The Contribution of Family Medicine and Family Medicine Leaders to Primary Health Care Development in Americas - from Alma-Ata to Astana and beyond.

Since 2012, the Besrour Centre for Global Family Medicine at the College of Family Physician of Canada has brought together its partners from the Americas annually, to reflect on the evolution of Family Medicine on the continent since Alma-Ata, and to look forward to future challenges. Family doctors are but one element of a strong health system. Family Medicine provides key ingredients to respond to population health needs especially as countries move through the epidemiological transition to face larger burdens of chronic disease and multimorbidity. In this paper, we provide a high-level overview of the state of Family Medicine on the continent. We then analyze trends in the education of family physicians to face this changing landscape, including the emphasis on the leader role of future family physicians. Postgraduate programs in Family Medicine in the Americas are placing increasing emphasis on teaching collaborative care in view of creating truly interdisciplinary health teams for the benefit of patients.

The Contribution of Family Medicine and Family Medicine Leaders to Primary Health Care Development in Americas - from Alma-Ata to Astana and beyond / A contribuição da Medicina de Família e dos líderes em Medicina de Família para o desenvolvimento da Atenção Primária à Saúde nas Américas - de Alma-Ata à Astana e além

Abstract Since 2012, the Besrour Centre for Global Family Medicine at the College of Family Physician of Canada has brought together its partners from the Americas annually, to reflect on the evolution of Family Medicine on the continent since Alma-Ata, and to look forward to future challenges. Family doctors are but one element of a strong health system. Family Medicine provides key ingredients to respond to population health needs especially as countries move through the epidemiological transition to face larger burdens of chronic disease and multimorbidity. In this paper, we provide a high-level overview of the state of Family Medicine on the continent. We then analyze trends in the education of family physicians to face this changing landscape, including the emphasis on the leader role of future family physicians. Postgraduate programs in Family Medicine in the Americas are placing increasing emphasis on teaching collaborative care in view of creating truly interdisciplinary health teams for the benefit of patients.

Resumo Desde 2012, o Centro Besrour de Medicina Global de Família, na Faculdade de Medicina de Família do Canadá, reúne seus parceiros das Américas anualmente para refletir sobre a evolução da Medicina de Família no continente desde Alma-Ata e para os desafios futuros. Os médicos de família são apenas um elemento de um forte sistema de saúde. A Medicina de Família fornece ingredientes-chave para responder às necessidades de saúde da população, especialmente à medida em que os países passam pela transição epidemiológica para enfrentar um fardo maior de doenças crônicas e de multimorbidade. Neste artigo, fornecemos uma visão geral de alto nível do estado da Medicina de Família no continente. Em seguida, analisamos as tendências na educação dos médicos de família para enfrentar esse cenário em mudança, incluindo a ênfase no papel de líder dos futuros médicos de família. Os programas de pós-graduação em Medicina de Família nas Américas estão enfatizando cada vez mais o ensino do cuidado colaborativo, a fim de criar equipes de saúde verdadeiramente interdisciplinares para o benefício dos pacientes.

Spiritual Dimensions of Nurse Practitioner Consultations in Family Practice.

Purpose of Study: To explore the spiritual dimensions of nurse practitioner consultations in primary care through the lens of availability and vulnerability. Design of Study and Methods Used: A hermeneutic phenomenological enquiry exploring the spiritual dimensions of primary care consultations consisting of two interviews per participant over an 18-month period was conducted with nurse practitioners in the United Kingdom. A purposive sample of eight nurse practitioners were recruited and interviewed. Interviews were fully transcribed and analyzed thematically. Findings: Participants identified that spirituality can be difficult to conceptualize and operationalize in practice. Participants articulated the meaning of spirituality and gave examples of when they had witnessed a spiritual dimension in practice. Key themes included how nurse practitioners conceptualize spirituality, the context for spirituality to be integrated into care, and the importance of spirituality as an aspect of holistic care. The concepts of Availability and Vulnerability were used intentionally as a lens in the study to explore whether these concepts and approaches to practice could enhance integration of spirituality into practice. Conclusion: Knowledge and understanding regarding spirituality in nurse practitioners consultations in primary care has been uncovered. A framework for operationalizing spirituality has been developed.

