Pharmacists teaching in family medicine residency programs: National survey

Objective

To determine the percentage of family medicine residency programs that have pharmacists directly involved in teaching residents, the types and extent of teaching provided by pharmacists in family medicine residency programs, and the primary source of funding for the pharmacists.

Design

Web-based survey.

Setting

One hundred fifty-eight resident training sites within the 17 family medicine residency programs in Canada.

Participants

One hundred residency program directors who were responsible for overseeing the training sites within the residency programs were contacted to determine the percentage of training sites in which pharmacists were directly involved in teaching. Pharmacists who were identified by the residency directors were invited to participate in the Web-based survey.

Main outcome measures

The percentage of training sites for family medicine residency that have pharmacists directly involved in teaching residents. The types and the extent of teaching performed by the pharmacists who teach in the residency programs. The primary source of funding that supports the pharmacists’ salaries.

Results

More than a quarter (25.3%) of family medicine residency training sites include direct involvement of pharmacist teachers. Pharmacist teachers reported that they spend a substantial amount of their time teaching residents using a range of teaching modalities and topics, but have no formal pharmacotherapy curriculums. Nearly a quarter (22.6%) of the pharmacists reported that their salaries were primarily funded by the residency programs.

Conclusion

Pharmacists have a role in training family medicine residents. This is a good opportunity for family medicine residents to learn about issues related to pharmacotherapy; however, the role of pharmacists as educators might be optimized if standardized teaching methods, curriculums, and evaluation plans were in place.     

Survey of Ontario primary care physicians' experiences with opioid prescribing

Objective

To measure physicians’ experiences with opioid-related adverse events and their perceived level of confidence in their opioid prescribing skills and practices.

Design

Mailed survey.

Setting

The province of Ontario.

Participants

A total of 1000 primary care physicians randomly selected from the College of Physicians and Surgeons of Ontario registration database.

Main outcome measures

Opioid-related adverse events and concerns (eg, number of patients, type of opioid, cause of the event or concern); physicians’ confidence, comfort, and satisfaction with opioid prescribing; physicians’ opinions on strategies to optimize their prescribing; and physicians’ perspectives of their interactions with pharmacists and nurses.

Results

The response rate was close to 66%, for a total of 658 participants. Almost all respondents reported prescribing opioids for chronic pain in the past 3 months. Eighty-six percent of respondents reported being confident in their prescribing of opioids, but 42% of respondents indicated that at least 1 patient had experienced an adverse event related to opioids in the past year, usually involving oxycodone, and 16.3% of respondents did not know if their patients had experienced any opioid-related adverse events. The most commonly cited factors leading to adverse events were that the patient took more than prescribed, the prescribed dose was too high, or the patient took alcohol or sedating drugs with the opioids. Most physicians had concerns about the opioid use of 1 or more of their patients; concerns included running out of opioids early, minimal access to pain and addiction treatment, and addiction and overdose. The reported number of physicians’ patients taking opioids was positively associated with their confidence and comfort levels in opioid prescribing and negatively associated with their belief that many patients become addicted to opioids.

Conclusion

Most physicians have encountered opioid-related adverse events. Comprehensive strategies are required to promote safe prescribing of opioids, including guidelines and comprehensive office-system materials.     

Use of natural health products in children: Experiences and attitudes of family physicians in Newfoundland and Labrador

Objective

To determine the experiences of family physicians in Newfoundland and Labrador with parents’ use of natural health products (NHPs) for their children and to assess physicians’ attitudes toward use of NHPs in children.

Design

A survey using the Dillman approach.

Setting

Newfoundland and Labrador.

Participants

All family physicians in the province.

Main outcome measures

Physician demographic characteristics; whether physicians inquire about the use of NHPs in children; the degree to which they think patients disclose use of NHPs in children; whether they counsel parents about the potential benefits or harms of NHPs; their own opinions about the usefulness of NHPs; whether they recommend NHPs in children and for what reasons; and the particular NHPs they have seen used in children and for what reasons.

Results

A total of 159 (33.1%) family physicians responded; 65.4% were men, 71.7% were Canadian medical graduates, and 46.5% practised in rural areas. Overall, 18.8% of family physicians said they regularly or frequently asked about NHP use; 24.7% counseled patients about potential harms. Only 1.9% of physicians believed NHPs were usually beneficial, but a similarly small number (8.4%) thought they were usually harmful. Most respondents were somewhat neutral; 59.7% said they never recommend NHPs for children, and a further 37.0% said they would only “sometimes” recommend NHPs.

Conclusion

Most physicians believed that NHPs were probably of little benefit but not likely to be harmful. Most NHPs used were vitamins and minerals. Physicians recognized that NHPs were often used by parents for children, but in general they believed NHPs had little effect on their day-to-day medical practices. Thirty-eight (24.7%) of the 154 physicians had at least once recommended an NHP (including vitamins) for their pediatric patients. Physicians believed that parents did not often disclose use of NHPs for their children, but at the same time physicians generally did not actively inquire.     

