A comparison of two approaches to producing competent primary care physicians.

The current shortage of primary care physicians demands that medical schools implement procedures to ameliorate this deficiency. Two general approaches to the problem were evaluated in regard to their utility as possible solutions. It was concluded that only an approach that advocates medical curriculum manipulation offers a viable direction for medical educators. Conversely, a technique that focuses primarily on the selection of medical school applicants possessing certain biographical characteristics was found to have a number of inherent shortcomings that negate its effectiveness.     

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.     

Early detection of depression by primary care physicians.

The overall prevalence of depression is from 3.5% to 27%. The burden of suffering is high and includes death through suicide. In most cases treatment is effective, but important episodes of depression are being missed. To determine whether a brief, systematic assessment for the early detection of depression should be part of the periodic health examination we searched MEDLINE and the Science Citation Index for randomized controlled trials that evaluated the effectiveness of early detection of depression with a questionnaire. Seven instruments met our quality criteria; the Beck Depression Inventory, the Center for Epidemiologic Studies Depression Scale, the Zung Self-Assessment Depression Scale, the General Health Questionnaire, the Hopkins Symptom Checklist, the Mental Health Inventory and the Hospital Anxiety and Depression Scale. The four randomized controlled trials failed to provide adequate evidence of the benefit of routine screening. Early detection is difficult because of depression's natural history, the role of symptoms, the cultural diversity of Canada and how detection instruments have been developed. Depression deserves careful attention from primary care physicians; however, further research and development is required before the widespread routine use of any detection test can be recommended.     

Educational package on hypertension for primary care physicians.

The usefulness of an educational package on hypertension that provides clinically important, up-to-date medical information and office "aids" to primary care physicians was tested in a randomized controlled trial. Fifty-six physicians completed a pretest multiple-choice questionnaire and were allocated at random either to a group that received the educational package (the "study group") or to a control group. There was a highly significant correlation between the pretest scores and the number of years since graduation (r = -0.55, p less than 0.0001), which indicated that younger physicians are more likely than older physicians to have an up-to-date knowledge of the management of hypertension. The increase in knowledge in the study group (17.5%) was significantly greater than that in the control group (2.7%). Furthermore, although the post-test scores in the control group were still significantly correlated with the number of years since graduation, those in the study group were not. It was concluded that although the older physicians knew less than their younger colleagues about hypertension, the use of the educational package significantly increased knowledge, and the increase was not limited by the physician's age.     

Attitudes of primary care physicians toward corporal punishment.

OBJECTIVE--The purpose of this study was to determine whether or not family physicians and pediatricians support the use of corporal punishment. The frequency with which these physicians offer anticipatory guidance on discipline was also studied. DESIGN--Self-report survey, mailed to study participants. PARTICIPANTS--The sample for this study was 800 family physicians and 400 pediatricians, randomly selected from the Ohio State Medical Board's roster of family physicians and pediatricians. Physicians with a subspecialty were excluded. Participants who did not return their surveys received a second, and if necessary, a third mailing of the survey. After three mailings, a total of 619 physicians (61%) completed a survey. MAIN OUTCOME MEASURE--Participants were considered to support corporal punishment if they would tell a parent in their medical practice that spanking would be an appropriate response to any one of a series of childhood misbehaviors presented in the survey. RESULTS--Of family physicians, 70% (95% confidence interval [CI], 66% to 75%) support use of corporal punishment. Of pediatricians, 59% (95% CI, 52% to 66%) support corporal punishment. Of pediatricians, 90% (95% CI, 86% to 94%) indicated that they include discipline issues either always or most of the time when providing anticipatory guidance to parents. Significantly fewer family physicians (52%; 95% CI, 47% to 57%) indicated that they discuss discipline either always or most of the time when providing anticipatory guidance (P less than .01). CONCLUSIONS--Most family physicians and pediatricians support the use of corporal punishment in spite of evidence that it is neither effective nor necessary, and can be harmful. Pediatricians offer anticipatory guidance on discipline more often than family physicians.