[Legal Analysis of the Implementation Rules of Delegation of Home Visits by Family Doctors to Non-Physician Health Professionals: Is the Implementation in Accordance with the Intention of the Law?] / Juristische Analyse der Umsetzungsregelungen der Delegation vertragsärztlicher Hausbesuche an nicht-ärztliche Gesundheitsberufe ­ ist die Umsetzung in Einklang mit dem Willen des Gesetzgebers?

Objective: Triggered by the AGnES model project of the University Medicine Greifswald, the Code of Social Law V was changed by the German Lower and Upper House of Parliament (Bundestag and Bundesrat) in 2008 so that the delegation of GP's activities to non-physician colleagues was allowed under highly restricted preconditions. Delegated home visits should become an integral part of the standard care in Germany. In this study, the implementation of § 87 para 2b clause 5 SGB V, established in Annex 8 of the Federal Collective Agreement, was checked for its legality in terms of qualification. Methods: The problem was checked with the legal methods of interpretation in pursuance of the norm and the methods of systematic, historic and teleologic interpretation. Results: Even though the Parliament clearly required orientation to the AGnES model project (in order to assure safety and effective care of delegated home visits), self-management in the implementation of the law remained far behind these guidelines. The main outcome of the legal analysis was that the implementation arrangements of the Code of Social Law V are predominantly illegal. Conclusions: The parties of the Federal Collective Agreement have to change the arrangements to meet the requirements of the Parliament and to avoid risks of liability for delegating GPs.

Failure to vaccinate.

Case histories are based on actual medical negligence claims or medicolegal referrals; however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved. This article discusses a case involving a patient who died as a result of overwhelming postsplenectomy infection. The case highlights the importance of regular vaccination and education of asplenic patients.

Medication prescribed by non-VA physicians. Final rule.

This document amends and adopts an interim final rule that governs the provision of medications to veterans when medication is prescribed by physicians who are not employees of nor are they providing care under contract with the Department of Veterans Affairs (VA). In a document published in the Federal Register on July 25, 2003, VA issued an interim final rule establishing a temporary program while also maintaining the program that it had in place before the interim final rule. Because the need cited in the interim final rule has abated and because the provisions added by the interim final rule were self-limiting in time and scope, we are removing these provisions which established the now obsolete temporary program.

To treat or not to treat.

The patient, Mr Christian Rossiter, was admitted to a residential care facility, Brightwater, in Perth on 4 November 2008. As a result of three serious injuries, the patient was quadriplegic. The third injury, involving a fall on 3 March 2008, resulted in Mr Rossiter developing spastic quadriplegia. He was admitted to hospital where he underwent treatment and rehabilitation before being transferred to Brightwater for ongoing care in November 2008. At this time, the patient's capacity to move was limited to some movement in one finger and some foot movement. He had a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube. During his stay in the residential care facility, the patient informed his general practitioner and the nursing staff that he wanted to die. He asked his GP and the staff at Brightwater to discontinue the provision of nutrition and hydration through the PEG tube. On 14 August 2009, the patient and Brightwater sought a declaration from the Supreme Court of Western Australia with regard to their respective rights and obligations. Specifically, the staff at Brightwater and the GP were concerned that compliance with Mr Rossiter's directions might result in criminal prosecution.

GP access to MRI: the Australian reality.

Twelve months ago, the Australian Medical Association (AMA) called upon the Federal Labor Government to implement a previous coalition policy allowing general practitioners to directly refer patients for magnetic resonance imaging (MRI) scans of the knee and brain. To support their position, the AMA commissioned a University of Sydney report evaluating the health care and economic outcomes of the policy. The AMA reported that the results supported the policy and would result in a $42 million saving from fewer computed tomography (CT) scans and fewer specialist referrals and consultations. Arguably, this was not an accurate portrayal of the results. Further research is needed, and ongoing dialogue with radiologists and other key stakeholders is urged, to ensure that access to MRI facilities will continue to meet future demand and that GPs will be adequately trained in utilising MRI services.

Primary care performance of alternatively licenced physicians in Ontario, Canada: a cross-sectional study using administrative data.