Mientras haya vida, hay todo: una mirada en la sexualidad del adulto mayor / While there is life, there is everything: a look at the elderly sexuality

Introducción.Desde un punto de vista integral, la sexualidad comprende aspectos de orden biopsicosocial. Los prejuiciosy el desconocimiento llevan a evitar hablar sobre este tema en la consulta con el adulto mayor (AM).Objetivo.Profundizar en la vivencia de la sexualidad del AM.Metodología.Estudio cualitativo, fenomenológico, realizado en dos centros de actividades recreativas para AM en SanMiguel de Tucumán, que incluyó 13 entrevistas semiestructuradas en profundidad a pacientes mayores de 60 años, 11 desexo femenino, seleccionados en forma intencional y por conveniencia en Agosto de 2018.Resultados.Existe una dicotomía entre quienes hablan del tema y quienes no; sin embargo, todos expresan el deseode naturalizarlo tanto en su círculo social como en la consulta médica. Los AM aceptan el proceso de envejecimiento,tienen una autopercepción positiva de su imagen y pese a los prejuicios, experiencias, comorbilidades y adversidades, seadaptan buscando formas para sentirse bien y disfrutar de una sexualidad plena.Conclusión.El envejecimiento y la sexualidad son conceptos dinámicos que confluyen con las experiencias de vida.Creemos que como médicos de familia es importante brindar una atención integral, abordando las diferentes dimensionesdel ser humano, incluyendo su sexualidad. (AU)

Introduction.Sexuality from an integral point of view includes aspects of biopsychosocial order. Prejudice and ignorancelead to avoid talking about this topic in the medical consultation with the Eldery.Objective.To deepen the experience of the sexuality of the Eldery.Methodology.Qualitative, phenomenological study, conducted in two centres of recreational activities for Senior Citizensin San Miguel de Tucumán, which included 13 in-depth semi-structured interviews to patients over 60 years of age, 11female, selected intentionally and for convenience in August 2018.Results.There is a dichotomy between those who talk about the subject and those who do not; however, all of themexpress the desire to naturalize it in both, their social circle and the medical consultation. The eldery patients acceptthe ageing process, have a positive self-perception of their image and despite prejudices, experiences, comorbidities andadversities, they adapt looking for ways to feel good and enjoy a full sexuality.Conclusion.Aging and sexuality are dynamic concepts that converge with life experiences. We believe that, as familydoctors, it is important to provide comprehensive care, addressing the different dimensions of the human being, wheresexuality is included. (AU)

CFHA Don Bloch Award acceptance speech, 2018.

Provides John S. Rolland's acceptance speech for the 2018 CFHA Don Bloch Award. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

An integrated, collaborative healthcare model for the early diagnosis and management of dementia: Preliminary audit results from the first transdisciplinary service integrating family medicine and geriatric psychiatry services to the heart of patients' homes.

BACKGROUND: The number of dementia cases is expected to rise exponentially over the years in many parts of the world. Collaborative healthcare partnerships are envisaged as a solution to this problem. Primary care physicians form the vanguard of early detection of dementia and influence clinical care that these patients receive. However, evidence suggests that they will benefit from closer support from specialist services in dementia care. An interdisciplinary, collaborative memory clinic was established in 2012 as a collaborative effort between a large family medicine based service and a specialist geriatric psychiatry service in Singapore. It is the first service in the world that integrates a family medicine based service with geriatric psychiatry expertise in conjunction with community-based partnerships in an effort to provide holistic, integrated care right into the heart of patients' homes as well as training in dementia care for family medicine physicians. We describe our model of care and the preliminary findings of our audit on the results of this new model of care. METHODS: This was a retrospective audit done on the electronic medical records of all patients seen at the Memory Clinic in Choa Chu Kang Polyclinic from August 2013 to March 2016. The information collected included gender, referral source, patient trajectories, presence of behavioural and psychological symptoms of dementia and percentage of caregivers found to be in need of support. A detailed outline of the service workflow and processes were described. RESULTS: A majority (93.5%) of the patients had their memory problems managed at the memory clinic without escalation to other specialist services. 22.7% of patients presented with behavioural and psychological symptoms of dementia. When initially assessed, a majority (82.2%) of patients' caregivers were found to be in need of support with 99.5% of such caregivers' needs addressed with memory clinic services. CONCLUSION: Our model of care has the potential to shape future dementia care in Singapore and other countries with a similar healthcare setting. Redesigning and evolving healthcare services to promote close collaboration between primary care practitioners and specialist services for dementia care can facilitate seamless delivery of care for the benefit of patients.

A 10-year review of health care reform on Family Practice Integrated Care Project-Taiwan experience.

