样法在上海市浦东新区抽取城区、城郊、郊区15家社区卫生服务中心的全科医生（包括中医全科医生）440例进行问卷调查,主要内容为家庭医生签约服务开展情况、工作胜任度及满意度。结果　440份问卷均有效回收,问卷有效回收率为100.0%。95.2%（419/440）全科医生表示完全/基本能够顺利进行社区首诊,81.0%（350/432）全科医生表示知识和能力完全/基本能够胜任工作,70.2%（302/430）全科医生表示工作压力很大/比较大。不同区域全科医生对工作压力、医疗联合体是否有利于家庭医生制度推行的评价比较,差异有统计学意义（P<0.05）;不同类型社区卫生服务中心全科医生对能否处理基本医疗中的技术难题、能否处理慢性病管理中的技术难题、工作压力、工作能力能否得到发挥的评价比较,差异有统计学意义（P<0.05）。全科医生对工作价值、工作收入的平均满意度评分<3.0分;对工作环境的平均满意度评分>3.0分;对工作支持系统中社区（居委）配合、团队支持的平均满意度评分>3.0分,对协同诊疗的平均满意度评分<3.0分。结论　浦东新区基层全科医生的工作胜任度较高,利于引导居民社区首诊、慢性病防治及健康管理,但仍需提高其对自身工作价值和工作收入的满意度,同时关注区域间差异,促进家庭医生制度持续发展。     

Where there is no surgeon: the effect of specialist proximity on general practitioners' referral rates

OBJECTIVE: To determine the effect of proximity of surgical specialists on general practitioners' (GPs') rates of referral of surgical problems to specialist care (ie, are surgical referral rates of GPs in rural or remote areas similar to those of GPs in urban centres?). DESIGN: A cross-sectional survey of GP-patient encounters. SETTING: The Bettering the Evaluation and Care of Health (BEACH) program, which involves all active registered GPs in Australia. PARTICIPANTS: A random sample of 3030 GPs, each providing details of 100 consecutive patient encounters. MAIN OUTCOME MEASURES: Proportion of surgical problems (including ophthalmological and obstetric and gynaecological) referred to surgical specialists (surgeons' rooms, hospital outpatient departments or hospital emergency departments). RESULTS: Absence of a local specialist did not significantly influence the proportion of surgical problems referred by GPs overall, but the proportion referred was significantly lower for obstetric (odds ratio [OR], 0.56; 95% CI, 0.44-0.70) and ophthalmological (OR, 0.60; 95% CI, 0.49-0.73) problems. Other factors independently associated with referral of a lower proportion of problems included male GPs, female and younger patients, holders of a Health Care Card, injury-related and non-cancer-related problems, follow-up presentations, and more than one problem managed at an encounter. CONCLUSIONS: Our findings confirm that rural and remote GPs undertake much of their patients' antenatal care, and are less likely to use specialists when managing ophthalmological problems. Absence of local specialists in other surgical specialties is not a barrier to referral of patients with surgical disorders.     

Physicians Taking Action Against Smoking: an intervention program to optimize smoking cessation counselling by Montreal general practitioners

In 1997 the Direction del la santé publique de Montréal-Centre initiated “Physicians Taking Action Against Smoking,” a 5-year intervention program to improve the smoking cessation counselling practices of general practitioners (GPs) in Montreal. Program development was guided by the precede-proceed model. This model advocates identifying factors influencing the outcome, in this case counselling practices. These factors are then used to determine the program objectives, to develop and tailor program activities and to design the evaluation. Program activities during the first 3 years included cessation counselling workshops and conferences for GPs, publication of articles in professional interest journals, publication of clinical guidelines for smoking cessation counselling and dissemination of educational material for both GPs and smokers. The program also supported activities encouraging smokers to ask their GPs to help them stop smoking. Results from 2 cross-sectional surveys, conducted in 1998 and 2000, of random samples of approximately 300 GPs suggest some improvements over time in several counselling practices, including offering counselling to more patients and discussing setting a quit date. More improvements were observed among female than male GPs in both psychosocial factors related to counselling and specific counselling practices. For example, improvements were noted among female GPs in self-perceived ability to provide effective counselling and in the belief that it is important to schedule specific appointments to help patients quit; in addition, the perceived importance of several barriers to counselling decreased among female GPs. A greater proportion of the female respondents to the 2000 survey offered written educational material than was the case in 1998, and a greater proportion of the male GPs devoted more time to counselling in 2000 than in 1998; however, among male GPs the proportion who discussed the pros and cons of smoking with patients in the precontemplation stage declined between 1998 and 2000, as did the proportion who referred patients in the preparation stage to community resources. Our experience suggests that an integrated, theory-based program to improve physicians' counselling practices could be a key component of a comprehensive strategy to reduce tobacco use.     

