Effectiveness of a multimodal training programme to improve general practitioners' burnout, job satisfaction and psychological well-being.

BACKGROUND: The changes in the models of care for mental disorders towards a community focus and deinstitutionalisation might have risen General practitioners' (GPs) workload, increasing their mental health concerns and the need for solutions. Pragmatic research into improving GPs' work-related health and psychological well-being is limited by focusing mainly on stressors and through not providing systematic attention to the development of positive mental health via interventions that develop psychological resources and capacities. The aim of this study was twofold: a) to determine the effectiveness of an intensive multimodal training programme for GPs designed to improve their management of mental-health patients; and b) to ascertain if the program could be also useful to improve the GPs management of their own burnout, job satisfaction and psychological well-being. METHOD: Eighteen GPs constituted a control group that underwent the routine clinical Mental health support programme for primary care. An experimental group (N = 20) additionally received a Multimodal training programme (MTP) with an Integrated Brief Systemic Therapy (IBST) approach. Through questionnaires and a clinical interview, level of burnout, professional satisfaction, psychopathological state and various indicators of the quality of administrative and healthcare management were analysed at baseline and 10 months after the programme. RESULTS: In relation to government of mental-health patients indicators, on the one hand MTP group showed statistically significant improvements in certain administrative health parameters, but on the other it did not improve opinions and attitudes towards mental illness. Regarding GPs management of their own burnout, job satisfaction and psychological well-being assessments, the MTP presented better scores on global psychopathological state and better evolution of satisfaction at work; psychopharmacology use dropped in both groups; in contrast, the MTP did not improve burnout levels. CONCLUSIONS: Findings of this preliminary study are promising for the MTP (with an IBST approach) practice in primary care. More research evidence is required from larger samples and randomized controlled trials to support both the hypothetical adoption of MTP (with an IBST approach) as a part of a continuing professional-training programme for GPs' management of mental-health patients and its positive effects on work-related health factors.

Frequency and characteristics of occupational dental trauma.

BACKGROUND: Dental trauma at the workplace may have important clinical and occupational consequences, but little is known about its profile. AIMS: To describe the frequency and characteristics of work-related dental injuries. METHODS: For all patients with occupational dental trauma seen at the FREMAP Hospital of Barcelona (Spain) between January 2000 and December 2006, we recorded their characteristics, type of work and nature of the trauma, including cause of the accident, extent of trauma, reason for referral to a dentist, and days of sick leave. RESULTS: The frequency of dental trauma was 1.71 per 1000 occupational accidents attended and was related to the worker's occupation. In security services, it was 7.37 per 1000 and 2.01 in transport services. The frequency was similar in both genders. The most common causal mechanisms were direct impact (38%), traffic accidents (29%) and falls at the same level (16%). Causal mechanisms differed according to gender and type of job. Most injuries consisted of dental fracture (54%), and 67% of the patients required referral to a dental surgery. Injuries were limited to the mouth in 52% of cases, 8% of which required sick leave, with a mean duration of 23.0±21.8 days. CONCLUSIONS: The frequency of dental trauma in this working population was low and was related to the worker's occupation. Causal mechanisms differed according to gender and type of job. Most dental injuries were severe and required referral to a dental surgery. Frequency of sick leave was low.

Predictors of the survival of AIDS cases in Barcelona, Spain.

Factors influencing the outcome of disease were analysed in 289 adults presenting with AIDS in Barcelona, Spain from January 1986 (31 cases) to December 1987 (258 cases). One hundred and fifty-four (53.3%) were parenteral drug addicts and 100 (34.6%) were male homosexuals. Ninety-six (33.2%) presented with tuberculosis, 148 (51.2%), with other opportunistic infections, 34 (11.7%) with Kaposi's sarcoma, and the remaining 11 with a lymphoma. By February 1988, 144 (49.8%) of the 289 had died, with an actuarial survival probability of 46.7% at 2 years (40.7%-52.7%, 95% confidence interval). The factors selected by the multivariate analysis as independently worsening the prognosis were: having been diagnosed as having AIDS before 1986, being more than 45 years old, not being a parenteral drug addict and presenting with an opportunistic infection other than a tuberculosis or with a malignancy. In conclusion, some factors influencing the prognosis for AIDS patients are very dependent upon the geographical area of the series.

