Utility of self-competency ratings during residency training in family medicine education-emerging countries: findings from Japan

Background

Family medicine education-emerging countries face challenges in demonstrating a new program’s ability to train residents in womb-to-tomb care and resident ability to provide such care competently. We illustrate the experience of a new Japanese family medicine program with resident self-competency assessments.

Methods

In this longitudinal cross-sectional study, residents completed self-competency assessment surveys online during 2011–2015. Each year of training, residents self-ranked their competence using a 100-point visual analog scale for 142 conditions: acute (30 conditions), chronic (28 conditions) women’s health (eight conditions), and geriatrics/home (12 conditions) care; procedures (38 types); health promotion (21 conditions).

Results

Twenty residents (11 women, 9 men) participated. Scores improved annually by training year from baseline to graduation; the mean composite score advanced from 31 to 65%. All subcategories showed improvement. Scores for care involving acute conditions rose from 49 to 75% (26% increase); emergency procedures, 46–65% (19% increase); chronic care, 33–73% (40% increase); women’s health, 16–59% (43% increase); procedural care, 26–56% (30% increase); geriatrics care-procedures, 8–65% (57% increase); health promotion, 21–63% (42% increase). Acute care, chronic care, and health promotion achieved the highest levels. Women’s health care, screenings, and geriatrics experienced the greatest increase. Health promotion gains occurred most dramatically in the final residency year.

Conclusions

A resident self-competency assessment provides a simple and practical way to conduct an assessment of skills, to monitor skills over time, to use the data to inform residency program improvement, and to demonstrate the breadth of family medicine training to policymakers, and other stakeholders.

     

Health inequalities and regional specific scarcity in primary care physicians: ethical issues and criteria

Objectives

A substantial body of evidence supports the beneficial health impact of an increase in primary care physicians for underserved populations. However, given that in many countries primary care physician shortages persist, what options are available to distribute physicians and how can these be seen from an ethical perspective?

Methods

A literature review was performed on the topic of primary care physician distribution. An ethical discussion of conceivable options for decision makers that applied prominent theories of ethics was held.

Results

Examples of distributing primary care physicians were categorised into five levels depending upon levels of incentive or coercion. When analysing these options through theories of ethics, contrasting, and even controversial, moral issues were identified. However, the different morally salient criteria identified are of prima facie value for decision makers.

Conclusions

The discussion provides clear criteria for decision makers to consider when addressing primary care physician shortages. Yet, decision makers will still need to assess specific situations by these criteria to ensure that any decisions they make are morally justifiable.     

Effective healthcare teams require effective team members: defining teamwork competencies

Background

Hospital in the home programs have been implemented in several countries and have been shown to be safe substitutions (alternatives) to in-patient hospitalization. These programs may offer a solution to the increasing demands made on tertiary care facilities and to surge capacity. We investigated the acceptance of this type of care provision with nurse practitioners as the designated principal home care providers in a family medicine program in a large Canadian urban setting.

Methods

Patients requiring hospitalization to the family medicine service ward, for any diagnosis, who met selection criteria, were invited to enter the hospital in the home program as an alternative to admission. Participants in the hospital in the home program, their caregivers, and the physicians responsible for their care were surveyed about their perceptions of the program. Nurse practitioners, who provided care, were surveyed and interviewed.

Results

Ten percent (104) of admissions to the ward were screened, and 37 patients participated in 44 home hospital admissions. Twenty nine patient, 17 caregiver and 38 provider surveys were completed. Most patients (88%–100%) and caregivers (92%–100%) reported high satisfaction levels with various aspects of health service delivery. However, a significant proportion in both groups stated that they would select to be treated in-hospital should the need arise again. This was usually due to fears about the safety of the program. Physicians (98%–100%) and nurse practitioners also rated the program highly. The program had virtually no negative impact on the physician workload. However nurse practitioners felt that the program did not utilize their full expertise.

Conclusion

Provision of hospital level care in the home is well received by patients, their caregivers and health care providers. As a new program, investment in patient education about program safety may be necessary to ensure its long term success. A small proportion of hospital admissions were screened for this program. Appropriate dissemination of program information to family physicians should help buy-in and participation. Nurse practitioners' skills may not be optimally utilized in this setting.     