Objective: Taiwan has launched a Family Practice Integrated Care Project (FPICP) to develop an accountable family doctor system since March 2003. We aim to report the effectiveness of this nationwide demonstration programme over a 10-year period. Methods: Papers and reports related to the FPICP published both in English and in Chinese from 2003 to 2015 were collected systematically based on keywords including 'family doctor', 'primary care', 'integrated care' and 'Taiwan'. Also collected and reviewed were national health insurance administration annual reports and related publications from Taiwan Association of Family Medicine. Quality care indicators including structure, process and outcome for programme monitoring were reported. Results: Up to June 2015, the project had enrolled a total of 10.5% of Taiwan's population. Approximately 24.9% of primary care physicians and 29.7% of community clinics joined the project to serve the members of 426 community health care groups (CHCGs). Compared to non-members, CHCG members received more preventive care services, especially in adult health examination (49% versus 19%), Pap smear (29% versus 22%), elderly influenza vaccination (42% versus 28%) and immunochemical faecal occult blood test (43% versus 31%) (P < 0.01). Members showed a markedly high level of satisfaction (>95%), especially in overall satisfaction, provision of health consultation and information, and improvement in understanding personal health condition. Conclusions: In the future, through the support of family physicians and CHCGs, a person-centred integrated health care delivery system can be an effective solution to the current barriers in the medical care system.

To clinician innovators: A special invitation.

Our vision for this special issue was simple: to inspire clinician innovators working in integrated care to not only consume the literature but also contribute to it. Growing the research capacity of clinician innovators in integrated care is vital for at least three reasons. First and foremost, real-world clinicians have an excellent vantage on the processes and outcomes that relate to the reach or the extent to which the given intervention or model of care engages its intended audience (Klesges, Estabrooks, Dzewaltowski, Bull, & Glasgow, 2005). Second, policy changes within the Affordable Care Act have facilitated the rapid uptake of integrated care in recent years (Beacham, Kinman, Harris, & Masters, 2012; Nash, Khatri, Cubic, & Baird, 2013), but the growth of the published evidence base has not kept pace. Third, clinician innovators in integrated care are well positioned to contribute to the evidence base because of the growing emphasis on demonstrating outcomes in health care. Many of the articles in this special issue highlight specific recommendations that clinician innovators can make to transform a local evaluation into one that produces generalizable findings worthy of publication. Our hope is that this special issue can help dismantle the "research" stereotype and inspire future clinician innovators to become more active participants. (PsycINFO Database Record

Redesigning primary care to tackle the global epidemic of noncommunicable disease.

Noncommunicable diseases (NCDs) have become the major contributors to death and disability worldwide. Nearly 80% of the deaths in 2010 occurred in low- and middle-income countries, which have experienced rapid population aging, urbanization, rise in smoking, and changes in diet and activity. Yet the health systems of low- and middle-income countries, historically oriented to infectious disease and often severely underfunded, are poorly prepared for the challenge of caring for people with cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We have discussed how primary care can be redesigned to tackle the challenge of NCDs in resource-constrained countries. We suggest that four changes will be required: integration of services, innovative service delivery, a focus on patients and communities, and adoption of new technologies for communication.

Meta-Kucha: the margin or the mainstream?

The inexorable push in integrated care is to move collaboration between biomedical and psychosocial clinicians into the mainstream of health care. This effort requires expanding small models to scale, convening statewide transformation initiatives, and leaving the comfortable confines of safety net clinics to prove integration in the for-profit systems that dominate American health care. CFHA's (Collaborative Family Health care Association's) Pecha Kucha Plenary assembled compelling narratives from the fringes of our health care system. The competing calls from the mainstream and from the margins force tension into our dialogue. However, for our model to be widely embraced, we need blueprints that fit most patients in most clinics. What we learned from the Pecha Kucha narratives is that people at the margins find ways of asserting their voices and achieving their needs. Sometimes it is through their own resilience and disruptiveness; other times it is through an advocate from the mainstream who shares their stories in such a compelling way that they bypass our well-crafted models and spark our souls.

Del lado de allá y del lado de acá. ¿Qué pueden aprender mutuamente los países emergentes latinoamericanos y España para mejorar sus perfiles del médico de familia? / From one side of the ocean to the other. What can emerging latinamerican countries and Spain learn from each other to improve their family physician profile?