OBJECTIVES: Medical Regulatory Authorities (MRAs) provide licences to physicians and monitor those physicians once in practice to support their continued competence. In response to physician shortages, many Canadian MRAs developed alternative licensure routes to allow physicians who do not meet traditional licensure criteria to obtain licences to practice. Many physicians have gained licensure through alternative routes, but the performance of these physicians in practice has not been previously examined. This study compared the performance of traditionally and alternatively licenced physicians in Ontario using quality indicators of primary care. The purpose of this study was to examine the practice performance of alternatively licenced physicians and provide evaluative evidence for alternative licensure policies. DESIGN: A cross-sectional retrospective examination of Ontario health administrative data was conducted using Poisson regression analyses to compare the performance of traditionally and alternatively licenced physicians. SETTING: Primary care in Ontario, Canada. PARTICIPANTS: All family physicians who were licenced in Ontario between 2000 and 2012 and who had complete medical billing data in 2014 were included (n=11 419). OUTCOME MEASURES: Primary care quality indicators were calculated for chronic disease management, preventive paediatric care, cancer screening and hospital readmission rates using Ontario health administrative data. RESULTS: Alternatively licenced physicians performed similarly to traditionally licenced physicians in many primary care performance measures. Minimal differences were seen across groups in indicators of diabetic care, congestive heart failure care, asthma care and cancer screening rates. Larger differences were found in preventive care for children less than 2 years of age, particularly for alternatively licenced physicians who entered Ontario from another Canadian province. CONCLUSIONS: Our findings demonstrate that alternatively licenced physicians perform similarly to traditionally licenced physicians across many indicators of primary care. Our study also demonstrates the utility of administrative data for examining physician performance and evaluating medical regulatory policies and programmes.

Validating the Test Plan Specifications for the American Board of Family Medicine's Certification Examination.

PURPOSE: To demonstrate the degree to which the American Board of Family Medicine's certification examination is representative of family physician practice with regard to frequency of diagnoses encounter and the criticality of the diagnoses. METHODS: Data from 2012 National Ambulatory Medical Care Survey was used to assess the frequency of diagnoses encountered by family physicians nationally. These diagnoses were also rated by a panel of content experts for how critical it was to diagnose and treat the condition correctly and then assign the condition to 1 of the 16 content categories used on the American Board of Family Medicine examination. These ratings of frequency and criticality were used to create 7 different new schemas to compute percentages for the content categories. RESULTS: The content category percentages for the 7 different schemas correlated with the 2006 to 2016 test plan percentages from 0.50 to 0.90 with the frequency conditions being more highly correlated and the criticality conditions being less correlated. CONCLUSIONS: This study supports the continued use of the current Family Medicine Certification Examination content specifications as being representative of current family medicine practice; however, small adjustments might be warranted to permit better representation of the criticality of the topics.

How do general practitioners assess the criteria for due care for euthanasia in concrete cases?

OBJECTIVE: In the Netherlands the law states that physicians are allowed to grant a request for euthanasia or physician-assisted suicide (EAS) if specific criteria for due care are met. This study investigated which sources physicians use to determine whether three of these criteria (unbearable and hopeless suffering, and no realistic alternatives for treatment) are met. METHODS: The data were collected for the project Support and Consultation on Euthanasia in the Netherlands. General practitioners (GPs) received a written questionnaire concerning the most recent request for EAS that they had received. Of the 3614 (60%) GPs who returned the questionnaire, 1681 described the most recent request for EAS. RESULTS: The study shows that physicians used different types of sources, and more than one source, to determine whether the criteria were met. More sources were used when the criteria were met or when a request resulted in EAS. The determination of every criterion required a different approach, but for all criteria discussions with colleagues were important. CONCLUSIONS: Using less sources when a criterion is not met could possibly lead to less extensive consideration of the criteria, and therefore to assessing too easily that the request does not meet the criteria for due care.

Board Certified Family Physician Workforce: Progress in Racial and Ethnic Diversity.

Diversification of the physician workforce has been a goal of Association of American Medical Colleges for several years and could improve access to primary care for under-served populations and address health disparities. We found that family physicians' demographics have become more diverse over time, but still do not reflect the national demographic composition. Increased collaboration with undergraduate universities to expand pipeline programs may help increase the diversity of students accepted to medical schools, which in turn should help diversify the family medicine workforce.

Euthanasia and physician-assisted suicide not meeting due care criteria in the Netherlands: a qualitative review of review committee judgements.

ObjectivesTo assess how Dutch regional euthanasia review committees (RTE) apply the euthanasia and physician-assisted suicide (EAS) due care criteria in cases where the criteria are judged not to have been met ('due care not met' (DCNM)) and to evaluate how the criteria function to set limits in Dutch EAS practice. DESIGN: A qualitative review using directed content analysis of DCNM cases in the Netherlands from 2012 to 2016 published on the RTE website (https://www.euthanasiecommissie.nl/) as of 31 January 2017. RESULTS: Of 33 DCNM cases identified (occurring 2012-2016), 32 cases (97%) were published online and included in the analysis. 22 cases (69%) violated only procedural criteria, relating to improper medication administration or inadequate physician consultation. 10 cases (31%) failed to meet substantive criteria, with the most common violation involving the no reasonable alternative (to EAS) criterion (seven cases). Most substantive cases involved controversial elements, such as EAS for psychiatric disorders or 'tired of life', in incapacitated patients or by physicians from advocacy organisations. Even in substantive criteria cases, the RTE's focus was procedural. The cases were more about unorthodox, unprofessional or overconfident physician behaviours and not whether patients should have received EAS. However, in some cases, physicians knowingly pushed the limits of EAS law. Physicians from euthanasia advocacy organisations were over-represented in substantive criteria cases. Trained EAS consultants tended to agree with or facilitate EAS in DCNM cases. Physicians and families had difficulty applying ambiguous advance directives of incapacitated patients. CONCLUSION: As a retrospective review of physician self-reported data, the Dutch RTEs do not focus on whether patients should have received EAS, but instead primarily gauge whether doctors conducted EAS in a thorough, professional manner. To what extent this constitutes enforcement of strict safeguards, especially when cases contain controversial features, is not clear.