Factors Associated with Physicians’ Choice of Working Sector

Objective

To analyse factors affecting physicians’ choice to work in either the public or the private sector.

Method

We undertook a longitudinal data analysis in the years 1988, 1993, 1998 and 2003 (n = 12 909) using a multilevel modelling technique. Factors related to economic factors, physician identity, appreciation as well as demographic factors were hypothesised to influence sector choice.

Results

Physicians seem to make their career choices prior to graduation, at least to some extent. Wage levels, the physician’s personal characteristics and whether or not the physician knew his or her place of work before graduation were the key factors affecting the decision-making process in the years 1988, 1993, 1998 and 2003. Physicians for whom wages were important were less likely to choose the public sector. Also, physicians who regarded themselves as entrepreneurial preferred to work in the private sector. If a physician had worked in the public sector during his or her medical training before graduation, the probability of applying for a vacancy in the public sector was higher.

Conclusion

It is not only economic factors, such as salary, that are involved in the physician’s decision to choose the working sector.     

Care From Family Physicians Reported by Pregnant Women in the United States

PURPOSE

We describe the proportion of family physicians providing care of any sort to pregnant women in the United States from 2000 to 2009.

METHODS

We used a repeat, cross-sectional design with data from the nationally representative Integrated Health Interview Series (2000–2009) for respondents who reported being pregnant at the time of the survey (N = 3,204). Using multivariate logistic regression, we modeled changes over time in pregnant women’s reports of care from family physicians. We used interaction terms to test for regional differences in trends.

RESULTS

Approximately one-third of pregnant women reported having seen or talked to a family physician for medical care during the prior year, a percentage that remained stable for the period of 2000 to 2009 (adjusted odds ratio for annual change = 1.006). Most pregnant women reported care from multiple types of clinicians, including family physicians, obstetrician-gynecologists, midwives, nurse practitioners, and physician assistants. There were regional differences in trends in family physician care; pregnant women in the North Central United States increasingly reported care from family physicians, whereas women in the South reported a decline (6.7% annual increase vs 4.7% annual decrease, P ≥.001).

CONCLUSIONS

Trends in family medicine care for pregnant women have remained steady for the nation as a whole, but they differ by region of the United States. Most pregnant women reported care from multiple clinicians, highlighting the importance of care coordination for this patient population.     

Medically unexplained illness and the diagnosis of hysterical conversion reaction (HCR) in women’s medicine wards of Bangladeshi hospitals: a record review and qualitative study

Background

Breast cancer is the leading cause of cancer mortality among Jordanian women. Breast malignancies are detected at late stages as a result of deferred breast health-seeking behaviour. The aim of this study was to explore Jordanian women’s views and perceptions about breast cancer and breast health.

Methods

We performed an explorative qualitative study with purposive sampling. Ten focus groups were conducted consisting of 64 women (aged 20 to 65?years) with no previous history and no symptoms of breast cancer from four governorates in Jordan. The transcribed data was analysed using latent content analysis.

Results

Three themes were constructed from the group discussions: a) Ambivalence in prioritizing own health; b) Feeling fear of breast cancer; and c) Feeling safe from breast cancer. The first theme was seen in women’s prioritizing children and family needs and in their experiencing family and social support towards seeking breast health care. The second theme was building on women’s perception of breast cancer as an incurable disease associated with suffering and death, their fear of the risk of diminished femininity, husband’s rejection and social stigmatization, adding to their apprehensions about breast health examinations. The third theme emerged from the women’s perceiving themselves as not being in the risk zone for breast cancer and in their accepting breast cancer as a test from God. In contrast, women also experienced comfort in acquiring breast health knowledge that soothed their fears and motivated them to seek early detection examinations.

Conclusions

Women’s ambivalence in prioritizing their own health and feelings of fear and safety could be better addressed by designing breast health interventions that emphasize the good prognosis for breast cancer when detected early, involve breast cancer survivors in breast health awareness campaigns and catalyse family support to encourage women to seek breast health care.     