Factors associated with rural practice among Australian-trained general practitioners

OBJECTIVE: To determine the factors associated with general practitioners' current practice location, with particular emphasis on rural location. DESIGN: Observational, retrospective, case-control study using a self-administered questionnaire. SETTING: Australian general practices in December 2000. PARTICIPANTS: 2414 Australian-trained rural and urban GPs. MAIN OUTCOME MEASURE: Current urban or rural practice location. RESULTS: For Australia as a whole, rural GPs were more likely to be male (odds ratio [OR], 1.42; 95% CI, 1.17-1.73), Australian-born (OR, 1.95; 95% CI, 1.55-2.45), and to report attending a rural primary school for "some" (OR, 2.21; 95% CI, 1.69-2.89) or "all" (OR, 2.79; 95% CI, 1.94-4.00) of their primary schooling. Rural GPs' partners or spouses were also more likely to report "some" (OR, 2.75; 95% CI, 2.07-3.66) or "all" (OR, 2.86; 95% CI, 2.02-4.05) rural primary schooling. A rural background in both GP and partner produced the highest likelihood of rural practice (OR, 6.28; 95% CI, 4.26-9.25). For individual jurisdictions, a trend towards more rural GPs being men was only significant in Tasmania. In all jurisdictions except Tasmania and the Northern Territory, rural GPs were more likely to be Australian-born. CONCLUSIONS: GPs' and their partners' rural background (residence and primary and secondary schooling) influences choice of practice location, with partners' background appearing to exert more influence.     

教学双方对全科医师规范化培训的评价与需求研究

背景　我国的全科医师培训面临着基础薄弱、建设规模大、基层医疗卫生服务需求难以满足等难题,上海市闵行区与高校合作,在政府部门的助力下,建立了医教研协同型服务体系,有利于全科医师培训质量的提升。目的　了解教学双方对全科医师规范化培训的评价与需求情况,以分析能有效提升全科医师培养水平的策略。方法　以上海市闵行区2家全科医师规范化培训基地的问卷有效回收的带教教师（n=36）和管理人员（n=10）为教学供方,以在培学员（n=36）和出站学员（n=30）为教学需方,于2016年4—6月采用自行设计的问卷进行调查,内容包括受试者的基本信息及其对全科医师规范化培训的认知、评价、需求情况。结果　共发放问卷120份,回收有效问卷112份（93.3%）。84.8%（39/46）的教学供方和69.7%（46/66）的教学需方对培训制度非常/比较了解。80.5%（37/46）的教学供方单位对培训制度感到非常/比较满意,56.0%（37/66）的教学需方单位对培训制度感到一般/不满意;80.5%（37/46）的教学供方个人认为培训制度合理但执行不到位,40.9%（27/66）的教学需方个人对目前的培训制度不满意。对于学员最需要提高的能力,43.5%（20/46）的教学供方认为是诊疗流程规范完备,28.3%（13/46）的教学供方和40.9%（27/66）的教学需方认为是临床诊疗能力。4类研究对象所在单位对培训制度的评价、个人对培训制度的评价以及认为学员最需要培养的能力、学员最需要提高的能力、考核最需要重视的方面、带教教师最需具备的能力比较,差异有统计学意义（P<0.05）。结论　全科医师规范化培训存在制度执行不到位的情况,教学需方对培训制度的满意度较低。教学双方的培训需求均侧重于临床实践能力,但不同角色教学供、需方对培训的评价与需求情况存在差异。     

General practitioner attitudes to case conferences: how can we increase participation and effectiveness?