[Minor cutaneous ambulatory surgery and cryotherapy. Comparative study between a dermatologist and family physicians]. / Cirugía menor ambulatoria dermatológica y crioterapia. Estudio comparativo entre un dermatólogo y médicos de familia.

INTRODUCTION: Lack of diagnostic skill in cutaneous surgery may lead to erroneous and potentially detrimental therapies. This study compares the diagnosis and treatment in cutaneous surgery, including cryotherapy, between a dermatologist and family physicians. METHODS: It is an observational, prospective study on a random sample of patients that consulted the dermatologist for candidate lesions. Each lesion was independently evaluated by a dermatologist and a family physician, both of whom assigned the clinical diagnosis and therapeutic advice. Concordance for diagnosis, recommended treatment and indication for cryotherapy was calculated by Cohen's kappa coefficient. RESULTS: Six hundred forty-six lesions were evaluated. Global kappa indexes were 0.69 (95 % CI, 0.65-0.73) for diagnostic concordance, 0.62 (95 % CI, 0.56-0.67) for recommended treatment and 0.73 (95 % CI, 0.67-0.78) for indication of cryotherapy. Diagnostic concordance was significantly better for melanocytic nevus, achrocordon and for lesions with multiple and monomorphous presentation, and worse for isolated pigmented lesions. For recommended treatment concordance was better for multiple and monomorphous lesions and worse for skin cancer and seborrheic keratosis. For indication of cryotherapy concordance was worse for skin cancer, melanocytic nevus, acrochordon and seborrheic keratosis. Family physicians made an erroneous indication for cryotherapy in 5.88 % of cases, including 3 non melanoma skin cancers. CONCLUSIONS: Concordance between dermatologists and family physicians for minor cutaneous surgery is generally good. Family physicians should be more careful in evaluating solitary pigmented lesions and patients at risk for skin cancer.

[Malaria. Analysis of 149 cases (1981-1987)]. / Paludismo. Análisis de 149 casos (1981-1987).

The epidemiological features of the 149 cases of malaria reported to the Institut Municipal de la Salut in Barcelona from 1981 to 1987 are reported. The yearly evolution of the number of cases showed a tendency to increase predominating in the summer months. The incidence rate for 1977 was 1.99/100,000. The districts with the highest rate of involvement were districts I (Ciutat Vella), owing to the immigration, and V (Sarrià-Sant Gervasi), probably owing to overseas visitors. There was a remarkable predominance of males (63.8%), patients aged 20-40 years, and cases of African origin (81.81%); 50.42% of these came from Equatorial Guinea. The most commonly isolated plasmodium was P. falciparum (52.53%), with a progressive increase throughout the years. Only 13.43% of patients had followed a correct chemoprophylaxis. Malaria is still the most important protozoan infection in the world. In the present study its possible reintroduction in Spain is discussed. The malarial endemic used to be very important in this country, and its eradication was not achieved until 1964.

[Care for women: where and how]. / La atención a la mujer: dónde y cómo.

OBJECTIVE: To analyse the demand for family planning, gynecological cancer tests and pregnancy supervision in an area with no public resources devoted specifically to these questions. To evaluate users' level of satisfaction and their readiness or otherwise to be visited at the Health Centre (HC), with a view to planning out a specific programme. DESIGN: Descriptive study. SITE. Health Centre at Castelldefels. (Barcelona). PATIENTS AND OTHER PARTICIPANTS: Random stratified sample of 595 women over 14, living within the centre's catchment area. The age distribution was selected in line with the town's population pyramid. MAIN MEASUREMENTS AND RESULTS: We undertook a self-administered, anonymous survey of 437 women. 4.9% of those sexually active between the ages of 14 and 20 and 13.2% of women aged between 21 and 45 use no contraceptive method. The greater attendance at private rather than public centres for contraception (73% as against 23.8/1000 p less than 0.001) and for regular check-ups (63.8% as against 32.1/1000 p less than 0.001) was notable. But for pregnancy care it was the other way round (29.3% as against 61.2/1000 p less than 0.001). 64.1% have regular check-ups; 48.8% annually. A higher level of satisfaction is shown by women seen at private (95.2%) than at public centres (75.1/1000 p = 0.0159). 68.9% would use a special care services for women if offered by the HC. CONCLUSIONS: Existing services offer scant cover to sections of the population more at risk and tend to make everything a medical problem. The public centres give little user-satisfaction. The Primary Care teams could cover these deficiencies with their services and would be welcome by the public.

