Use of natural health products in children: Survey of parents in waiting rooms

Objective

To determine how common it is for parents to give natural health products (NHPs) to their children, which NHPs are being used, why they are being used, and parents’ assessments of the benefits and side effects of NHPs.

Design

Survey.

Setting

Newfoundland and Labrador.

Participants

Parents waiting in their family doctors’ offices.

Main outcome measures

Parent and child demographic characteristics; pediatric chronic medical conditions affecting the children; prescribed medications, over-the-counter medications, and NHPs used by the children; why the medications and NHPs were being used, the dose, and parents’ assessments of the effectiveness and side effects; and where parents had heard about the NHPs, whether they had told their physicians that the children were taking the products, and where they had obtained the products.

Results

A total of 202 (53.4%) of the 378 eligible adults who were approached completed the survey. This represented 333 children. Mean (SD) age of the children was 5.1 (3.3) years. Overall, 28.7% of parents reported using nonvitamin NHPs for their children. A total of 137 children (41.1%) had taken NHPs (including vitamins); 61.1% of the NHPs being used were vitamins. The remainder fell under teas (primarily chamomile and green teas), echinacea, fish or omega-3 oils, and a large category of “other” products. These NHPs were most commonly used to improve general health, improve immunity, and prevent colds and infections. Approximately half of the parents (51.7%) believed their children had benefited from taking NHPs, and 4.4% believed their children had experienced adverse side effects. Slightly less than half of the parents (45.0%) had informed their physicians that their children were taking NHPs.

Conclusion

Overall, 45.5% of parents attending physicians’ offices reported using NHPs in their children. If vitamins are not included in the definition of NHPs, this rate drops to 28.7%. Parents most commonly use NHPs to maintain the general health of their children, to prevent colds, and to boost children’s immune systems. About half of the parents believed the NHPs helped, very few had noticed any side effects, and approximately half had informed their physicians that they were giving their children NHPs.     

Use of natural health products in children: Qualitative analysis of parents’ experiences

Objective

To gain a more thorough understanding of why parents choose to give their children natural health products (NHPs), parents’ sources of information about NHPs, and the extent of disclosure and conversation with family doctors about the use of NHPs.

Design

Qualitative study.

Setting

Newfoundland and Labrador.

Participants

Parents of children who were using NHPs (N = 20).

Methods

Individual, semistructured interviews were carried out with parents to obtain a better understanding of the reasoning behind the use of NHPs. Key themes emerging from the qualitative data were identified according to a number of criteria, including relevance to the research objectives, frequency with which a theme was mentioned, relative importance of the themes based on the amount of text taken up to address an issue, and emphasis (eg, emphatic or emotional speech).

Main findings

The types of NHPs used by parents participating in this study varied, except for the use of multivitamins. In addition, use of the products themselves was variable and inconsistent. Parents reported few concerns about the use of NHPs. The most commonly reported source of information about NHPs was family and friends. Most participants had not spoken to their family doctors about the use of NHPs.

Conclusion

Participants considered NHPs to be “natural” and seemed to equate this assessment with safety. This might explain why these parents sought advice and information from family and friends rather than from their family doctors and often failed to disclose the use of NHPs to their children’s family doctors.     

Family practice patients' use of acetylsalicylic acid for cardiovascular disease prevention

Objective

To determine the prevalence of acetylsalicylic acid (ASA) use among family practice patients and the proportions of patients using ASA for primary and secondary cardiovascular prevention.

Design

Cross-sectional, self-reported, waiting room questionnaire.

Setting

Two family medicine clinics in Alberta.

Participants

Patients 50 years of age and older.

Main outcome measures

Overall prevalence of ASA use, proportion of ASA use for primary or secondary cardiovascular prevention, ASA use by patient age and sex, the proportion of patients who initiated ASA therapy on the advice of a physician, adverse events, and patient beliefs about ASA therapy.

