Physician perspectives on delays in cancer diagnosis in Alberta: a qualitative study.

BACKGROUND: Delays in cancer diagnosis have been associated with reduced survival, decreased quality of life after treatment, and suboptimal patient experience. The objective of the study was to explore the perspectives of a group of family physicians and other specialists regarding potentially avoidable delays in diagnosing cancer, and approaches that may help expedite the process. METHODS: We conducted a qualitative study using interviews with physicians practising in primary and outpatient care settings in Alberta between July and September 2019. We recruited family physicians and specialists who were in a position to discuss delays in cancer diagnosis by email via the Cancer Strategic Clinical Network and the Alberta Medical Association. We conducted semistructured interviews over the phone, and analyzed data using thematic analysis. RESULTS: Eleven family physicians and 22 other specialists (including 7 surgeons or surgical oncologists, 3 pathologists, 3 radiologists, 2 emergency physicians and 2 hematologists) participated in interviews; 22 were male (66.7%). We identified 4 main themes describing 9 factors contributing to potentially avoidable delays in diagnosis, namely the nature of primary care, initial presentation, investigation, and specialist advice and referral. We also identified 1 theme describing 3 suggestions for improvement, including system integration, standardized care pathways and a centralized advice, triage and referral support service for family physicians. INTERPRETATION: These findings suggest the need for enhanced support for family physicians, and better integration of primary and specialty care before cancer diagnosis. A multifaceted and coordinated approach to streamlining cancer diagnosis is required, with the goals of enhancing patient outcomes, reducing physician frustration and optimizing efficiency.

Mapping the Location of Health Centers in Relation to "Maternity Care Deserts": Associations With Utilization of Women's Health Providers and Services.

BACKGROUND AND OBJECTIVES: The aim was to explore the association between community health centers' (CHC) distance to a "maternity care desert" (MCD) and utilization of maternity-related health care services, controlling for CHC and county-level factors. MEASURES: Utilization as: total number of CHC visits to obstetrician-gynecologists, certified nurse midwives, family physicians (FP), and nurse practitioners (NP); total number of prenatal care visits and deliveries performed by CHC staff. RESEARCH DESIGN: Cross-sectional design comparing utilization between CHCs close to MCDs and those that were not, using linked 2017 data from the Uniform Data System (UDS), American Hospital Association Survey, and Area Health Resource Files. On the basis of prior research, CHCs close to a "desert" were hypothesized to provide higher numbers of FP and NP visits than obstetrician-gynecologists and certified nurse midwives visits. The sample included 1261 CHCs and all counties in the United States and Puerto Rico (n=3234). RESULTS: Results confirm the hypothesis regarding NP visits but are mixed for FP visits. CHCs close to "deserts" had more NP visits than those that were not. There was also a dose-response effect by MCD classification, with NP visits 3 times higher at CHCs located near areas without any outpatient and inpatient access to maternity care. CONCLUSIONS: CHCs located closer to "deserts" and NPs working at these comprehensive, primary care clinics have an important role to play in providing access to maternity care. More research is needed to determine how best to target resources to these limited access areas.

Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States.

BACKGROUND: Rural health disparities and access gaps may contribute to higher maternal and infant morbidity and mortality. Understanding and addressing access barriers for specialty women's health services is important in mitigating risks for adverse childbirth events. The objective of this study was to investigate rural-urban differences in health care access for women of reproductive age by examining differences in past-year provider visit rates by provider type, and quantifying the contributing factors to these findings. METHODS AND FINDINGS: Using a nationally-representative sample of reproductive age women (n = 37,026) from the Medical Expenditure Panel Survey (2010-2015) linked to the Area Health Resource File, rural-urban differences in past-year office visit rates with health care providers were examined. Blinder-Oaxaca decomposition analysis quantified the portion of disparities explained by individual- and county-level sociodemographic and provider supply characteristics. Overall, there were no rural-urban differences in past-year visits with women's health providers collectively (65.0% vs 62.4%), however differences were observed by provider type. Rural women had lower past-year obstetrician-gynecologist (OB-GYN) visit rates than urban women (23.3% vs. 26.6%), and higher visit rates with family medicine physicians (24.3% vs. 20.9%) and nurse practitioners/physician assistants (NPs/PAs) (24.6% vs. 16.1%). Lower OB-GYN availability in rural versus urban counties (6.1 vs. 13.7 providers/100,000 population) explained most of the rural disadvantage in OB-GYN visit rates (83.8%), and much of the higher family physician (80.9%) and NP/PA (50.1%) visit rates. Other individual- and county-level characteristics had smaller effects on rural-urban differences. CONCLUSION: Although there were no overall rural-urban differences in past-year visit rates, the lower OB-GYN availability in rural areas appears to affect the types of health care providers seen by women. Whether rural women are receiving adequate specialized women's health care services, while seeing a different cadre of providers, warrants further investigation and has particular relevance for women experiencing high-risk pregnancies and deliveries.