Hip fracture prevention strategies in long-term care: a survey of Canadian physicians' opinions

OBJECTIVE

To garner Canadian physicians’ opinions on strategies to reduce hip fractures in long-term care (LTC) facilities, focusing on secondary prevention.

DESIGN

A cross-sectional survey using a mailed, self-administered, written questionnaire.

SETTING

Canada.

PARTICIPANTS

Family physician members of the Ontario Long-Term Care Association (n = 165) and all actively practising geriatricians registered in the Canadian Medical Directory (n = 81).

MAIN OUTCOME MEASURES

The strength of recommendations for fracture-reduction strategies in LTC and barriers to implementing these strategies.

RESULTS

Of the 246 physicians sent the questionnaire, 25 declined study materials and were excluded. Of the 221 remaining, 120 responded for a response rate of 54%. About two-thirds of respondents were family physicians (78 of 120) and the rest were mostly geriatricians. Most respondents strongly recommended the following secondary prevention strategies for use in LTC after hip fracture: calcium, vitamin D, oral aminobisphosphonates, physical therapy, and environmental modification (such as handrails). Most respondents either did not recommend or recommended limited use of etidronate, intravenous bisphosphonates, calcitonin, raloxifene, testosterone (for hypogonadal men), and teriparatide. Postmenopausal hormone therapy was discouraged or not recommended by most respondents. Support was mixed for the use of hip protectors, B vitamins, and folate. Barriers to implementation identified by most respondents included a lack of strong evidence of hip fracture reduction (for B vitamins and folate, cyclic etidronate, and testosterone), side effects (for postmenopausal hormone therapy), poor compliance (for hip protectors), and expense (for intravenous bisphosphonates and teriparatide). Some respondents cited side effects or poor compliance as barriers to using calcium and potent oral bisphosphonates.

CONCLUSION

Canadian physicians favour the use of calcium, vitamin D, potent oral bisphosphonates, physical therapy, and evironmental modifications for LTC residents after hip fracture. Further study at the clinical and administrative levels is required to find ways to overcome the specific barriers to implementation and effectiveness of these interventions.     

Effect of colleague and coworker abuse on family physicians in Canada

Objective

To assess the effects of physician-colleague and coworker abuse on family physicians in Canada.

Design

A mixed-methods, bilingual study that included surveys and telephone interviews.

Setting

Canada.

Participants

Family physicians in active practice who were members of the College of Family Physicians of Canada in 2009.

Methods

Surveys were mailed to a random sample of family physicians (N = 3802), and 37 family physicians who had been abused in the past year participated in telephone interviews.

Main findings

A total of 770 surveys (20%) were completed. A small number of respondents reported having been subjected to abuse by physician colleagues (9%) or coworkers (6%) in the previous month. Many of the respondents reported that the same physician colleagues or coworkers were repeat abusers. More than three-quarters (77%) of the physician-colleague abusers were men, whereas more than three-quarters (77%) of the other coworker abusers were women. Interviewed family physicians described feeling humiliated and unappreciated, and developed symptoms of anxiety or depression. As a result of the abuse, some family physicians terminated their employment or refused to work in certain environments. The most striking effect of this abuse was that respondents reported losing confidence in their professional abilities and skills.

Conclusion

Although only a small number of family physicians experience abuse by physician colleagues and other coworkers, the effects can be considerable. Victims reported a loss of confidence in their clinical abilities and some subsequently were faced with mental health issues.     

Community-wide measures of wellness in a remote First Nations community experiencing opioid dependence: Evaluating outpatient buprenorphine-naloxone substitution therapy in the context of a First Nations healing program

Objective

To document the development of unique opioid-dependence treatment in remote communities that combines First Nations healing strategies and substitution therapy with buprenorphine-naloxone.

Design

Quantitative measurements of community wellness and response to community-based opioid-dependence treatment.

Setting

Remote First Nations community in northwestern Ontario.

Participants

A total of 140 self-referred opioid-dependent community members.

Intervention

Community-developed program of First Nations healing, addiction treatment, and substitution therapy.

Main outcome measures

Community-wide measures of wellness: number of criminal charges, addiction-related medical evacuations, child protection agency cases, school attendance, and attendance at community events.

Results

The age-adjusted adult rate of opioid-dependence treatment was 41%. One year after the development of the in-community healing and substitution therapy program for opioid dependence, police criminal charges had fallen by 61.1%, child protection cases had fallen by 58.3%, school attendance had increased by 33.3%, and seasonal influenza immunizations had dramatically gone up by 350.0%. Attendance at community events is now robust, and sales at the local general store have gone up almost 20%.