OBJECTIVES: To identify general practitioners' views on the barriers to using case conferencing (as outlined in the Medical Benefits Schedule (MBS) Enhanced Primary Care package) and to develop a set of principles to encourage greater GP participation in case conferences. DESIGN: Qualitative study, involving semistructured questions administered to focus groups of GPs, conducted between April and July 2001 as part of a broader study of case coordination in palliative care. PARTICIPANTS: 29 GPs from urban, regional, and rural areas of Queensland. PRINCIPAL FINDINGS: Many of the GPs' work practices militated against participation in traditionally structured case conferences. GPs thought the range of MBS item numbers should be expanded to cover alternative methods of liaison (eg, phone consultations with other service providers). The onerous bureaucratic processes required to claim reimbursement were an additional disincentive. CONCLUSIONS: GPs would probably be more likely to participate in case conferences if they were initiated by specialist services and arranged more flexibly to suit GP work schedules.     

Public health and preventive healthcare in children: current practices of Victorian GPs and barriers to participation

OBJECTIVES: To assess general practitioners' attitudes to and involvement in child public health activities and identify barriers affecting their participation. DESIGN: Cross-sectional written questionnaire survey of a representative sample of actively practising GPs. SETTING: General practices in the State of Victoria. PARTICIPANTS: 840 GPs returned questionnaires (65% response rate), and, of these, 792 (94%) saw children 0-12 years. MAIN OUTCOME MEASURES: Attitudes to and involvement in public health promotion; predictive factors for GPs' involvement. RESULTS: The odds of GPs' involvement in child public health issues were increased by being female (odds ratio [OR], 1.88), receiving basic medical qualifications outside Australia (OR, 1.55), attending continuing education and postgraduate training (OR, 1.60), and having confidence in dealing with newborns and infants (OR, 1.93) and preschool children (OR, 2.94) (both P < 0.05). Older GPs, compared with younger GPs, had significantly lower odds of involvement (P < 0.01). After adjustment, GPs had higher odds of involvement if they agreed it was important for them to take part in health promotion, or in screening and surveillance (OR, 2.76 and 1.94, respectively; P < or = 0.05); and lower odds if they agreed that screening and surveillance should be mainly done by maternal and child health nurses (OR, 0.60). The most common barriers to involvement were insufficient time, inadequate financial reimbursement for long consultations, inappropriateness of raising these issues in children presenting with illness, and lack of community resources. CONCLUSIONS: Increasing GPs' involvement in child public health will require attention to barriers (time, remuneration and perceived appropriateness), continuing education and changes in workforce composition and patterns.     

中国全科医生配置公平性研究

背景　当今社会面临人口老龄化、慢性病高发等问题，实施全科医生制度是保障和维护居民健康的重要途径。足够数量的全科医生是居民获得全科服务的必要条件。近年来全科医生数量有长足的发展，但是其在不同经济发展水平地区分布情况存在差异，了解各经济发展水平地区全科医生的情况，并引导各个地区合理配置全科医生是实现全民健康的重要环节。目的　分析中国全科医生在不同经济发展水平地区分布情况及变化趋势。方法　根据2013-2018年中华人民共和国国家数据网站中各地区生产总值，将中国大陆地区31个省（自治区、直辖市）分为5个不同的经济水平组，结合2013-2017年中国卫生与计划生育统计年鉴及2018年中国卫生健康统计年鉴中各地区全科医生数量，对各组全科医生的分布情况进行描述性分析，利用集中指数分析历年公平性变化趋势，并通过泰尔指数分解配置总体差异。结果　2012-2017年，中国全科医生数量从10.98万人增至25.27万人，增幅为130.15%。最高经济水平组的每万人口全科医生数量均明显高于其他各经济水平组，2017年达到每万人口3.61人。同期，全科医生集中指数先下降后上升，2015年最低（0.192 1）。分解的泰尔指数贡献率显示，不同经济水平组间历年差异贡献率均超过70%。结论　中国全科医生数量明显增加，经济发展水平较高地区的全科医生数量及注册为全科医学专业的医生比例均较高；全科医生在不同经济发展水平地区的分布公平性差，且差异主要源于不同经济水平组之间。     