Objetivo: Se realizó un estudio cualitativo con el objetivo de encontrar factores estratégicos en medicina de familia que impliquen oportunidades de aprendizaje que los países del Norte desarrollado puedan utilizar de los países del Sur emergentes, y viceversa. Diseño, emplazamiento y participantes: A partir de un muestreo no aleatorio, intencionado, seguido de muestra en bola de nieve, hasta la saturación de los datos, se realizaron por parte médicos de familia de atención primaria de Toledo y Tenerife en España, y Paraguay, México, y Perú, diarios de campo de un día habitual y su contexto socio-sanitario, y se evaluaron mediante análisis del contenido y un estudio DAFO (Debilidades, Amenazas, Fortalezas y Oportunidades). Mediciones principales y resultados: Se obtuvieron 24 diarios de un día normal (9 médicos en España, 7 en México, 4 en Paraguay, y 4 en Perú). Se encontraron "fortalezas" del Sur en la coexistencia de trabajo ambulatorio y hospitalario, en el amplio rango de tareas asistenciales, en el mayor peso de actividades de promoción y educación para la salud dirigidas a la población, en la presencia de actividades comunitarias de campo, en la integración de la medicina tradicional, en la mejor relación médico-paciente, y percepción más positiva de la carga de trabajo. Y "fortalezas" del Norte en las actividades de prevención, promoción y educación para la salud integradas en la asistencia por enfermedades en el centro de salud, y en la mayor existencia de recursos materiales. Conclusiones: Hay áreas donde podría aprender el médico de familia español del latinoamericano y viceversa (AU)

Objective: A qualitative study was carried out with the aim to find strategic factors involving learning opportunities that northern developed countries could use from emerging countries in the South and vice versa. Design, setting and participants: A non-random intentional sampling, followed by a snowball sampling until data saturation were carried out by a group of primary health care family physicians in Toledo and Tenerife in Spain and Paraguay, Mexico and Peru. Field diaries of a normal day and its health and social care context were kept and analyzed, and a SWOT study (strengths weaknesses, opportunities and threats) was performed. Main measures and results: Twenty-four diaries of a normal day were obtained (9 physicians in Spain, 7 in Mexico, 4 in Paraguay and 4 in Peru). Some strengths were found in the South in the coexistence of ambulatory care and hospital work, in the wide range of care tasks, in the greater weight of health promotion and educational activities targeted to the population, in the presence of community field activities, in the integration of traditional medicine, in the better patient-doctor relationship and a more positive perception of the workload. And the strengths in northern countries were: more prevention, health promotion and educational actions integrated in visits to the family physician in primary care settings and more material resources available. Conclusions: There are some areas in which the Spanish family physician could learn from the latinamerican physician and vice versa (AU)

Working together in the best interest of patients.

The findings by Peterson et al. show that over half of all family physicians work with nurse practitioners, physician assistants, and certified nurse midwives. While tensions surrounding leadership of teams remain an issue, there are many systems problems that all primary care providers need to face together. This commentary presents the challenges we need to address in order to keep the focus of our care on the patient.

Most family physicians work routinely with nurse practitioners, physician assistants, or certified nurse midwives.

The U.S. physician workforce is struggling to keep pace with the demand for health care services, a situation that may worsen without efforts to enhance team-based care. More than half of family physicians work with nurse practitioners, physician assistants, or certified nurse midwives, and doing so helps ensure access to health care services, particularly in rural areas.

Impact of physician preferences for homeopathic or conventional medicines on patients with musculoskeletal disorders: results from the EPI3-MSD cohort.

OBJECTIVE: The objective of this study was to assess the effect of physician practicing preferences (PPP) in primary care for homeopathy (Ho), CAM (Complementary and alternative medicines) with conventional medicine (Mx) or exclusively conventional medicine (CM) on patients with musculoskeletal disorders (MSDs), with reference to clinical progression, drug consumption, side effects and loss of therapeutic opportunity. METHODS: The EPI3-MSD study was a nationwide observational cohort of a representative sample of general practitioners (GP) and their patients in France. Recruitment of GP was stratified by PPP, which was self-declared. Diagnoses and comorbidities were recorded by GP at inclusion. Patients completed a standardized telephone interview at inclusion, one, three and twelve months, including MSD-functional scales and medication consumption. RESULTS: 1153 MSD patients were included in the three PPP groups. Patients did not differ between groups except for chronicity of MSDs (>12 weeks), which was higher in the Ho group (62.1%) than in the CM (48.6%) and Mx groups (50.3%). The twelve-month development of specific functional scores was identical across the three groups after controlling for baseline score (p > 0.05). After adjusting for propensity scores, NSAID use over 12 months was almost half in the Ho group (OR, 0.54; 95%CI, 0.38-0.78) as compared to the CM group; no difference was found in the Mx group (OR, 0.81; 95% CI: 0.59-1.15). CONCLUSION: MSD patients seen by homeopathic physicians showed a similar clinical progression when less exposed to NSAID in comparison to patients seen in CM practice, with fewer NSAID-related adverse events and no loss of therapeutic opportunity.