Conclusion

Community-wide wellness measures have undergone dramatic public health changes since the development of a First Nations healing program involving opioid substitution therapy with buprenorphine-naloxone. Funding for such programs is ad hoc and temporary, and this threatens the survival of the described program and other such programs developing in this region, which has been strongly affected by an opioid-dependence epidemic.     

Lyme disease: Knowledge, beliefs, and practices of physicians in a low-endemic area

Objective

To determine physicians’ level of awareness and knowledge of Lyme disease (LD) in a low-prevalence area and whether physicians’ practices align with current guidelines for treatment of LD.

Design

A 23-item questionnaire assessing demographic characteristics, general knowledge about LD, laboratory testing for LD, and responses to 3 clinical scenarios.

Setting

British Columbia (BC).

Participants

Pediatricians, FPs, and internal medicine specialists who were licensed to practise in BC.

Main outcome measures

Knowledge of signs and symptoms of LD, beliefs about risk of LD, attitudes toward LD in patients in their practices, and application of accepted practice guidelines for the treatment of LD in clinical scenarios.

Results

Overall, 80.6% of respondents were FPs. Average knowledge score was 72.5% for FPs and 75.0% for other specialists. Most respondents (75.6% of FPs and 71.8% of other specialists) underestimated the occurrence of erythema migrans (EM), and only 26.1% and 28.3%, respectively, knew that EM alone was diagnostic for LD. A total of 30.5% of FPs and 12.1% of other specialists reported having treated a patient for the disease despite not believing that the patient had LD. Of all the respondents, 62.1% knew that LD was a reportable disease in BC. Respondents’ reports of risk of LD in their areas were appropriately associated with actual risk based on ecological niche.

Conclusion

Physicians are knowledgeable about the clinical signs and symptoms of LD and aware of the risk of the disease despite being in a low-endemic area. Physicians in BC are comfortable with treating patients empirically for LD. Education is needed to inform physicians that EM is diagnostic and no laboratory testing is indicated before treatment. Raising awareness among physicians that LD is reportable might improve reporting of future cases.     

Colorectal cancer screening practices in Saskatchewan: Survey of family physicians

Objective

To evaluate current colorectal cancer (CRC) screening practices in Saskatchewan and identify barriers to screening with the goal of improving current practice.

Design

Survey of family physicians.

Setting

Saskatchewan.

Participants

A total of 773 family physicians were surveyed.

Main outcome measures

Demographic characteristics, individual screening practices, and perceived barriers to screening.

Results

The response rate to the survey was 44.5%. When asked what method they used for fecal occult blood testing, almost 40% of respondents were either unsure or did not answer the question. Of those who did respond, 35.8% employed hemoccult testing following digital rectal examination, a practice not recommended for CRC screening. Screening guidelines for average-risk patients were generally well adhered to, with 79.9% of respondents recommending screening beginning at age 50. For screening patients at increased risk of CRC owing to family history, only 64.2% of respondents began screening 10 years before the age of the index patient at diagnosis. Physicians who were more likely to follow guidelines were female, in practice fewer than 10 years, trained in Canada, and practising in urban areas. More than 90% of family physicians agreed that a standard provincewide screening program would be beneficial.

Conclusion

We have identified considerable knowledge gaps with regard to CRC screening. There is confusion about which fecal occult blood tests are recommended for screening. Also, screening guidelines for patients with a family history of CRC are poorly understood. These findings suggest that better physician education about CRC screening is required. Introduction of a provincewide screening program should improve overall screening success.     

Awareness of do-not-resuscitate orders: What do patients know and want?

Objective

To assess outpatient understanding of and previous experiences with do-not-resuscitate (DNR) orders and to gauge patient preferences with respect to DNR discussions.

Design

Cross-sectional, self-administered survey.

Setting

Four urban primary care physician offices in Vancouver, BC.

Participants

A total of 429 consecutive patients 40 years of age and older presenting for routine primary care between March and May 2009.

Main outcome measures

Awareness of, knowledge about, and experiences with DNR decisions; when, where, and with whom patients wished to discuss DNR decisions; and differences in responses by sex, age, and ethnicity, assessed using χ² tests of independence.

Results

The response rate was 90%, with 386 of 429 patients completing the surveys. Most (84%) respondents had heard of the terms do not resuscitate or DNR. Eighty-six percent chose family physicians as among the people they most preferred to discuss DNR decisions with; 56% believed that initial DNR discussions should occur while they were healthy; and 46% thought the discussion should take place in the office setting. Of those who were previously aware of DNR orders, 70% had contemplated DNR for their own care, with those older than 60 years more likely to have done so (P = .02); however, only 8% of respondents who were aware of DNR orders had ever discussed the subject with a health care provider. Few patients (16%) found this topic stressful.

