Developing and testing the usability, acceptability, and future implementation of the Whole Day Matters Tool and User Guide for primary care providers using think-aloud, near-live, and interview procedures.

BACKGROUND: Canada's 24-Hour Movement Guidelines for Adults have shifted the focus from considering movement behaviours (i.e., physical activity, sedentary behaviour, and sleep) separately to a 24-h paradigm, which considers how they are integrated. Accordingly, primary care providers (PCPs) have the opportunity to improve their practice to promote all movement behaviours cohesively. However, PCPs have faced barriers to discussing physical activity alone (e.g., time, competing priorities, inadequate training), leading to low frequency of physical activity discussions. Consequently, discussing three movement behaviours may seem challenging. Tools to facilitate primary care discussions about physical activity have been developed and used; however, few have undergone usability testing and none have integrated all movement behaviours. Following a synthesis of physical activity, sedentary behaviour, and sleep tools for PCPs, we developed the Whole Day Matters Tool and User Guide that incorporate all movement behaviours. The present study aimed to explore PCPs' perceptions on the usability, acceptability, and future implementation of the Whole Day Matters Tool and User Guide to improve their relevancy among PCPs. METHODS: Twenty-six PCPs were observed and audio-video recorded while using the Tool and User Guide in a think-aloud procedure, then in a near-live encounter with a mock service-user. A debriefing interview using a guide informed by Normalization Process Theory followed. Recordings were transcribed verbatim and analysed using content analysis and a critical friend to enhance rigour. RESULTS: PCPs valued aspects of the Tool and User Guide including their structure, user-friendliness, visual appeal, and multi-behaviour focus and suggested modifications to improve usability and acceptability. Findings are further discussed in the context of Normalization Process Theory and previous literature. CONCLUSIONS: The Tool and User Guide were revised, including adding plain language, reordering and renaming sections, reducing text, and clarifying instructions. Results also informed the addition of a Preamble and a Handout for adults accessing care (i.e., patients/clients/service-users) to explain the evidence underpinning the 24-Hour Movement Guidelines for Adults and support a person-centered approach. These four resources (i.e., Tool, User Guide, Preamble, Handout) have since undergone a consensus building process to arrive at their final versions before being disseminated into primary care practice.

Resident and Family Physician Perspectives on Billing: An Exploratory Study.

Introduction: Within revenue cycle management, billing is an important activity for physicians with financial implications across remuneration models. We assessed the self-reported billing confidence of residents and attending physicians practicing at an academic family health team in a single payer setting. Methods: All residents and attending physicians working or who had worked at the team were invited to complete a 20-question electronic survey on their exposure to billing education and their self-reported confidence with various billing activities. Results: Twenty-five percent (n=40) of eligible physicians completed the survey. There were statistically significant differences between attending and resident physicians' billing experience (median 117.5 vs. 7.5 months). Analysis of free text comments revealed the positive impact of early billing exposure and opportunities for longitudinal feedback. Conclusion: Despite the small sample size, findings suggest that early exposure of family medicine residents to billing with standardized training contributes to a more positive experience during residency.

Management of patients with elevated Self-BAT scores or other bleeding symptoms: Updated overview for primary care practitioners.

OBJECTIVE: To provide recommendations for management of patients presenting with elevated self-administered bleeding assessment tool (Self-BAT) scores or other bleeding symptoms in a primary care setting. SOURCES OF INFORMATION: Primary research sources, clinical review articles, and interviews with research staff, hematologists, and family physicians were used to create the poster tools and reference guide resources. MAIN MESSAGE: Recommendations to manage a patient with an elevated Self-BAT score or other bleeding symptoms include reviewing the results of the Self-BAT to clarify relevant symptoms, performing initial diagnostic laboratory tests, and doing basic symptom management. Clinical judgment should be used when determining whether referral to a hematologist is necessary, but referral should be considered if the bleeding score is abnormal or if initial management options are ineffective. Some bleeding symptoms warrant evaluation by a gastroenterologist, obstetrician-gynecologist, or otolaryngologist. CONCLUSION: Primary care providers should conduct a thorough review of the Self-BAT results and associated management recommendations when working with a patient presenting with an elevated score or other bleeding manifestations. A review consists of the clarification of relevant symptoms, appropriate initial laboratory workups, and patient education. Treatment options for symptom management should be explored while recognizing the threshold for referral to a hematologist.