A survey of the working status of family medicine physicians in clinics and hospitals in Korea.

BACKGROUND: In the approximately 35 years since family medicine was established in South Korea, family medicine physicians have sought to expand their expertise to cover clinical fields beyond primary medicine. This study examines their working status and compares the working conditions of family medicine physicians in clinics and hospitals in Korea. METHODS: We conducted an online survey with 4057 family medicine physicians in Korea in 2016. The results were analyzed using descriptive statistics. RESULTS: Of the respondents, 572 doctors were working in clinics and 441 in hospitals. In the analysis of treatment pattern by doctors, the rate of chronic disease management was 84.7% in clinics and 93.4% in hospitals (p <  0.001), and the rate of diseases covered by national insurance was 74.8% in clinics and 76.9% in hospitals (p = 0.005). Among physicians younger than 40 years, the rate of chronic disease management and diseases covered by national insurance were 64.6 and 68.0% in clinics and 93.6 and 78.5% in hospitals, retrospectively. CONCLUSIONS: Family medicine physicians working in hospitals have higher rates of chronic disease management and diseases covered by national insurance. This discrepancy of treatment pattern became larger for doctors younger than 40 years. More in-depth studies of the treatment pattern and its tendencies between family medicine physicians in clinics and hospitals are needed in the future.

Residency Program Characteristics and Individual Physician Practice Characteristics Associated With Family Physician Scope of Practice.

PURPOSE: A family physician's ability to provide continuous, comprehensive care begins in residency. Previous studies show that patterns developed during residency may be imprinted upon physicians, guiding future practice. The objective was to determine family medicine residency characteristics associated with graduates' scope of practice (SCoP). METHOD: The authors used (1) residency program data from the 2012 Accreditation Council for Graduate Medicine Education Accreditation Data System and (2) self-reported data supplied by family physicians when they registered for the first recertification examination with the American Board of Family Medicine (2013-2016)-7 to 10 years after completing residency. The authors used linear regression analyses to examine the relationship between individual physician SCoP (measured by the SCoP for primary care [SP4PC] score [scale of 0-30; low = small scope]) and individual, practice, and residency program characteristics. RESULTS: The authors sampled 8,261 physicians from 423 residencies. The average SP4PC score was 15.4 (standard deviation, 3.2). Models showed that SCoP broadened with increasing rurality. Physicians from unopposed (single) programs had higher SCoP (0.26 increase in SP4PC); those from major teaching hospitals had lower SCoP (0.18 decrease in SP4PC). CONCLUSIONS: Residency program characteristics may influence family physicians' SCoP, although less than individual characteristics do. Broad SCoP may imply more comprehensive care, which is the foundation of a strong primary care system to increase quality, decrease cost, and reduce physician burnout. Some residency program characteristics can be altered so that programs graduate physicians with broader SCoP, thereby meeting patient needs and improving the health system.

Preventive care among primary care patients living with spinal cord injury.