Coronary heart disease in primary care: accuracy of medical history and physical findings in patients with chest pain – a study protocol for a systematic review with individual patient data

Background

Within the 52 health districts in South Africa, the family physician is seen as the clinical leader within a multi-professional district health team. Family physicians must be competent to meet 90% of the health needs of the communities in their districts. The eight university departments of Family Medicine have identified five unit standards, broken down into 85 training outcomes, for postgraduate training. The family medicine registrar must prove at the end of training that all the required training outcomes have been attained. District health managers must be assured that the family physician is competent to deliver the expected service. The Colleges of Medicine of South Africa (CMSA) require a portfolio to be submitted as part of the uniform assessment of all registrars applying to write the national fellowship examinations. This study aimed to achieve a consensus on the contents and principles of the first national portfolio for use in family medicine training in South Africa.

Methods

A workshop held at the WONCA Africa Regional Conference in 2009 explored the purpose and broad contents of the portfolio. The 85 training outcomes, ideas from the WONCA workshop, the literature, and existing portfolios in the various universities were used to develop a questionnaire that was tested for content validity by a panel of 31 experts in family medicine in South Africa, via the Delphi technique in four rounds. Eighty five content items (national learning outcomes) and 27 principles were tested. Consensus was defined as 70% agreement. For those items that the panel thought should be included, they were also asked how to provide evidence for the specific item in the portfolio, and how to assess that evidence.

Results

Consensus was reached on 61 of the 85 national learning outcomes. The panel recommended that 50 be assessed by the portfolio and 11 should not be. No consensus could be reached on the remaining 24 outcomes and these were also omitted from the portfolio. The panel recommended that various types of evidence be included in the portfolio. The panel supported 26 of the 27 principles, but could not reach consensus on whether the portfolio should reflect on the relationship between the supervisor and registrar.

Conclusion

A portfolio was developed and distributed to the eight departments of Family Medicine in South Africa, and the CMSA, to be further tested in implementation.     

Evidence-based medicine in primary care: qualitative study of family physicians

Background

The objectives of this study were: a) to examine physician attitudes to and experience of the practice of evidence-based medicine (EBM) in primary care; b) to investigate the influence of patient preferences on clinical decision-making; and c) to explore the role of intuition in family practice.

Method

Qualitative analysis of semi-structured interviews of 15 family physicians purposively selected from respondents to a national survey on EBM mailed to a random sample of Canadian family physicians.

Results

Participants mainly welcomed the promotion of EBM in the primary care setting. A significant number of barriers and limitations to the implementation of EBM were identified. EBM is perceived by some physicians as a devaluation of the 'art of medicine' and a threat to their professional/clinical autonomy. Issues regarding the trustworthiness and credibility of evidence were of great concern, especially with respect to the influence of the pharmaceutical industry. Attempts to become more evidence-based often result in the experience of conflicts. Patient factors exert a powerful influence on clinical decision-making and can serve as trumps to research evidence. A widespread belief that intuition plays a vital role in primary care reinforced views that research evidence must be considered alongside other factors such as patient preferences and the clinical judgement and experience of the physician.

Discussion

Primary care physicians are increasingly keen to consider research evidence in clinical decision-making, but there are significant concerns about the current model of EBM. Our findings support the proposed revisions to EBM wherein greater emphasis is placed on clinical expertise and patient preferences, both of which remain powerful influences on physician behaviour.

     

Diagnosis and treatment of risk factors in Germany and the UK

Objective

To estimate the impact of different systems of family practitioners’ payment on process of care: fee-for-service vs. capitation.

Design

Cross sectional international survey using cardiovascular prevention as an indicator of the quality of care.

Setting

Family physicians’ practices in Germany (fee-for-service) and the UK (capitation).

Subjects

778 patients attending for consultation regardless of morbidity or risk factor status.

Main outcome measures

Intervals since last consultation, since last BP-measurement, prevalence of known hypertension.