Determining the Impact of an Educational Intervention on Family Medicine Residents' Social Cognitions and Behavior for Discussing Physical Activity.

Problem: Primary care providers are recognized as important advocates for physical activity (PA); yet, clinical PA discussions remain infrequent. Educational approaches promoting the uptake of strategies that are proven to increase patient PA levels are effective for improving primary care providers' social cognitions and behavior for discussing PA with patients. However, research on the effectiveness of such educational interventions among family medicine residents is limited. Intervention: Using the Theory of Planned Behavior (TPB), an interactive, educational intervention was developed to increase PA discussion between first year family medicine residents and their patients. This study aimed to determine the impact of the intervention on residents' social cognitions and behavior for discussing PA with all adult (18-64 years) patients. Context: The intervention condition was comprised of 15 first year residents (2017/2018) who: (1) received the full intervention, and (2) completed both the pre- and post-intervention TPB questionnaires assessing changes in PA discussion social cognitions, and (3) had their medical charts reviewed for PA discussion behavior. The nonintervention condition was comprised of 15 first-year residents (2016/2017) who were randomly selected to have their medical charts reviewed for PA discussion behavior. Impact: Although no significant differences in social cognitions were observed pre- vs. post-intervention, intervention condition residents' perceptions of feeling adequately trained to discuss PA increased post-intervention (p = 0.005). A difference in residents' PA discussion behavior was observed between conditions at post (p = 0.01), where PA was discussed at more patient visits among intervention condition residents. Lessons Learned: Findings suggest that the observed effect of resident PA discussion behavior being greater in the intervention condition at post may be attributed to the intervention condition residents having received the theory-based, educational workshops. This study highlights the importance of educating and training residents on strategies for PA discussion; however, future interventions should address both the reflective and automatic processing aspects of behavior and strive to influence organizational factors that impact resident behavior for discussing PA.Supplemental data for this article is available online at at 10.1080/10401334.2021.1891542.

Analysis of factors affecting Canadian medical students' success in the residency match.

BACKGROUND: In North America, there is limited data to support deliberate application strategies for post-graduate residency training. There is significant interest in determining what factors play a role in Canadian medical graduate (CMG) matching to their first choice discipline and heightened concern about the number of students going unmatched altogether. METHODS: We analyzed matching outcomes of CMGs based on seven years (2013-2019) of residency application data (n= 13,499) from the Canadian Residency Matching Service (CaRMS) database using descriptive and binary logistic regression modeling techniques. RESULTS: The sample was 54% female, with 60% between the ages of 26 and 29, and 60% attended medical schools in Ontario. Applicants who received more rankings from residency programs were more likely (OR = 1.185, p < 0.001) to match. Higher research activities (OR = 0.985, p < 0.001) and number of applications submitted (OR = 0.920, p < 0.001) were associated with a reduced likelihood of matching. Number of volunteer activities and self-report publications did not significantly affect matching. Being male (OR = 0.799, p < 0.05) aged <25 (OR = 0.756, p < 0.05), and from Eastern (OR = 0.497, p < 0.01), or Western (OR = 0.450, p < 0.001) Canadian medical schools were predictors of remaining unmatched. CONCLUSIONS: This study identified several significant associations of demographic and application factors that affected matching outcomes. The results will help to better inform medical student application strategies and highlight possible biases in the selection process.