Objective: Context/Objective: Family physicians may lack the knowledge or resources to adequately support patients with spinal cord injury (SCI). Our objectives were to determine patterns of preventive care for patients with SCI in a primary care setting (i.e. cancer screening, influenza vaccinations, general physicals, bone mineral density tests), and determine physicians' level of comfort with providing primary care to patients with SCI.Design: i) Retrospective chart review, ii) Survey of physicians in the family practice.Setting: Six primary care practice sites in Ontario, Canada.Participants: All adult rostered patients of the family practice with SCI; All family physicians in the six sites.Outcome Measures: Proportion of patients up-to-date on cancer screening, proportion of patients with influenza vaccinations, general physicals, bone mineral density tests; physicians' level of comfort with providing care to patients with SCI.Results: Sixty patients were included in analyses. Rates of cancer screening were generally poor. The highest uptake was seen for cervical cancer screening, where 50% of eligible women were up-to-date on Pap tests. Only 36.7% of patients were up-to-date on colorectal cancer screening. Only 14 (23.3%) patients had a documented general physical exam in their electronic record. There was a recorded flu vaccination for 55% of patients, and of those, there was a median of 19 months since last vaccination. Fifteen physicians (21.4%) responded to the survey. Ten physicians reported at least one patient with SCI, with the maximum being 20 patients. Comfort level in managing SCI-relevant conditions varied and was lowest for spasticity, respiratory issues and autonomic dysreflexia, where only 27.3% of respondents had some level of comfort.Conclusion There are many opportunities to improve the preventive care of patients living with SCI.

Caring for patients with mental disorders in primary care: a qualitative study on French GPs' views, atittudes and needs.

Background: Patients suffering from mental health disorders have complex care needs, associating poorer physical health status and depreved social condition. Given their central role in primary health care, GPs should be highly involved in providing global and cooperative care to these patients in partnership with mental health specialists. Objective: To understand the GP's views, attitudes and needs in the care of patients with mental disorders. Methods: We led a qualitative study from June to July 2017, with semi-structured interviews led on GPs' activity in Marseille (France). We performed an inductive thematic content analysis, using Excel software. Results: We interviewed 22 GPs. The GPs felt comfortable providing total care for their patients with anxiety and depression (most of the time perceived as 'minor cases'), whereas they felt uncomfortable and poorly integrated in the care of patients with psychotic symptoms (often perceived as 'severe'). They wanted to improve communication with psychiatrists. Conclusion: The GPs seemed to assess the complexity of the cases and therefore their ability to deal with them, based on the type of their patients' psychiatric symptoms. For the 'severe patients', they felt they didn't have a significant role to play as a family doctor, while it has been shown that these patients have poorer physical health and need more coordinated care than other patient groups. An improved communication between GPs and mental health providers could reduce the difficulties for GPs in the care of people with mental health disorders and make possible a whole patient-centred approach.

Self-reported use of family physician, chiropractor and physiotherapy services among adult Canadians with chronic back disorders: an observational study.

BACKGROUND: Chronic back disorders (CBD) are prevalent, costly, and among the most common reasons for seeking primary care; however, little is known regarding the comparative use of family physician, chiropractic, and physiotherapy services among people with CBD in Canada. Elucidating these differences may identify potential gaps in access to care and inform the development of strategies to improve access. The research objectives were to investigate patterns of health care use and to profile factors associated with self-reported use of family physicians, chiropractors, and physiotherapists among adult Canadians with CBD. METHODS: The combined 2009 and 2010 Canadian Community Health Surveys conducted by Statistics Canada were used to investigate self-reported health care use among adults with CBD. This complex survey employs population weights and bootstrapping to be representative of the Canadian population. Following descriptive analyses, we used multiple logistic regression to profile self-reported health care use while statistically controlling for possible confounding effects. RESULTS: The majority of adult respondents with CBD sought care only with a family physician (53.8%), with 20.9% and 16.2% seeking care with combined family physician/chiropractor or family physician/physiotherapist, respectively. Few respondents sought care only with a chiropractor (2.5%) or physiotherapist (1.0%). After adjustment, differential patterns of utilization (p < 0.05) were evident between provider groups with respect to age, gender, socioeconomic status, rural/urban residence, functional limitations, and presence of co-morbidities. CONCLUSIONS: This research highlights potential inequities in access to physiotherapists and chiropractors in relation to family physicians among adult Canadians with CBD, particularly among lower socioeconomic status and rural/remote populations.

Conventional and complementary cancer treatments: where do conventional and complementary providers seek information about these modalities?