Results

There is a higher overall level of activity under FFS, but under capitation FPs seem to concentrate their efforts on the more severely ill or at risk. This would explain that under different systems of remuneraton the quality of care (outcome) is usually similar.

Conclusions

In areas of uncertainty FFS seems to stimulate activity or intervention, whereas under capitation FPs are rather reluctant to engage in procedures or interventions that are not sufficiently evaluated. Under prepaid remuneration FPs adjust in a way that the quality of care does not suffer.     

Mentoring and Facilitating Professional Engagement as Quality Enhancement Strategies: An Overview and Evaluation of the Family Child Care Partnerships Program

Background

The importance of professional development training for individuals tasked with providing quality early child care is widely accepted. However, research assessing the impact of specific, long-term professional development programs on changes in caregiver behavior is largely absent, as is research about the processes and mechanisms of such training efforts that produce changes in child care practices.

Objective

We specify the underlying activities and processes of a mentor–delivered quality enhancement and professional development program, Family Child Care Partnerships (FCCP), and present the results of two studies using implementation data to examine program effectiveness as measured by mentors’ observational assessments of the global quality of caregiving practices and providers’ self-reported professional engagement.

Methods

Study 1 consisted of 365 family child care providers who were invited to participate in FCCP. Study 2 was a subsample of Study 1 and consisted of 109 providers. We used latent difference score modeling to examine changes in global child care quality from program entry to program departure and bivariate associations among changes in quality and professional engagement.

Results

Significant increases were found between pre- and post-enrollment assessments of caregiving quality and professional engagement. Increases in professional engagement were associated with increases in quality.

Conclusions

Findings are discussed in the context of the limited information available to guide quality improvement and professional development in family child care and in light of recommendations that the early childhood care and education field develop methods of training that embed knowledge and skills development in practice.     

?Work-Life-Balance“ im Arztberuf – geschlechtsspezifische Unterschiede in den Erwartungen von Medizinstudierenden

Background

Considering the growing demand of medical care in the future, the current shortage of physicians requires concepts to meet the challenges of changing expectations regarding working conditions.

Methods

In the Competence Centre of General Practice in Baden-Wuerttemberg, an online survey of medical students was conducted in order to evaluate gender-specific differences regarding the expectations about future working conditions in the medical profession. A questionnaire developed for that purpose contained several aspects, e.g.??work-life balance?? or??personal values??. Gender-specific differences were examined by means of the Mann-Whitney U test. Moreover a linear regression model with gender, age and number of semesters as independent variables was used.

Results

A total of 1,299 medical students participated in the survey. Flexible working hours were important for 57.1% of women and 50.4% of men. Compatibility of family and work was an important issue for 92.3% of women and 86.7% of men. However, the possibility of working part-time was important for 72.7% of women but only 22.2% of men. Besides gender, age and number of semesters also influenced the appraisal of??work-life balance?? and??personal values??.

Conclusions

This study reveals gender-specific differences in expectations regarding future work-life balance. To achieve sustainable physician care in the light of a growing proportion of female physicians, gender-specific organization of working time is important to ensure the compatibility of family and work.     

Obstetrician-gynecologist experiences with abortion training: physician insights from a qualitative study

Background

Abortion is one of the most contested, yet common surgical procedures in the United States and a required component of obstetrics and gynecology resident education. Approaches to abortion training are variable.

Study Design

We conducted in-depth interviews with 30 physicians who had graduated 5–10 years prior from four US residency programs with routine abortion training. Interviews focused on their experiences with abortion during training and in practice.

Results

Graduates' positive and negative experiences demonstrated that many valued teaching about the social issues surrounding abortion as well as training in surgical skills. Respondents found training rewarding when attending physicians openly discussed their personal commitment to abortion practice, respected differences of opinions about abortion and demonstrated high regard for abortion training. Some residents who opted out of surgical training for abortion valued partially participating in the rotation.

Conclusions

Many physicians-in-training consider didactics related to the social context of care and respect for moral boundaries important components of abortion training.     