基于人才培养的上海市某区全科医生综合能力评价研究

背景　我国全科人才队伍建设相对滞后,合格的全科医生输入严重不足,制约了基层医疗卫生服务水平。目前国内外对全科医生的能力评价主要依据世界家庭医师组织提出的6项核心胜任力,我国对全科医生能力评价研究较晚,研究多侧重从社区卫生服务中心主任、社区卫生服务中心机构、全科医生的临床能力等出发,对全科医生个人综合能力评价的相关研究较为缺乏。目的　建立全科医生综合能力评价体系,评价上海市某区全科医生的综合能力,从而指导全科医生实践,为建立全科人才队伍、培养优秀全科人才起到指导作用。方法　运用层次结构分析法建立全科医生综合能力评价体系,于2018年6月在上海市某区12家社区卫生服务中心中随机选取4名全科医生,共48名作为调查对象,通过问卷自评的形式对上海市某区全科医生综合能力进行评价。结果　研究从临床诊疗能力、公共卫生服务能力、科研能力、人文素养4个方面构建了全科医生综合能力评价体系。并对上海市某区全科医生进行评价,结果显示上海市某区全科医生评价的总平均得分为78.45分,该区全科医生综合能力属于中等偏上水平。人文素养得分最高,科教能力得分最低,临床诊疗能力和公共卫生服务能力位居中间。其中科教能力评分较低,仅为54.49分。结论　全科医生的培养必须多角度进行,在医疗、公共卫生、人文、科研方面,特别针对科研和教学等薄弱点,要提高认识、加大投入力度,提升全科医生综合能力。     

The independent effect of age of general practitioner on clinical practice

OBJECTIVE: To establish the extent to which general practitioner age alone explains variations in patient morbidity and treatment patterns. SETTING: An on-going, national survey of general practice activity in Australia. PARTICIPANTS: A random sample of 5013 GPs with a minimum of 375 general practice Medicare items claimed in the previous 3 months. Each GP contributed details of 100 consecutive encounters, with about 1000 GPs sampled each year between 1998 and 2003. MAIN OUTCOME MEASURES: Effect of practitioner age on GP activity after removing the influence of measured confounding factors: doctor, patient and practice characteristics; number of problems; and morbidity managed at encounters. RESULTS: GP age played a significant role in practice style. In comparison with young GPs (< 35 years), older GPs provided more home visits (P < 0.001) and attendances at residential aged-care facilities (P = 0.044); were more likely to manage chronic problems (P < 0.001); had higher prescribing rates (P < 0.001), and lower rates of pathology ordering (P < 0.001) and non-pharmacological treatments (P < 0.001). Individual body system management rates also differed significantly between younger and older GPs. CONCLUSION: A GP's age plays a significant role in determining practice style. Our results have implications in terms of the ageing GP population and in the wider context of the ageing medical labour force.     

Prevalence of fatigue in general practice

Background

Fatigue is an important symptom in general practice due to its association with physical, psychological and social problems.

Aim

To determine the prevalence of fatigue as an unsolicited symptom during general practice consultations.

Methods

A random sample of GPs practising in Ireland was invited to provide data on consultations held over one day. Data were recorded on the presence of fatigue as a main or supporting symptom, social and demographic characteristics.

Results

Data were recorded by 89 GPs on 1,428 consultations. The prevalence of fatigue was 25%. It was the main reason for attending the dcctor in 6.5% and a secondary reason in 19%. Sixty-two per cent of patients were female and 48% were eligible for free GP services. The mean age was 47.1 years. The presence of fatigue was associated with: attending a female GP, being female, attending a GP who had been qualified for fewer years and attending the GP frequently.