Adoption of new drugs by physicians: a survival analysis.

BACKGROUND: New drugs often substitute others cheaper and with a risk-benefit balance better established. Our aim was to analyse the diffusion of new drugs during the first months of use, examining the differences between family physicians and specialists. METHODS: Prescription data were obtained of cefditoren, duloxetine, etoricoxib, ezetimibe, levocetirizine, olmesartan, pregabalin and tiotropium 36 months after their launching. We obtained the monthly number of prescriptions per doctor and the number prescribers of each drug by specialty. After discarding those with less than 10 prescriptions during this period, physicians were defined as adopters if the number of prescriptions was over the 25th percentile for each drug and level (primary or secondary care). The diffusion of each drug was studied by determining the number of adopter family physicians throughout the study period. Among the group of adopters, we compared the month of the first prescription by family physicians to that of other specialists using the Kaplan-Meier method. RESULTS: The adoption of the drugs in primary care follows an exponential diffusion curve that reaches a plateau at month 6 to 23. Tiotropium was the most rapidly and widely adopted drug. Cefditoren spread at a slower rate and was the least adopted. The diffusion of etoricoxib was initially slowed down due to administrative requirements for its prescription. The median time of adoption in the case of family physicians was 4-6 months. For each of the drugs, physicians of a specialty other than family physicians adopted it first. CONCLUSIONS: The number of adopters of a new drug increases quickly in the first months and reaches a plateau. The number of adopter family physicians varies considerably for different drugs. The adoption of new drugs is faster in specialists. The time of adoption should be considered to promote rational prescribing by providing timely information about new drugs and independent medical education.

La investigación en atención primaria como área de conocimiento. Informe SESPAS 2012 / Research in primary care as an area of knowledge. SESPAS Report 2012

La atención primaria de salud ofrece grandes oportunidades para la investigación. Constituye un área de conocimiento propio, que es necesario desarrollar para mejorar la calidad de sus servicios y la salud de los pacientes. Estas oportunidades son únicas para la investigación clínica de base poblacional, con un enfoque de promoción de la salud y de prevención de la enfermedad, ya sea primaria, secundaria o terciaria. Es prioritario investigar en el desarrollo del modelo biopsicosocial de atención, nuevos modelos de atención integrada y atención comunitaria. Cabe destacar la actividad y la estructura generada por la Red de Investigación en Actividades Preventivas y de Promoción de la Salud (redIAPP), que ha atraído a su alrededor gran parte de la actividad investigadora en atención primaria de salud en nuestro país. A pesar del esfuerzo de diversas instituciones y fundaciones, así como de unidades docentes y de investigación, el desarrollo de la investigación no ha alcanzado el volumen, la relevancia, la calidad y el impacto deseables. La presencia de los profesionales de atención primaria de salud en las estructuras de investigación sigue siendo escasa, y la inversión en proyectos y líneas de investigación propias es pobre. Para poder invertir esta situación se precisa una serie de medidas: consolidar estructuras organizativas de apoyo específicas, con adecuada dotación de personal y recursos económicos; facilitar que los profesionales puedan compatibilizar su labor clínica con una dedicación específica a la investigación, para que elaboren proyectos relevantes y consoliden líneas de investigación estables de contenidos acordes con el área de conocimiento propio, y que se apliquen a la mejora de la calidad y a la innovación de los servicios de atención primaria de salud (AU)

Primary care offers huge potential for research. This setting is an area of knowledge that must expand to improve the quality of its services and patients’ health. Population-based clinical studies with a focus on health promotion and primary, secondary and tertiary disease prevention offer unique research opportunities. Developing research in the biopsychosocial model of clinical practice and new models of integrated healthcare and community care is therefore a priority. The framework and activities carried out by the Research Network in Preventive Activities and Health Promotion have been instrumental in the development of research in primary care in Spain. Despite the efforts invested by various institutions, foundations, teaching and research departments in primary care research, the projected outputs in terms of volume, quality and impact have not been achieved. The involvement of primary care professionals in research platforms is insufficient, with scarce contribution toward investment in specific primary care research projects. To change the current status of research in primary care, a number of measures are required, namely, the consolidation of research organisms specific to primary care with adequate allocation of funding and staff, and the allocation of specific time for research to primary care professionals to enable them to produce significant projects and consolidate established research lines in their areas of expertise, with applications mainly in quality improvement and innovation of primary care services (AU)