'The biggest car crash in NHS history': the media portrayal of GP pay before and after the introduction of the Health and Social Care Bill 2011.

BACKGROUND: The introduction of the Health and Social Care Bill (2011) changed the role of GPs to include commissioning of health services. Aim This study aimed to identify any differences in the media portrayal of GPs before and after the introduction of the Bill. METHODS: We retrospectively searched four British newspapers over the period 2009-2013 using the media database Nexis. In order to directly compare the findings of the study with the work of Tanner et al., articles relating to GP pay were analysed using thematic analysis. Themes were identified and each article was scored to determine whether it portrayed GPs positively or negatively. RESULTS: GPs were portrayed slightly less negatively after the introduction of the Bill. The theme of 'high salaries' persisted despite reference to 'pay freezes'. References to decreased trust in the patient-doctor relationship appeared after the introduction of the Bill. CONCLUSION: Negative portrayal of GP pay has continued and a lack of trust in GPs has started to be portrayed. This trend may exacerbate the low morale amongst the profession and difficulties in recruiting and retaining GPs.

The Single Graduate Medical Education (GME) Accreditation System Will Change the Future of the Family Medicine Workforce.

BACKGROUND: Due to the Accreditation Council for Graduate Medical Education (ACGME)/American Osteopathic Association (AOA) single-accreditation model, the specialty of family medicine may see as many as 150 programs and 500 trainees in AOA-accredited programs seek ACGME accreditation. This analysis serves to better understand the composition of physicians completing family medicine residency training and their subsequent certification by the American Board of Family Medicine. METHODS: We identified residents who completed an ACGME-accredited or dual-accredited family medicine residency program between 2006 and 2016 and cross-tabulated the data by graduation year and by educational background (US Medical Graduate-MD [USMG-MD], USMG-DO, or International Medical Graduate-MD [IMG-MD]) to examine the cohort composition trend over time. RESULTS: The number and proportion of osteopaths completing family medicine residency training continues to rise concurrent with a decline in the number and proportion of IMGs. Take Rates for USMG-MDs and USMG-IMGs seem stable; however, the Take Rate for the USMG-DOs has generally been rising since 2011. CONCLUSIONS: There is a clear change in the composition of graduating trainees entering the family medicine workforce. As the transition to a single accreditation system for graduate medical education progresses, further shifts in the composition of this workforce should be expected.

GPs' views on changing the law on physician-assisted suicide and euthanasia, and willingness to prescribe or inject lethal drugs: a survey from Wales.

If physician-assisted suicide/euthanasia is legalised in the UK, this may be the work of GPs. In the absence of recent or comprehensive evidence about GPs' views on either legalisation or willingness to take part, a questionnaire survey of all Welsh GPs was conducted of whom 1202 (65%) responded. Seven hundred and fifty (62.4% of responders) and 671 (55.8% of responders) said that they did not favour a change in the law to allow physician-assisted suicide/voluntary euthanasia respectively. These data provide a rational basis for determining the position of primary care on this contentious issue.

Concerning mistreatment of older people: clinical and ethical thoughts based on a study of known cases.

Following a report by the Health Ministry recommending a greater implication of general practitioners (GP) in the diagnosis and care of mistreated older people, we wanted to evaluate what was actually their role in this matter. A study was made of files of mistreated older persons referred to the social services in a Parisian suburb. For each file, we noted who raised the first suspicions of mistreatment, who diagnosed it, what happened next, and what precisely the GP's role was. Out of 600 files, we found 12 cases, concerning 14 persons (two couples). Although all the patients had health problems requiring frequent consultations with their GP, none of these situations were diagnosed by the GP. In all cases, the GP played only a secondary role, if at all. The following points are discussed: The link between family problems and history cannot be ignored in the follow up of such situations. The GP's role is discussed regarding clinical knowledge of mistreatment and the legal rules they have to deal with. Our results bring to light how the balance between the person's autonomy and the necessary direct action is especially delicate in this field.