Conclusion

The prevalence of fatigue reported in this study is over three times higher than that reported in earlier work. Doctor characteristics appear to be as important as patient characteristics in determining fatigue.     

Comparison of activity level and service intensity of male and female physicians in five fields of medicine in Ontario.

OBJECTIVE: To examine the extent to which physician's sex explains variation in the activity level and service intensity of a cohort of physicians in each of five medical fields after other sources of variation are taken into account. DESIGN: Data from the Ontario Ministry of Health (MOH) and the CMA were analysed by means of multivariate regression techniques for panel data. SETTING: Ontario. PARTICIPANTS: A total of 137 dermatologists, 974 general internists, 330 pediatricians and 941 psychiatrists and a random sample of 2771 family physicians and general practitioners who met the eligibility criteria. Physicians were eligible if they billed the MOH for at least three quarters in 1983, did not bill as a medical laboratory director, provided direct patient care, did not have an alternative funding arrangement with the MOH, remained in the same specialty throughout the study period (1983-90) and billed from an Ontario address. OUTCOME MEASURES: Three measures of total activity level (annual number of services provided, annual fee-for-service billings and annual mean number of patients seen per quarter) and one measure of service intensity (annual mean number of services per patient per quarter). RESULTS: Although several variables (e.g., full-time work status, age, type of practice and recent practice move) influenced the four measures examined, physician's sex contributed significantly to explaining variation in activity in 70% of the regression equations. The women provided 33.0% fewere services per year than the men in family and general practice (p < 0.001), 25.0% fewer services in general internal medicine (p < 0.01), 22.1% fewer services in pediatrics (p < 0.05) and 22.3% fewer services in psychiatry (p < 0.001). Total billings by the women in these fields were also significantly less than those of their male colleagues, the difference being greatest among the family physicians and general practitioners (28.0%) and the general internists (27.0%) (p < 0.001). The women in these four fields saw significantly fewer patients per quarter than their male colleagues, the difference being greatest in psychiatry (33.0%) (p < 0.001). Sex affected service intensity in three fields. The female psychiatrists (14.8%) (p < 0.001) and general intenists (5.5%) (p < 0.10) provided more services per quarter than their male colleagues, whereas the female family physicians and general practitioners delivered 2.2% fewer services per patient per quarter than their male colleagues (p < 0.01). In two specialties differences between women aged 40 years or less and those over 40 years were observed. In general internal medicine the younger women had higher activity levels than the older women (p < 0.01). Conversely, in dermatology the younger women had lower activity levels (p < 0.05) and provided fewer services per patient per quarter (p < 0.001) than the older women. CONCLUSIONS: Although physician's sex explained much of the variation in activity level and service intensity, even after other important correlates were controlled for, the type and extent of differences observed between female and male physicians depended on the particular medical field examined. To understand the effect of the large increase in the number of women on the physician workforce, more detailed analyses by medical field are needed of the volume, mix and intensity of services provided by men and women, with adjustment for any possible differences in the patients seen in their practices.     

全科医生临床实践中知识型临床问题的处理现状研究

背景　当前国内大力推进分级诊疗,难点之一是提高全科医生的首诊能力,研究全科医生在日常临床实践中需解决的问题,有助于提供针对性的辅助,提高其岗位胜任力。目的　调查全科医生临床实践中遇到知识型临床问题的频率及处理现状。方法　于2020年2-4月,采用便利抽样法对参加全科医师协会活动的300名医生进行线上问卷调查,了解其遇到知识型临床问题的频率、种类和处理方式,并采用多因素Logistic回归分析影响问题查询率和解答率的因素。结果　回收有效问卷297份（99.0%）,其中女性医生、中高级职称医生、工作10年以上者分别占69.7%（207/297）、75.2%（221/294）和48.5%（144/297）。117例（39.4%）全科医生经常或每天遇到无法现场解答的临床问题,约每接诊4.6名患者遇到1个问题;最常见的问题涉及药品使用、病理生理、鉴别诊断和疾病诊断。仅50.7%（150/296）全科医生会查询大部分（>60%）问题;仅12.9%（38/296）能找到>80%的问题答案,主要查询途径是教科书、通用搜索网站（如百度）、咨询他人;91例（30.6%）报告工作场所提供专业信息检索工具。多因素Logistic回归分析结果显示单元接诊量较少、遇到问题频率较低和习惯检索专业信息的医生更可能查找问题（P<0.05）;遇到问题频率较低和积极查询问题者找到正确答案的比例更高（P<0.05）。结论　全科医生在临床实践中遇到知识型临床问题而未得到有效解答的现象常见,主要包括诊断和治疗方面的问题。缺乏时间和高效率的问题检索习惯是妨碍临床问题解答的主要影响因素。     