CONTEXTE: En Amérique du Nord, les données qui soutiennent les stratégies délibérées de candidature pour la formation en résidence postdoctorale sont limitées. Il existe un intérêt important dans la détermination des facteurs qui jouent un rôle dans le jumelage des diplômés canadiens en médecine (DCM) à leur discipline de premier choix et dans les préoccupations croissantes au sujet du nombre d'étudiants non jumelés. MÉTHODES: Nous avons analysé les résultats des DCM sur une période de sept ans (2013-2019) à partir de données de demandes de résidence (n = 13 499) tirées de la base de données du Service canadien de jumelage des résidents (CaRMS) en utilisant des techniques de modélisation par régression logistique binaire. RÉSULTATS: L'échantillon comportait 54 % de femmes, avec 56 % âgées de 26 à 29 ans, et 60 % qui allaient à des facultés de médecine en Ontario. Les candidats qui avaient reçu plus de classements des programmes de résidences étaient plus susceptibles d'être jumelés (RC = 1,185, p < 0,001). Les activités scientifiques de pointe (RC = 0,985, p < 0,001) et un certain nombre de candidatures soumises (RC = 0,90, p < 0,001) étaient associées avec une probabilité réduite de jumelage. Un certain nombre d'activités bénévoles et des publications autodéclarées ne modifiaient pas le jumelage de manière importante. Être un homme (RC = 0,799, p < 0,05) âgé de moins de 25 ans (RC = 0,756, p < 0,05) et de facultés canadiennes de médecine de l'Est (RC = 0,497, p < 0,01) et de l'Ouest (RC = 0,450, p < 0,001) étaient des prédicteurs des candidatures non jumelées. CONCLUSIONS: Cette étude a établi plusieurs associations importantes de facteurs démographiques et de candidatures qui touchaient les résultats des jumelages. Les résultats aideront à mieux informer les stratégies de candidatures des étudiants en médecine et montrent les biais possibles dans le processus de sélection.

Indicateurs du risque cardiovasculaire liés à la grossesse: Approche des soins de première ligne pour la gestion et la prévention postnatales de maladies futures.

OBJECTIF: Définir les indicateurs de risque cardiovasculaire liés à la grossesse et leur lien avec une maladie cardiovasculaire (MCV) subséquente, et offrir des conseils sur la façon dont les fournisseurs de soins de première ligne peuvent contribuer à réduire le risque de future MCV par l'entremise du dépistage et de l'intervention précoces. SOURCES D'INFORMATION: Sources primaires de recherche, revues systématiques et méta-analyses, et revues de synthèse clinique. MESSAGE PRINCIPAL: La maladie cardiovasculaire est la principale cause de décès chez les femmes. Puisque les facteurs de risque sous-jacents de MCV sont souvent présents plusieurs années avant que la MCV se déclare, il importe de recourir à des moyens novateurs pour identifier les femmes qui devraient se soumettre à un dépistage du risque de MCV à un plus jeune âge. La grossesse et le post-partum en donnent l'occasion, puisque certaines complications liées à la grossesse (troubles hypertensifs, diabète gestationnel, naissance prématurée idiopathique, accouchement d'un bébé accusant un retard de croissance intra-utérine ou abruptio placentae) identifient avec fiabilité les femmes qui présentent des facteurs de risque sous-jacents et souvent non reconnus de MCV. CONCLUSION: Les femmes aux prises avec au moins 1 de ces complications liées à la grossesse doivent être identifiées dès l'accouchement et recevoir un suivi formel après avoir accouché, y compris : anamnèse détaillée, examen physique, dépistage biochimique, counseling sur les modifications du mode de vie et, possiblement, interventions thérapeutiques. Le lien entre les complications de la grossesse et une future MCV est la première occasion d'évaluer le risque de MCV dans le but de préserver la santé et de prévenir la maladie.

Pregnancy-related cardiovascular risk indicators: Primary care approach to postpartum management and prevention of future disease.