Results

A total of 807 patients completed the questionnaire; the response rate was 89.1%. Overall, 39.8% of patients reported taking ASA regularly. Of those who took ASA, 87.0% did so for cardiovascular prevention (53.1% for primary prevention and 46.9% for secondary prevention). Of patients taking ASA for primary prevention, 62.8% did so upon the advice of their family physicians. Patients who took ASA believed that the benefits of taking ASA outweighed the risks; those who did not take ASA were unsure of the benefit-to-risk profile.

Conclusion

Many family practice patients take ASA, and more than half of those taking ASA take it for primary cardiovascular prevention. Family physicians appear to have an influence on patients'' decisions to take ASA. Educating family physicians and patients about the potential benefits and risks of ASA therapy would help promote the use of ASA in those who might receive the greatest overall benefit.     

Primary care role in expanded newborn screening: After the heel prick test

Objective

To examine the role of primary care providers in informing and supporting families who receive positive screening results.

Design

Cross-sectional survey.

Setting

Ontario.

Participants

Family physicians, pediatricians, and midwives involved in newborn care.

Main outcome measures

Beliefs, practices, and barriers related to providing information to families who receive positive screening results for their newborns.

Results

A total of 819 providers participated (adjusted response rate of 60.9%). Of the respondents, 67.4% to 81.0% agreed that it was their responsibility to provide care to families of newborns who received positive screening results, and 64.2% to 84.8% agreed they should provide brochures or engage in general discussions about the identified conditions. Of the pediatricians, 67.3% endorsed having detailed discussions with families, but only 24.1% of family physicians and 27.6% of midwives endorsed this practice. All provider groups reported less involvement in information provision than they believed they should have. This discrepancy was most evident for family physicians: most stated that they should provide brochures (64.2%) or engage in general discussions (73.5%), but only a minority did so (15.3% and 27.7%, respectively). Family physicians reported insufficient time (42.2%), compensation (52.2%), and training (72.3%) to play this role, and only a minority agreed they were up to date (18.5%) or confident (16.5%) regarding newborn screening.

Conclusion

Providers of primary newborn care see an information-provision role for themselves in caring for families who receive positive newborn screening results. Efforts to further define the scope of this role combined with efforts to mitigate existing barriers are warranted.     

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.     

Physicians as parents: Parenting experiences of physicians in Newfoundland and Labrador

OBJECTIVE

To investigate the experiences of physicians as parents and to see if there were any differences in the parenting challenges perceived by male and female physicians.

DESIGN

Mailed survey.

SETTING

Newfoundland and Labrador.

PARTICIPANTS

The survey was mailed to 180 male and 180 female licensed physicians, with a response rate of 60% (N = 216).

MAIN OUTCOME MEASURES

Self-reported experiences of being a parent and a physician.

RESULTS

Female physicians reported spending significantly more time on child care activities and domestic activities than their male counterparts did (P < .001). There was no significant difference in the number of professional hours between the 2 sexes, but income was significantly lower for female physicians (P < .001). More women than men had positive physician-parent role models, although very few physicians of either sex had such role models. Female physicians reported bearing the most responsibility for the day-to-day functioning of the family; male physicians relied on their female partners to carry out the main family responsibilities. Women reported feeling guilty about their performance as mothers and as doctors. Male physicians reported regrets about the lack of time with family.

CONCLUSION

Although women make up an increasing percentage of the physician work force in Canada, they still face challenges as they continue to take primary responsibility for child care and domestic activities. Women are torn between their careers and their families and sometimes feel inadequate in both roles. Male physicians regret having a lack of time with family. Strategies need to be employed in both the workplace and at home to achieve an acceptable balance between being a physician and being a parent.     

Effect of field notes on confidence and perceived competence: Survey of faculty and residents

Objective

To evaluate the effectiveness of field notes in assessing teachers’ confidence and perceived competence, and the effect of field notes on residents’ perceptions of their development of competence.

Design

A faculty and resident survey completed 5 years after field notes were introduced into the program.

Setting

Five Dalhousie University family medicine sites—Fredericton, Moncton, and Saint John in New Brunswick, and Halifax and Sydney in Nova Scotia.

Participants

First- and second-year family medicine residents (as of May 2009) and core family medicine faculty.