Impact of tuberculosis on the new AIDS definition in Barcelona [corrected].

The impact of the new AIDS definition on tuberculosis in Barcelona is evaluated. In 1988 active epidemiological surveillance demonstrated a tuberculosis incidence rate of 58.31/100,000 and an AIDS incidence rate of 9.93/100,000 according to the old definition, and 14.16/100,000 according to the CDCs' new definition (42.5% increase). The majority of these new cases are HIV-positive drug abusers with extrapulmonary tuberculosis. Pulmonary or extra-pulmonary tuberculosis is also observed more frequently in drug abusers than in homosexuals (odds ratio = 7.4; CL 95%; 3.5-15.5). Up until 1986, 39% of AIDS cases were homosexuals and 36% drug abusers. In 1988, according to the old AIDS definition, 54.2% of AIDS cases were drug abusers and 31.9% were male homosexuals but with the new definition it is even more striking that the high risk group is still drug abusers. Today we must add to the old social problem of tuberculosis the problem of drug abusers, and all the difficulties of compliance with chemotherapy or antituberculous chemoprophylaxis. New strategies will have to be devised to deal with this new problem.

[The teaching health centers of Barcelona. The opinions of residents]. / Los centros de salud docentes de Barcelona. Opiniones de los residentes.

OBJECTIVE: To examine different aspects of the teaching health centres (THC) in the province of Barcelona as evaluated by the ex-residents (Exc-R) from general practice and community medicine (GP&CM). DESIGN: Descriptive study, gathering information by means of a self-administered postal questionnaire, with an addressed reply envelope. SETTING: Barcelona teaching unit (BTU). PARTICIPANTS: Eighty-one general practitioners whose qualifying years were 1987-89, 1988-90 and 1989-91, and who did their last residents year in the THC of the BTU. MEASUREMENTS AND MAIN RESULTS: There are significant differences (p < 0.05) between the various THC, in terms of: quality of teaching material and library; evaluation of the tutor in terms of attendance of classes and comment on medical histories; and average evaluation of tutor by the Ex-R. CONCLUSIONS: We propose that anonymous evaluations made by residents of their tutors should be generalised and used for, amongst other purposes, maintaining or revoking the accreditations of specific THC or tutors.

[The reform of primary health care: the economic, care and satisfaction results]. / Reforma de la atención primaria de salud: resultados económicos, asistenciales y de satisfacción.

OBJECTIVE: To compare the overall effect on the general public before and after the primary care reform, its economic outcome and professional satisfaction, following the model of the European Foundation for Quality Management. DESIGN: A descriptive analysis of results at reformed primary care centres compared with results at non-reformed centres in the same city. SETTING: The study was conducted at Sant Boi de Llobregat, a town of 77,591 inhabitants in Baix Llobregat county (Barcelona). 32.7% of the population was covered by two reformed centres. The rest was covered by one single non-reformed primary care centre. MEASUREMENTS AND RESULTS: Clinical audits and data on pharmaceutical prescription quality were used to find attendance. For economic results, the formula of attribution of cost/inhabitant and cost/inhabitant seen, including the costs of labour, structure, referral, further tests and pharmacy, were used. The satisfaction of the outside customer (user) was measured by a population survey. Internal customer satisfaction was measured by a survey of the professionals. Results were compared with those for 1997. The study showed that the reformed primary care sector's results, measured in terms of professional satisfaction, user-outside customer, attendance, economic results and social impact, were better than the non-reformed sector's. Inside and outside customers' satisfaction was higher in the reformed network. The cost per inhabitant in the reformed network was 31,874 pesetas, against 25,177 in the non-reformed network. The cost per inhabitant seen was 34,482 and 44,603, respectively. CONCLUSIONS: The reform creates efficient resource management and greater satisfaction of the general public and professionals, when an indicator sensitive to the real use of services is used.

[Alcohol consumption by primary care physicians]. / Consumo de alcohol entre los médicos de atención primaria.