OBJECTIVE: To define pregnancy-related cardiovascular risk indicators and their association with developing future cardiovascular disease (CVD), and to provide guidance on how primary care providers can help lower future CVD risk through early identification and intervention. SOURCES OF INFORMATION: Primary research sources, systematic reviews and meta-analyses, and clinical review articles. MAIN MESSAGE: Cardiovascular disease is the leading cause of death in women. As underlying CVD risk factors are often present for years before the onset of CVD, it is important to use innovative ways to identify women who should undergo CVD risk screening at a younger age. Pregnancy and the postpartum period afford that opportunity, given that the development of certain pregnancy complications (hypertensive disorders of pregnancy, gestational diabetes mellitus, idiopathic preterm birth, delivery of a baby with intrauterine growth restriction, or placental abruption) can reliably identify women with underlying, often unrecognized, CVD risk factors. CONCLUSION: Women with 1 or more of these pregnancy complications should be identified at the time of delivery and have formalized postpartum follow-up, including a thorough history, a physical examination, biochemical screening, counseling around lifestyle modification, and possible therapeutic intervention. The link between pregnancy complications and future CVD affords the earliest opportunity for CVD risk assessment for health preservation and disease prevention.

Canadian National Guidelines and Recommendations for Integrating Career Advising Into Medical School Curricula.

Career planning, decision making about specialty choice, and preparation for residency matching are significant sources of stress for medical students. Attempts have been made to structure and formalize career advising by including it in accreditation standards. There is an expressed need for national guidelines on career advising for medical students. The Future of Medical Education in Canada Postgraduate (FMEC PG) Implementation Project was created to ensure Canadian medical trainees receive the best education possible. From this, a diverse sub-working group (SWG), representing different Canadian regions, was formed to review career advising processes across the country. The SWG developed, through a modified formal consensus methodology, a strategy for medical student career advising that is adaptable to all schools in alignment with existing accreditation standards. The SWG outlined five guiding principles and five essential elements for Canadian universities offering an MD degree with recommendations on how to integrate the elements into each school's career advising system. The five essential elements are a structured approach to career advising, information about available career options, elective guidance, preparation for residency applications, and social accountability. This Perspective endorses the view of the FMEC PG Implementation Project that national guidelines are important to ensure Canadian medical schools are consistently meeting accreditation standards by providing reliable and quality career advising to all medical students. The SWG's position, based on national and provincial feedback, is that these guidelines will stimulate discourse and action regarding the requirements and processes to carry out these recommendations nationwide and share across borders.

The reliability of determining "leg dominant pain".

BACKGROUND CONTEXT: Patients with back dominant pain generally have a worse prognosis after spine surgery when compared with patients with leg dominant pain. Despite the importance of determining whether patients with lumbar spine pain have back or leg dominant pain as a predictor for success after decompression surgery, there are limited data on the reliability of methods for doing so. PURPOSE: To assess the test-retest reliability of a patient's ability to describe whether their lumbar spine pain is leg or back dominant using standardized questions. STUDY DESIGN/SETTING: Prospective, blinded, test-retest cohort study performed in an academic spinal surgery clinic. PATIENT SAMPLE: Consecutive patients presenting for consultation to one of three spinal surgeons for lumbar spine pain were enrolled. OUTCOME MEASURES: Eight questions to ascertain a patient's dominant location of pain, either back dominant or leg dominant, were identified from the literature and local experts. METHODS: These eight questions were administered in a test-retest format over two weeks. The test-retest reliability of these questions were assessed in a self-administered questionnaire format for one group of patients and by a trained interviewer in a second group. RESULTS: The test-retest reliability of each question ranged from substantial (eg, interviewer-administered percent question, weighted kappa=0.77) to slight (eg, self-administered pain diagram, weighted kappa=0.09). The Percent question was the most reliable in both groups (self-administered, interviewer). All questions in the interviewer-administered group were significantly (p<.001) more reliable than the self-administered group. Depending on the question, between 0% and 32% of patients provided a completely opposite response on test-retest. There was variability in prevalence of leg dominant pain, depending on which question was asked and there was no single question that identified all patients with leg dominant pain. CONCLUSION: A patient's ability to identify whether his or her lumbar spine pain is leg or back dominant may be unreliable and depends on which questions are asked, and also how they are asked. The Percent question is the most reliable method to determine the dominant location of pain. However, given the variability of responses and the generally poorer reliability of many specific questions, it is recommended that multiple methods be used to assess a patient's dominant location of pain.