The role of the physician in Israel’s maternal child health clinics: surveys of professional and parental perceptions

Background

Preventative health services are a pediatric health care cornerstone, which strives to promote health and prevent illness and injury. In Israel, Maternal Child Health Clinics (MCHC) provide these well child services for ages 0–6 years. MCHC care includes physician visits; however, the physician’s role is not well defined. The study purpose was to provide a basis for setting policies that determine the role of physicians in the provision of MCHC services. To get broad input we included MCHC stakeholders - parents, MCHC physicians, non-MCHC physicians and MCHC nurses, specifically to obtain insights regarding the MCHC physician role and to characterize the stakeholder demographics, service utilization, and practice patterns.

Methods

Professional groups completed self-administered written questionnaires (n = 398). Parents were interviewed during MCHC visits using a structured questionnaire (n = 1052). All provided demographic data, service characteristics and agreement with ten potential MCHC physician roles - Physical Examination, Abnormal Health Condition Detection, Developmental Screening, Anticipatory Guidance, Parent-Child Interaction Counseling, MCHC Staff Advice, Children-at-Risk Detection, Growth Surveillance, Vaccination Counseling, and Inter-physician Communication.

Results

The study findings seem to indicate a true shortage of MCHC physicians. The median age of MCHC physicians was significantly higher than both non-MCHC physicians and MCHC nurses. There was agreement among stakeholders regarding some roles (Physical Examination, Developmental Screening and Detection of Abnormal Health Conditions) but not others. Most parents reported having at least one MCHC physician encounter. Parents who did not visit the physician were younger and had fewer children.

Conclusions

Stakeholders view MCHC physicians as integral to MCHC care. Roles traditionally regarded as part of primary prevention were less likely to be attributed to physicians than screening roles considered secondary prevention.Updating and standardization of the MCHC physician role is needed along with a national strategy to recruit and train MCHC physicians.to ensure optimal pediatric preventive health care in Israel.

     

A survey of physicians who care for older persons in Southwest China

Objective

The aim of this survey is to determine the main barriers of geriatric health care from the physicians’ point of view and compare the improvement before and after the Continue Medical Education (CME) provided by International Association of Gerontology and Geriatrics (IAGG).

Design

Cross-sectional survey.

Setting and Participants

Five hundred samples were generated using systematic random sampling from the address lists of physicians in Southwest China who had received the IAGG CME or been trained in Sichuan Association of Geriatrics (SAG) CME.

Measurements

The interview instrument examined demographics and information on geriatric education.

Results

Of the 500 physician sampled, 461(92.2 percent) responded. 34.3 percent of the respondents reported that over 70 percent of their patients were older persons. 76.8 percent of the respondents felt that they lacked geriatric knowledge. Only 15.6 percent of the respondents had geriatric curriculum before graduation, and 26.0 percent received geriatric trainings after graduation. Most physicians felt that “Language barrier” and “Insufficient geriatric education in undergraduate medical school and postgraduate education” were the main challenges in practicing geriatric medicine. Geriatric training and knowledge are inadequate due to the lack of geriatric curriculums in medical schools and CME for physicians who practice geriatrics. With the help of IAGG, CME in Southwest China provided more workshops on geriatric progress in year 2011 than in year 2007–2010. Eighty percent of the physicians acknowledged that the IAGG CME was helpful for their clinical practice. The physicians paid more attention to geriatric syndromes rather than age-related pathophysiology alone.

Conclusion

CME provided by geriatric associations is helpful. Collaboration between different geriatric societies such as IAGG and SAG may be a good model for spreading geriatric knowledge and should be considered by medical educational administration.     

Cost and care models for acutely ill nursing home residents in Germany: the example of pneumonia

Background

Hospitalisation of acutely ill nursing home residents is associated with health risks such as infections, complications, or falls, and results in high costs for the health care system. Taking the case of pneumonia, nursing homes generally can ensure care according to guidelines.

Aim

Extrapolation of overall expenditures for the German statutory health insurance system from the hospitalisation of nursing home residents with respiratory infection/pneumonia; developing alternative cost scenarios to compare nursing home care with hospital care in consideration of patients’ condition.