Main outcome measures

Residents’ outcome measures included beliefs about the effects of field notes on performance, learning, reflection, clinical skills development, and feedback received. Faculty outcome measures included beliefs about the effect of field notes on guiding feedback, teaching, and reflection on clinical practice.

Results

Forty of 88 residents (45.5%) participated. Fifteen of 50 faculty (30.0%) participated, which only permitted a discussion of trends for faculty. Residents believed field note–directed feedback reinforced their performance (81.1%), helped them learn (67.6%), helped them reflect on practice and learning (66.7%), and focused the feedback they received, making it more useful (62.2%) (P < .001 for all); 63.3% believed field note–directed feedback helped with clinical skills development (P < .01). Faculty believed field notes helped to provide more focused (86.7%) and effective feedback (78.6%), improved teaching (75.0%), and encouraged reflection on their own clinical practice (73.3%).

Conclusion

Most surveyed residents believed field note use improved the feedback they received and helped them to develop competence through improved performance, learning, reflection, and clinical skills development. The trends from faculty information suggested faculty believed field notes were an effective teaching, feedback, and reflection tool.     

Healthy fish consumption and reduced mercury exposure: counseling women in their reproductive years

Objective

To provide family physicians with a practical, evidence-based approach to counseling women about healthy fish eating.

Sources of information

MEDLINE was searched for articles published between 1999 and 2008. Most studies described in this article provide level II or III evidence.

Main message

Fish is an important component of a healthy diet for women in their reproductive years owing to the beneficial effects of omega-3 fatty acids on the neurologic development of the fetus. However, some fish species contain considerable methylmercury, which crosses the placenta and has harmful effects on neurobehavioural development. As many jurisdictions have issued fish consumption advisories, which can be confusing, women would benefit from individualized assistance from a trusted source, their family physicians, to clarify the risks and benefits of eating fish.

Conclusion

We recommend that family physicians counsel women in their reproductive years about healthy choices regarding fish in their diet, and provide appropriate resources.     

Must we appear to be all-knowing?: Patients’ and family physicians’ perspectives on information seeking during consultations

Objective

To compare patients’ opinions about family physicians looking up medical information during consultations with family physicians’ expectations of how patients would respond to their using sources to find answers to medical questions.

Design

Survey.

Setting

North York, Ont.

Participants

One hundred fifty-three family practice patients, 54 family physicians, and 21 family practice residents.

Main outcome measures

Patients’ self-reported confidence in their family physicians and their perceptions of the quality of care after seeing physicians look up medical information, both without specifying the physician’s source of information and with reference to several specific information media. Family physicians’ predictions for how patients would respond to their using resources to answer medical questions.

Results

When the information source used by physicians was not specified, 9% and 7% of patients reported decreased confidence and perceived lower quality of care, respectively. When the information source used by physicians was specified, the proportions of negative responses for patients’ confidence and their perceptions of quality of care were 39% and 31%, respectively, for Internet search engines (ISEs); 8% and 7% for online resources designed for physicians (ORDP); 27% and 27% for personal digital assistants (PDAs); and 10% and 9% for hard-copy medical textbooks (HMTs). When the information source was not specified, 32% and 12% of physicians expected patients to report negative responses for confidence and perceptions of quality of care, respectively. When the information source was specified, 51% and 33% of physicians expected patients to report negative responses for confidence and perceptions of quality of care, respectively, for their use of ISEs; 16% and 8% for ORDP; 20% and 12% for PDAs; and 36% and 21% for HMTs. Younger patients were more likely to respond negatively to physicians’ use of resources, especially if the source was an ISE (P < .001). Physicians earlier in their careers were more likely to expect negative patient responses (P < .05).

Conclusion

Family physicians overestimated the decrease in patients’ confidence caused by seeing them look up medical questions. While most patients responded positively, a substantial proportion of younger patients reported decreased confidence. Patients believed the best sources of information were ORDP and HMTs.     

Qualitative study of employment of physician assistants by physicians: Benefits and barriers in the Ontario health care system

Objective

To explore the experiences and perceptions of Ontario physician assistant (PA) employers about the barriers to and benefits of hiring PAs.