BACKGROUND: Both conventional health care providers and complementary therapists treat cancer patients. To provide effective treatment, both types of providers should to be familiar with their own as well as alternative types of treatment. Our aim was to compare how conventional health care providers (oncology doctors, oncology nurses, family physicians) and complementary therapists (acupuncturists, reflexologists, massage therapists) seek information about conventional and complementary cancer treatments. METHOD: This analysis was conducted on the basis of feedback from 466 participants. We used self-administered questionnaires in a cross-sectional study. RESULTS: The majority of the medical doctors (96%) searched for evidence-based information regarding conventional cancer treatments. They gathered this information mostly from guidelines, which is considered best practice and is expected from Norwegian health personnel. Eighty-one percent of the nurses gather this information from evidence based resources such as UpToDate. Colleagues were asked for information by 58% of the medical doctors and 64% of the nurses. Moreover, 50% of the medical doctors and 57% of the nurses searched for evidence-based information about complementary cancer modalities. The acupuncturists gathered evidence-based information for both conventional (79%) and complementary (77%) modalities, followed by the reflexologists (54 and 54%, respectively) and massage therapists (54 and 52%, respectively). Nearly half of the acupuncturist (49%) asked a colleague for information. CONCLUSION: To provide safe cancer care, it is important that advice about complementary modalities is based on current and evidence-based evaluations. The majority of the medical doctors and nurses in this study sought information according to evidence-based medicine regarding conventional cancer treatments, and about half of them gathered evidence-based information about complementary cancer modalities. This was also true for the complementary therapists as they gathered information about complementary and conventional treatments from evidence-based evaluations. This demonstrates that since the term evidence-based medicine was first introduced in 1991, the approach has grown extensively and both conventional and complementary providers use this approach to seek information.

Comprehensive practice: Normative definition across 3 generations of alumni from a single family practice program, 1985 to 2012.

OBJECTIVE: To determine the range of services and procedures offered by family physicians who define themselves as comprehensive practitioners and compare responses across 3 generations of alumni of a single family practice program. DESIGN: Cross-sectional survey. SETTING: Western University in London, Ont. PARTICIPANTS: All graduates of the family medicine program between 1985 and 2012. MAIN OUTCOME MEASURES: Self-reported provision of the following types of care: in-office care, in-hospital care, intrapartum obstetrics, housecalls, palliative care, after-hours care, nursing home care, minor surgery, emergency department care, sport medicine, and walk-in care. Sex, training site (urban or rural), size of community of practice, practice model, and satisfaction with practice were also reported. RESULTS: Participants practised in 7 provinces and 1 territory across Canada, but principally in Ontario. A small number were located in the United States. There was a decline in the number of services provided across 3 generations of graduates, with newer graduates providing fewer services than the older graduates. Significant decreases across the 3 groups were observed in provision of housecalls (P = .004), palliative care (P = .028), and nursing home care (P < .001). Non-significant changes were seen in provision of intrapartum obstetrics across the 3 alumni groups, with an initial decline and then increase in reported activity. Most respondents were in a family health organization or family health network practice model and those in such models reported offering significantly more services than those in family health group or salary models (P < .001). CONCLUSION: The normative definition of comprehensive care varies across 3 generations of graduates of this family medicine program, with newer physicians reporting fewer overall services and procedures than older graduates. Greater understanding of the forces (institutional, regulatory, economic, and personal) that determine the meaning of comprehensive primary care is necessary if this foundational element of family medicine is to be preserved.

Wide Gap between Preparation and Scope of Practice of Early Career Family Physicians.

We found substantial gaps between preparation for, and practice of, early career family physicians in nearly all clinical practice areas. With reported intentions of graduates for a broad scope of practice, gaps between practice and preparation suggest family physicians early in their careers may not be finding opportunities to provide comprehensive care.

Critical Factors to Practicing Medical Acupuncture in Family Medicine: Patient and Physician Perspectives.