OBJECTIVE: To find the consumption of alcoholic drinks by Primary Care doctors. DESIGN: A descriptive study using an anonymous questionnaire. SETTING: Health base areas located in the Baix Llobregat and in Barcelona city. MEASUREMENTS AND MAIN RESULTS: Total coverage was 68.7%. In the group which replied, daily consumption along with week-end consumption predominated. Men consumed alcohol more often and in greater quantity than women. The prevalence of excessive drinkers according to the PAPPS criteria was 5.9%. 29% of the doctors exceeded the level of alcohol consumption considered acceptable by their own criteria, no gender differences being appreciated. Similarly, 33% of them accepted consumption above that recommended by the experts. CONCLUSIONS: The consumption of alcoholic drinks found among Primary Care doctors was low in comparison with other studies of medical groups or the general population. The Primary Care doctor occupies a privileged position in the prevention of excessive consumption of alcoholic drinks, which implies that their own alcohol consumption and training could have an impact on carrying out preventive activities in this field.

Cirugía menor ambulatoria dermatológica y crioterapia. Estudio comparativo entre un dermatólogo y médicos de familia / Minor cutaneous ambulatory surgery and cryotherapy. Comparative study between a dermatologist and family physicians

Introducción. En cirugía dermatológica, una menor habilidad diagnóstica podría conducir a tratamientos erróneos y potencialmente perjudiciales. En este trabajo se compara el diagnóstico y la decisión terapéutica en cirugía dermatológica, incluyendo la crioterapia, entre un dermatólogo y médicos de familia. Métodos. Estudio prospectivo observacional, sobre una muestra no seleccionada de pacientes que consultan al dermatólogo por lesiones candidatas. Cada lesión fue evaluada independientemente por un dermatólogo y un médico de familia, consignando ambos el diagnóstico clínico y el consejo terapéutico. Se calculó la concordancia para el diagnóstico, tratamiento recomendado e indicación de crioterapia mediante el estadístico kappa de Cohen. Resultados. Se evaluaron 646 lesiones. Los índices kappa globales fueron 0,69 (intervalo de confianza [IC] del 95 %, 0,65-0,73) en concordancia diagnóstica, 0,62 (IC del 95 %, 0,56-0,67) en tratamiento recomendado y 0,73 (IC del 95 %, 0,67-0,78) en indicación de crioterapia. La concordancia diagnóstica resultó significativamente mejor en nevus melanocítico, acrocordón y en lesiones con presentación múltiple y monomorfa, y peor en lesiones pigmentadas aisladas. En tratamiento recomendado fue mejor para lesiones múltiples y monomorfas, y peor en cáncer de piel y queratosis seborreica. En indicación de crioterapia fue peor en cáncer de piel, nevus melanocítico, acrocordón y queratosis seborreica. Los médicos de familia indicaron crioterapia incorrectamente en el 5,88 % de casos, incluyendo tres cánceres de piel no melanoma. Conclusiones. La concordancia entre dermatólogos y médicos de familia en cirugía menor dermatológica es en general buena. Los médicos de familia deberían ser cautos en lesiones pigmentadas solitarias y pacientes de riesgo para cáncer de piel

Introduction. Lack of diagnostic skill in cutaneous surgery may lead to erroneous and potentially detrimental therapies. This study compares the diagnosis and treatment in cutaneous surgery, including cryotherapy, between a dermatologist and family physicians. Methods. It is an observational, prospective study on a random sample of patients that consulted the dermatologist for candidate lesions. Each lesion was independently evaluated by a dermatologist and a family physician, both of whom assigned the clinical diagnosis and therapeutic advice. Concordance for diagnosis, recommended treatment and indication for cryotherapy was calculated by Cohen's kappa coefficient. Results. Six hundred forty-six lesions were evaluated. Global kappa indexes were 0.69 (95 % CI, 0.65-0.73) for diagnostic concordance, 0.62 (95 % CI, 0.56-0.67) for recommended treatment and 0.73 (95 % CI, 0.67-0.78) for indication of cryotherapy. Diagnostic concordance was significantly better for melanocytic nevus, achrocordon and for lesions with multiple and monomorphous presentation, and worse for isolated pigmented lesions. For recommended treatment concordance was better for multiple and monomorphous lesions and worse for skin cancer and seborrheic keratosis. For indication of cryotherapy concordance was worse for skin cancer, melanocytic nevus, acrochordon and seborrheic keratosis. Family physicians made an erroneous indication for cryotherapy in 5.88 % of cases, including 3 non melanoma skin cancers. Conclusions. Concordance between dermatologists and family physicians for minor cutaneous surgery is generally good. Family physicians should be more careful in evaluating solitary pigmented lesions and patients at risk for skin cancer