Baby boomer doctors and nurses: demographic change and transitions to retirement

OBJECTIVES: To examine the effect of demographic change on employment patterns for general practitioners, medical specialists and nurses since 1986, and to compare their patterns of retirement. DESIGN AND SETTING: Secondary analysis of previously unpublished Australian Bureau of Statistics Census data for the years 1986, 1991, 1996 and 2001. MAIN OUTCOME MEASURES: Age distribution of GPs, specialists and nursing workforce; attrition rates as GPs, specialists and nurses left the workforce; and hours worked according to age group. RESULTS: The age profile of the GP, specialist and nursing workforce has aged since 1986 (P < 0.001), with the "baby boomer" generation making up more than half the workforce in 2001. A large proportion of GPs continued to work beyond the traditional retirement age of 65 years, with nurses retiring at a younger age than doctors (P < 0.001). All GP cohorts worked fewer hours in 2001 than they did in 1986 (P < 0.001), with "generation X" GPs working fewer hours than the baby boomers did at the same age (P < 0.001). CONCLUSIONS: Attrition of baby boomer clinicians will place unprecedented pressure on the medical workforce, and policy makers face a critical challenge to ensure workforce needs are met over the next 20 years. Policies and incentives to encourage ongoing employment among older clinicians, albeit at reduced hours, are crucial if the Australian health workforce is to be adequate to meet the growing community demand of the 21st century.     

Training general practitioners to recognise and respond to psychological distress and suicidal ideation in young people

OBJECTIVE: To determine the effectiveness of a training program for general practitioners in recognising and responding to psychological distress and suicidal ideation in young people. DESIGN AND SETTING: The study, conducted in general practice surgeries in Tasmania, Victoria and Western Australia in 1996 and 1997, used a pre-/posttest design to audit consecutive young patients presenting in the six weeks before and the six weeks after the GPs' participation in the training program. PARTICIPANTS: Consisted of 23 GPs who attended a youth suicide prevention workshop and 423 patients aged 15-24 years who presented to the GPs' surgeries (203 pre-workshop and 220 post-workshop). INTERVENTION: GPs attended a one-day training workshop designed to enhance their ability to recognise, assess and manage young patients at risk of suicide. MAIN OUTCOME MEASURES: Scores on three patient self-report inventories (General Health Questionnaire-12 [GHQ-12], Center for Epidemiological Studies Depression Scale [CES-D] and Depressive Symptom Inventory--Suicidality Subscale [DSI-SS]); a GP-completed form for each patient summarising presenting complaint(s), psychological assessment and proposed management plan. RESULTS: After training, GPs demonstrated increased recognition rates of psychologically distressed patients scoring above the cut-offs of the GHQ-12 (48% increase; odds ratio [OR], 1.748; 95% CI, 0.904-03.381) and CES-D (39.5% increase; OR, 2.067; 95% CI, 1.031-4.143); enquiry about suicidal ideation increased by 32.5% (OR, 1.483; 95% CI, 0.929-2.366); and identification of suicidal patients (determined by DSI-SS score) increased by 130% (OR, 3.949; 95% CI, 1.577-9.888). Training did not lead to any significant change in GPs' patient management strategies. CONCLUSIONS: A one-day training course can significantly enhance GP detection rates of psychological distress and suicidal ideation in young patients, but higher recognition rates do not necessarily lead to changes in patient management.