INTRODUCTION: Although an increasing number of physicians are completing medical acupuncture training, only half of those physicians are able to successfully incorporate acupuncture into practice. We conducted a qualitative study to identify the factors and barriers that can enhance and impede physicians' delivery of and patients' engagement in medical acupuncture within the family medicine clinic. METHODS: We conducted interviews with 15 family physicians and 17 patients in a US family medicine clinic that has integrated medical acupuncture into its practice. Audio recordings were transcribed and analyzed by 2 members of the study team in ATLAS.ti, using the constant comparative method. RESULTS: We identified 3 physician themes of factors/barriers that impact delivery/engagement: 1) patients' aversion to needles, 2) time challenges, and 3) access to resources. We identified 3 additional themes from patient interviews: 1) appointment access; 2) wanting noninvasive, no side effects alternative; and 3) openness to anything. DISCUSSION: The factors and barriers reported by physicians/patients help illustrate conditions needed to enhance physicians' ability to provide acupuncture and patients' willingness to engage and sustain it. Participants' experiences help to illustrate strategic approaches to managing these barriers-strategies that can be used by other individuals/institutions to enhance care delivery and patient engagement.

French family physician experience concerning the outpatient care for women suffering from nausea and vomiting in pregnancy.

OBJECTIVE: To explore thoughts and attitudes among French family physicians on the outpatient care for women suffering from nausea and vomiting in pregnancy (NVP). DESIGN AND SETTING: A retrospective study was conducted among family physicians who had taken care of pregnant women who gave birth in our hospital in 1 year. PATIENTS AND METHODS: Fifty-nine French family physicians responded to a questionnaire assessing their experience about outpatient care for women suffering from NVP. Analysis were done according to the physicians' age, as the annual demographics data analysis from the French Medical Council. RESULTS: More than 89% of family physicians asked systematically the question concerning NVP (53/59), which were estimated as a frequent symptom (n=44, 74.6%). The intensity of NVP was assessed as mild in 28.8% (n=17), moderate in 62.7% (n=37), severe in 6.8% (n=4) and unbearable in 1.7% (n=1). Physicians younger than 40 years questionned less frequently about NVP compared to those older than 40 or older than 60 years (66.7% vs. 90.5% vs. 95.5%, respectively; P=0.04). Severe and unbearable NVP were significantly estimated more frequent among younger physicians (33.3% vs. 6.8%; P=0.03). Treatments (sick leave, diet, drugs, homeopathy, acupuncture or psychotherapy) did not differ between groups. DISCUSSION AND CONCLUSION: Outpatient care for women suffering from NVP may vary according to the physician. French family physicians played a key role in NVP. Younger family physician considered NVP as a frequent symptom which needed active management in severe forms.

Family Physicians Report Considerable Interest in, but Limited Use of, Telehealth Services.

PURPOSE: Little is known about the attitudes toward and adoption of telehealth services among family physicians (FPs), the largest primary care physician group. We conducted a national survey of FPs, randomly sampled from membership organization files, to investigate use of and barriers to using telehealth services. METHODS: Using bivariate analyses, we examined how telehealth usage affected FPs' identified barriers to using telehealth services. Logistic regressions show the factors associated both with using telehealth services and with barriers to using telehealth services. RESULTS: Surveys reached 4980 FPs; 1557 surveys were eligible for analysis (31% response rate). Among FPs, 15% reported using telehealth services during 2014. After controlling for the characteristics of the physicians and their practice, FPs who were based in a rural setting, worked in a practice owned by an integrated health system or other ownership structure, and provided hospital/urgent/emergency care were more likely to use telehealth. Physician and practice characteristics by telehealth use status, sex of the physician, practice location, years in practice, care provided, and practice ownership were associated with the barriers identified. CONCLUSIONS: Telehealth use was limited among FPs. Many of the barriers to using telehealth services cited by FPs are amenable to policy modification.

Maternal morbidity and perinatal outcomes among women in rural versus urban areas.