Methods

Data provided by health insurance funds were extrapolated to the German statutory health insurance system and weighted via German-DRG case values. Care processes (hospital vs. nursing home) were modelled, and treatment steps were divided into cost categories. The patient’s condition was standardised via the Barthel Index.

Results

Total expenditures of € 163.3 million were incurred for inpatient care of nursing home residents transferred to hospitals for respiratory infection/pneumonia in 2013 in Germany. Process modelling reveals lower direct costs for nursing home care as well as better development of patients’ condition. Looking at operators of nursing homes, both care scenarios necessitate additional services without reimbursement.

Conclusion

Expenditure projections for the hospital care of nursing home residents with pneumonia reveal high saving potential. Avoidance of hospital admission serves to considerably reduce the insurers’ expenditures but also the duration and severity of illness. The study illustrates economic incentive structures for health care providers and indicates courses of action for health policy and nursing homes operators.

     

Exploring factors influencing residents’ health outcomes in long-term care facilities: 1-year follow-up using latent growth curve model

Purpose

This study explored the residents’ health outcomes of long‐term care (LTC) facilities and examined the risk factors in individual and institutional levels during 1 year of admission.

Methods

The study included four stages of interviews with residents in 31 nursing homes and 64 residential care homes. Three hundred and twenty-five residents at baseline were interviewed, and 206 completed the interviews at follow‐up. Five outcomes including residents’ physical/mental functional status and subjective health status in Short Form‐36 were analyzed using latent growth curve models (LGCMs).

Results

Only the physical component summary (PCS) had increased significantly. The most influential risk factors to outcomes were the intra‐individual-level time‐varying variables, including self‐rated health and with/without tubing care. Some predictive inter‐individual-level factors were also found. For institutional characteristics, small‐sized homes (<49 beds) with low occupancy rates showed a lower growth rate in residents’ mental component summary (MCS) and PCS over 1 year and private sector homes showed the most significant growth rates in MCS.

Conclusions

The methodological strength using LGCMs provides a framework for systematically assessing the influence of risk factors from various levels on residents’ outcomes and follow‐up change. It is evident that factors in various levels all influenced residents’ outcomes which support critical information for case mix and quality management in LTC facilities. Under the scenario of a surplus of institutional care in Taiwan, we suggest that institutions must focus more on residents’ psychological well‐being and care quality, especially in small‐sized homes in relation to the outcomes of its residents.     

A call for better care: the impact of postnatal contact services on women’s parenting confidence and experiences of postpartum care in Queensland,Australia

Background

Universal postnatal contact services are provided in several Australian states, but their impact on women’s postnatal care experience has not been evaluated. Furthermore, there is lack of evidence or consensus about the optimal type and amount of postpartum care after hospital discharge for maternal outcomes. This study aimed to assess the impact of providing Universal Postnatal Contact Service (UPNCS) funding to public birthing facilities in Queensland, Australia on women’s postnatal care experiences, and associations between amount and type (telephone or home visits) of contact on parenting confidence, and perceived sufficiency and quality of postnatal care.

Methods

Data collected via retrospective survey of postnatal women (N?=?3,724) were used to compare women who birthed in UPNCS-funded and non-UPNCS-funded facilities on parenting confidence, sufficiency of postnatal care, and perceived quality of postnatal care. Associations between receiving telephone and home visits and the same outcomes, regardless of UPNCS funding, were also assessed.

Results

Women who birthed in an UPNCS-funded facility were more likely to receive postnatal contact, but UPNCS funding was not associated with parenting confidence, or perceived sufficiency or perceived quality of care. Telephone contact was not associated with parenting confidence but had a positive dose–response association with perceived sufficiency and quality. Home visits were negatively associated with parenting confidence when 3 or more were received, had a positive dose–response association with perceived sufficiency and were positively associated with perceived quality when at least 6 were received.

Conclusions

Funding for UPNCS is unlikely to improve population levels of maternal parenting confidence, perceived sufficiency or quality of postpartum care. Where only minimal contact can be provided, telephone may be more effective than home visits for improving women’s perceived sufficiency and quality of care. Additional service initiatives may be needed to improve women’s parenting confidence.