Conclusion

Most respondents were well informed about the meaning of DNR, thought DNR discussions should take place when patients were still healthy, preferred to discuss DNR decisions with family physicians, and did not consider the topic stressful. Yet few respondents reported having had a conversation about DNR decisions with any health care provider. Disparity between patient preferences and experiences suggests that family physicians can and should initiate DNR discussions with younger and healthier patients.     

Collaboration between family physicians and nurse clinicians: Opinions of graduates in family medicine

Objective

To determine whether graduating family physicians are exposed to collaboration between family physicians and nurse clinicians during their training, as well as their opinions about shared care between doctors and nurse clinicians in the delivery of patient care.

Design

Anonymous online survey.

Setting

Two French-Canadian university family medicine residency programs.

Participants

The 2010 and 2011 graduating family physicians (N = 343) from the University of Montreal and Laval University in Quebec.

Main outcome measures

The extent to which nurse clinicians in graduating family physicians’ training milieu were involved in preventive and curative patient care activities, and graduates’ opinions about nurse clinicians sharing care with physicians.

Results

Of 343 graduates, 186 (54.2%) participated in the survey. Although as residents in family medicine their exposure to shared care with nurse clinicians was somewhat limited, respondents indicated that they were generally quite open to the idea of sharing care with nurse clinicians. More than 70% of respondents agreed or strongly agreed that nurse clinicians could adjust, according to protocols of clinical guidelines, the treatment of patients with diabetes, hypertension, and asthma, as well as regulate medication for pain control in terminally ill patients. By contrast, respondents were less favourable to nurse clinicians adjusting the treatment of patients with depression. More than 80% of respondents agreed or strongly agreed that nurse clinicians could initiate treatment via a medical directive for routine hormonal contraception, acne, uncomplicated cystitis, and sexually transmitted infections. Respondents’ opinions on nurse clinicians initiating treatment for pharyngitis and otitis were more divided.

Conclusion

Graduating family physicians are quite open to collaborating with nurse clinicians. Although they have observed some collaboration between physicians and nurses, there are areas of shared clinical activities in which they would benefit from further exposure and training.     

Establishing physician advocates for human papillomavirus vaccination in British Columbia

Objective

To survey general practitioners in oncology (GPOs) in British Columbia (BC) to identify opportunities for them to serve as public supporters of human papillomavirus (HPV) vaccination.

Design

A mailed or online survey.

Setting

British Columbia.

Participants

Forty-two GPOs who worked in the community in BC.

Main outcome measures

Current practices, knowledge, and resource needs concerning HPV, the vaccine, and the HPV immunization program, and the willingness of respondents to be contacted to participate in stated public HPV vaccine supporter activities.

Results

The survey found that 42% of surveyed GPOs were willing to act as public supporters of the HPV vaccine. The survey also identified education needs among GPOs concerning HPV, the vaccine, and the HPV immunization program in BC.

Conclusion

This study found that GPOs in BC are willing to publicly support the HPV immunization program. This study shows that involving physicians in the promotion of public health programs is a viable option that should be further explored and evaluated.     

Family physicians who have focused practices in oncology: Results of a national survey

Objective

To characterize the demographic characteristics, practice profile, and current work life of general practitioners in oncology (GPOs) for the first time.

Design

National Web survey performed in March 2011.

Setting

Canada.

Participants

Members of the national GPO organization. Respondents were asked to forward the survey to non-member colleagues.

Main outcome measures

Profile of work as GPOs and in other medical roles, training received, demographic characteristics, and professional satisfaction.

Results

The response rate was 73.3% for members of the Canadian Association of General Practitioners in Oncology; overall, 120 surveys were completed. Respondents worked in similar proportions in small and larger communities. About 60% of them had participated in formal training programs. Most respondents worked part-time as GPOs and also worked in other medical roles, particularly palliative care, primary care practice, teaching, and hospital work. More GPOs from cities with populations of greater than 100 000 worked solely as GPOs than those from smaller communities (P = .0057). General practitioners in oncology played a variety of roles in the cancer care system, particularly in systemic therapy, palliative care, inpatient care, and teaching. As a group, more than half of respondents were involved in the care of each of the 11 common cancer types. Overall, 87.8% of respondents worked in outpatient care, 59.1% provided inpatient care, and 33.0% provided on-call services; 92.8% were satisfied with their work as GPOs.

Conclusion

General practitioners in oncology are involved in all cancer care settings and usually combine this work with other roles, particularly with palliative care in rural Canada. Training is inconsistent but initiatives are under way to address this. Job satisfaction is better than that of Canadian FPs in general. As generalists, FPs bring a valuable skill set to their work as GPOs in the cancer care system.