BACKGROUND: Most studies examining geographic barriers to maternity care in industrialized countries have focused solely on fetal and neonatal outcomes. We examined the association between rural residence and severe maternal morbidity, in addition to perinatal mortality and morbidity. METHODS: We conducted a retrospective population-based cohort study of all women who gave birth in British Columbia, Canada, between Jan. 1, 2005, and Dec. 31, 2010. We compared maternal mortality and severe morbidity (e.g., eclampsia) and adverse perinatal outcomes (e.g., perinatal death) between women residing in areas with moderate to no metropolitan influence (rural) and those living in metropolitan areas or areas with a strong metropolitan influence (urban). We used logistic regression analysis to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: We found a significant association between death or severe maternal morbidity and rural residence (adjusted OR 1.15, 95% CI 1.03-1.28). In particular, women in rural areas had significantly higher rates of eclampsia (adjusted OR 2.70, 95% CI 1.79-4.08), obstetric embolism (adjusted OR 2.16, 95% CI 1.14-4.07) and uterine rupture or dehiscence (adjusted OR 1.96, 95% CI 1.42-2.72) than women in urban areas. Perinatal mortality did not differ significantly between the study groups. Infants in rural areas were more likely than those in urban areas to have a severe neonatal morbidity (adjusted OR 1.14, 95% CI 1.02-1.29), to be born preterm (adjusted OR 1.06, 95% CI 1.01-1.11), to have an Apgar score of less than 7 at 5 minutes (adjusted OR 1.24, 95% CI 1.13-1.31) and to be large for gestational age (adjusted OR 1.14, 95% CI 1.10-1.19). They were less likely to be small for gestational age (adjusted OR 0.90, 95% CI 0.85-0.95) and to be admitted to an neonatal intensive care unit (NICU) (adjusted OR 0.36, 95% CI 0.33-0.38) compared with infants in urban areas. INTERPRETATION: Compared with women in urban areas, those in rural areas had higher rates of severe maternal morbidity and severe neonatal morbidity, and a lower rate of NICU admission. Maternity care providers in rural regions need to be aware of potentially life-threatening maternal and perinatal complications requiring advanced obstetric and neonatal care.

Asking patients about their religious and spiritual beliefs: Cross-sectional study of family physicians.

OBJECTIVE: To examine family physicians' practices in and opinions on asking patients about their religious and spiritual beliefs, as well as physicians' comfort levels in asking. DESIGN: Cross-sectional study using self-administered questionnaires. SETTING: Kitchener-Waterloo, Ont. PARTICIPANTS: A total of 155 family physicians with office practices. MAIN OUTCOME MEASURES: Frequency of asking patients about their religious and spiritual beliefs and physicians' comfort levels in asking. Separate multiple linear regression analyses were conducted for each of these outcomes. RESULTS: A total of 139 questionnaires were returned for a response rate of 89.7 %. Of the respondents, 51.8 % stated that they asked patients about their religious and spiritual beliefs sometimes. Physician opinion that it was important to ask patients about religious and spiritual beliefs (P = .001) and physician comfort level with asking (P < .001) were significantly associated with physicians' frequency of asking patients about their religious and spiritual beliefs. Comfort level with asking patients about their religious and spiritual beliefs was significantly associated with the opinions that it was important to ask (P = .004) and that it was their business to ask (P = .003), as well as with lack of training as the reason for not asking (P = .007). CONCLUSION: This study found that family physicians were more likely to ask patients about their religious and spiritual beliefs if they had higher comfort levels in asking or if they believed that asking was important. Further, this study found that family physicians' comfort level with asking was higher if they believed that it was important to ask and that it was their business to ask about religious and spiritual beliefs. Physician comfort levels with asking patients about religious and spiritual beliefs can be addressed through adequate training and education.

Violence in general practice: a gendered risk?

This article focuses on the extent to which violence against family doctors in England is experienced in gendered terms. It draws on data from two studies: a postal survey of 1,300 general practitioners (GPs) (62% response rate) and in-depth interviews with 26 doctors who have been assaulted or threatened; and 13 focus groups with primary care teams and 19 in-depth interviews with GPs who had expressed an interest in the topic of violence against doctors. Most GPs, regardless of gender, reported receiving verbal abuse over the last two years, often interpreted as a consequence of declining deference to professionals, while actual physical assaults and threats were much rarer and more likely to be reported by men. Overall, women GPs were much more likely to express concern about violence and to take personal precautions, although younger male GPs working in inner-city practices also had high levels of concern. The study shows how some aspects of family doctors' work has been organised on gendered lines and how these contribute to the differences in experience of violence. We suggest that the increasing proportion of women among family doctors may have implications for these, often tacit, organisational routines.