Design

A qualitative design using semistructured interviews.

Setting

Rural and urban eastern and southwestern Ontario.

Participants

Seven family physicians and 7 other specialists.

Methods

The 14 physicians participated in semistructured interviews, which were audiorecorded and transcribed verbatim. An iterative approach using immersion and crystallization was employed for analysis.

Main findings

Physician-specific benefits to hiring PAs included increased flexibility, the opportunity to expand practice, the ability to focus more time on complex patients, overall reduction in work hours and stress, and an opportunity for professional fellowship. Physicians who hired PAs without government financial support said PAs were affordable as long as they were able to retain them. Barriers to hiring PAs included uncertainty about funding, the initial need for intensive supervision and training, and a lack of clarity around delegation of acts.

Conclusion

Physicians are motivated to hire PAs to help deal with long wait times and long hours, but few are expecting to increase their income by taking on PAs. Governments, medical colleges, educators, and regulators must address the perceived barriers to PA hiring in order to expand and optimize this profession.     

Treatment and follow-up of anxiety and depression in clinical-scenario patients: Survey of Saskatchewan family physicians

Objective

To explore family physicians’ recommendations for treatment of, and number of weeks to first follow-up visit for, clinical-scenario patients presenting with symptoms of either a major depressive episode (MDE) or generalized anxiety disorder (GAD), as well as physicians’ perceived barriers to optimal care for these patients.

Design

Cross-sectional survey.

Setting

Saskatchewan.

Participants

A total of 331 family physicians practising in Saskatchewan as of December 2007.

Main outcome measures

Type of treatment and number of weeks to first follow-up visit recommended for clinical-scenario patients, as well as family physicians’ barriers to providing optimal care.

Results

The response rate was 49.7% (331 of 666 surveys returned). Most physicians recommended treatment of the GAD-scenario patient (93.7%) and the MDE-scenario patient (90.1%). Most physicians recommended immediate (65.6%) rather than delayed (28.1%) treatment of the GAD-scenario patient, and immediate (55.6%) rather than delayed (34.5%) treatment of the MDE-scenario patient. Pharmacotherapy alone (26.3%) was the most commonly recommended immediate treatment of the GAD-scenario patient; combination pharmacotherapy and counseling (15.8%) was the most commonly recommended immediate treatment of the MDE-scenario patient. Most physicians recommended that the first follow-up visit occur within 2 weeks for the GAD (79.4%) and the MDE (82.5%) clinical-scenario patients. Physicians were more likely to identify themselves rather than patients and the health care system as barriers to providing optimal care to the GAD (39.4%) and the MDE (39.8%) clinical-scenario patients.

Conclusion

Most family physicians recommend immediate treatment and early follow-up for patients presenting with symptoms of GAD or MDE. Physician-related barriers outweigh patient and health system barriers to providing optimal care to patients with common psychiatric disorders.     

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.     

What do children know about medications?: A review of the literature to guide clinical practice

Objective

To guide physicians in their communications with children about medications.

Quality of evidence

PubMed, EMBASE, and the Cochrane Library were searched from 1980 up to August 2009 for qualitative and quantitative research that investigated children’s knowledge of and beliefs about medications (levels of evidence II and III). Findings presented relate to healthy children aged 6 to 12 years old unless stated otherwise.

Main message

In order to improve children’s use of medicine, experts suggest that physicians communicate directly with children about medications, instead of communicating only with parents or caregivers. Children as young as 6 years old form opinions about medications, and many of these opinions persist in the adult population. This article reviews what we know about how children identify medication; children’s fear of medication; how they believe medication works; and their understanding of the medication-related concepts of medication efficacy, side effects, and treatment compliance. This knowledge will help physicians communicate more effectively with children about their medications.

Conclusion

Family physicians can help children understand why they take medicine and how to use it appropriately starting at an early age. This early training might affect their medication-taking behaviour throughout their adult lives. Studies in Canada are needed to further understand children’s beliefs about medication and to see if these beliefs correlate with international data.     

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.