Las odiseas de los Ulises. Estudio de los relatos de un día normal de trabajo del médico de familia en Paraguay, México, Perú y España / The odysseys of Ulysses. A study of tales in a normal working day of the family doctor in Paraguay, Mexico, Peru, and Spain

OBJETIVO: Examinar en diferentes países el perfil profesional del médico de familia y el contexto socio-sanitario donde aplica su trabajo. DISEÑO: Metodología cualitativa de elaboración de diarios de campo de un día habitual. Emplazamiento: Atención primaria de Toledo y Tenerife en España, y Paraguay, México y Perú. Participantes y contextos: Muestreo no aleatorio, intencionado, seguido de muestra en bola de nieve, hasta la saturación de los datos. MÉTODO: Los participantes escribieron un diario de un día habitual trabajo, sus circunstancias y contexto sociosanitario, y se estudiaron mediante análisis del contenido. Como técnicas para controlar los sesgos se usaron la verificación de los participantes y la triangulación entre los resultados obtenidos y la bibliografía existente, y los datos de diarios encontrados en Internet. Se realizó un mapa mental para transcribir de forma gráfica e integral los resultados. 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 algunas similitudes, pero numerosas diferencias entre países. En los contextos humildes pero animosos, rurales, con raíces tradicionales y poco demandantes, se encontraban un mayor rango de tareas del médico de familia, la coexistencia de trabajo público y privado, y de medicina moderna y tradicional, con mayor presencia de asistencia familiar y comunitaria, más satisfacción del médico y mejor relación médico-paciente. CONCLUSIONES: El perfil profesional del médico de familia es diverso y dependiente del contexto variable, y no se deriva directamente de la teoría externa de la medicina de familia

OBJECTIVE: To examine the professional profile of the family doctor in different countries and the social welfare context where their work is carried out. DESIGN: Qualitative Methodology of production of field diaries of a normal day. Location: Primary Heath Care of Toledo and Tenerife in Spain, and Paraguay, Mexico, and Peru. Participants and contexts: Non-random sampling, intentional, followed by snowball sample until data saturation. METHOD: Participants wrote a diary of a typical day's work, their circumstances and socio-health context, and were studied by content analysis. Techniques to control the biases were used the check the participants and the triangulation between the obtained results and the existing bibliography, and data found on the Internet daily. We performed a mental map to transcribe the results graphically and in a comprehensive form. RESULTS: A total of 24 diaries of a normal day were obtained (9 doctors in Spain, 7 in Mexico, 4 in Paraguay, and 4 in Peru). We found some similarities, but many differences between countries. In contexts of humble but spirited, rural, with traditional roots and undemanding, there was a wider range of tasks of the family doctor, the coexistence of public and private work, and modern and traditional medicine, with greater presence of family and community care, more physician satisfaction and better patient-physician relationship. CONCLUSIONS: The professional profile of the family doctor is diverse and a context-dependent variable, and is not derived directly from external theory of family medicine

[USE OF COMPLEMENTARY AND ALTERNATIVE MEDICINE AMONG FAMILY MEDICINE PATIENTS--EXAMPLE OF THE TOWN OF CAKOVEC]. / UPOTREBA KOMPLEMENTARNE I ALTERNATIVNE MEDICINE KOD PACIJENATA U OBITELJSKOJ MEDICINI--PRIMJER GRADA CAKOVCA.

The use of complementary and alternative medicine (CAM) is widespread around the world including Croatia. The number of studies that investigate both quantitative and qualitative use of CAM in Croatia is limited. The aim of this study was to investigate the use of CAM among family medicine patients in the town of Cakovec and the rate they report it to their family doctor. This was a cross-sectional study in a sample of 300 patients that visited primary health center for any reason. We used anonymous questionnaire already employed in a previous investigation (Cizmesija et al. 2008), which describes socioeconomic characteristics, modalities of CAM use, and reasons for use. We also added questions on the type of herbs used and use of over-the-counter vitamin and mineral supplements. On data analysis we used descriptive statistics, χ2-test and Fisher's exact test, while the level of statistical significance was set at p ≤ 0.05. The response rate was 76%. Out of the total number of patients, 82% used some modality of CAM. Women, patients with secondary school education, employed and retired persons used CAM more often. Students and pupils reported least use of CAM. The most commonly used were herbs (87%), bioenergy (29%), diet therapy (28%), chiropractics (22%), and homeopathy and acupuncture (11% each). Vitamin and mineral supplements were used by 77% of study subjects. CAM was most frequently used for respiratory, urinary and musculoskeletal problems, as well as to improve overall health condition. Of the respondents that reported CAM use, 55% believed it would help them, 43% used it because they wanted to try something new, while only 2% indicated dissatisfaction with their physician as the reason for using CAM. Statistically, there were more subjects that used CAM and did not notify their family doctor about it, which could indicate poor communication between family doctors and health care users. Our results are consistent with a previous quantitative study conducted in Croatia and with literature data on the countries with a predominant use of western medicine. Qualitative data from previous studies in Croatia could explain the cultural and socioeconomic context of CAM use. Dissatisfaction with their physician as the reason for using CAM was rarely indicated, suggesting that CAM most probably fills the gap between successful and unsuccessful treatment, and perception that evidence based medicine has its own limitations. The arguments to turn to CAM therapy could involve poor doctor to patient ratio, i.e. 1750 patients per family medicine doctor on average, and the 20% increase in the number of diseases and conditions diagnosed by family medicine units. In conclusion, these results suggest that the use of CAM is common among patients in family medicine. When taking patient history, doctors should ask about CAM use and be aware of the patient beliefs and lifestyle. When patients strongly believe in CAM methods, there is the need of making compromise in therapy, with explanation of the possible side effects and at the same time continuous follow up. There is the need of additional education of family doctors and population about good and bad effects of CAM. In Croatia, accent should be on herbalism because this modality is most widespread.

Qualitative evaluation of a local coronary heart disease treatment pathway: practical implications and theoretical framework.

BACKGROUND: Coronary heart disease (CHD) is a common medical problem in general practice. Due to its chronic character, shared care of the patient between general practitioner (GP) and cardiologist (C) is required. In order to improve the cooperation between both medical specialists for patients with CHD, a local treatment pathway was developed. The objective of this study was first to evaluate GPs' opinions regarding the pathway and its practical implications, and secondly to suggest a theoretical framework of the findings by feeding the identified key factors influencing the pathway implementation into a multi-dimensional model. METHODS: The evaluation of the pathway was conducted in a qualitative design on a sample of 12 pathway developers (8 GPs and 4 cardiologists) and 4 pathway users (GPs). Face-to face interviews, which were aligned with previously conducted studies of the department and assumptions of the theory of planned behaviour (TPB), were performed following a semi-structured interview guideline. These were audio-taped, transcribed verbatim, coded, and analyzed according to the standards of qualitative content analysis. RESULTS: We identified 10 frequently mentioned key factors having an impact on the implementation success of the CHD treatment pathway. We thereby differentiated between pathway related (pathway content, effort, individual flexibility, ownership), behaviour related (previous behaviour, support), interaction related (patient, shared care/colleagues), and system related factors (context, health care system). The overall evaluation of the CHD pathway was positive, but did not automatically lead to a change of clinical behaviour as some GPs felt to have already acted as the pathway recommends. CONCLUSIONS: By providing an account of our experience creating and implementing an intersectoral care pathway for CHD, this study contributes to our knowledge of factors that may influence physicians' decisions regarding the use of a local treatment pathway. An improved adaptation of the pathway in daily practice might be best achieved by a combined implementation strategy addressing internal and external factors. A simple, direct adaptation regards the design of the pathway material (e.g. layout, PC version), or the embedding of the pathway in another programme, like a Disease Management Programme (DMP). In addition to these practical implications, we propose a theoretical framework to understand the key factors' influence on the pathway implementation, with the identified factors along the microlevel (pathway related factors), the mesolevel (interaction related factors), and system- related factors along the macrolevel.