Process evaluation of two large randomized controlled trials to understand factors influencing family physicians' use of antibiotic audit and feedback reports.

BACKGROUND: Unnecessary antibiotic prescriptions in primary care are common and contribute to antimicrobial resistance in the population. Audit and feedback (A&F) on antibiotic prescribing to primary care can improve the appropriateness of antibiotic prescribing, but the optimal approach is uncertain. We performed two pragmatic randomized controlled trials of different approaches to audit and feedback. The trial results showed that A&F was associated with significantly reducing antibiotic prescribing. Still, the effect size was small, and the modifications to the A&F interventions tested in the trials were not associated with any change. Herein, we report a theory-informed qualitative process evaluation to explore potential mechanisms underlying the observed effects. METHODS: Ontario family physicians in the intervention arms of both trials who were sent A&F letters were invited for one-on-one interviews. Purposive sampling was used to seek variation across interested participants in personal and practice characteristics. Qualitative analysis utilized inductive and deductive techniques informed by the Clinical Performance Feedback Intervention Theory. RESULTS: Modifications to the intervention design tested in the trial did not alter prescribing patterns beyond the changes made in response to the A&F overall for various reasons. Change in antibiotic prescribing in response to A&F depended on whether it led to the formation of specific intentions and whether those intentions translated to particular behaviours. Those without intentions to change tended to feel that their unique clinical context was not represented in the A&F. Those with intentions but without specific actions taken tended to express a lack of self-efficacy for avoiding a prescription in contexts with time constraints and/or without an ongoing patient relationship. Many participants noted that compared to overall prescribing, A&F on antibiotic prescription duration was perceived as new information and easily actionable. CONCLUSION: Our findings indicate that contextual factors, including the types of patients and the setting where they are seen, affect how clinicians react to audit and feedback. These results suggest a need to test tailored feedback reports that reflect the context of how, where, and why physicians prescribe antibiotics so that they might be perceived as more personal and more actionable. TRIAL REGISTRATION: Clinical Trial registration IDs: NCT04594200, NCT05044052.

Characteristics of family physicians with additional training or focused practices in caring for older adults: Population-based retrospective cohort study.

OBJECTIVE: To identify FPs with additional training and focused practice activities relevant to the needs of older patients within health administrative data and to describe their medical practices and service provision in community-based primary care settings. DESIGN: Retrospective cohort study. SETTING: Ontario. PARTICIPANTS: Family physicians with Certificates of Added Competence in care of the elderly from the College of Family Physicians of Canada or focused practice billing designations in care of the elderly. MAIN OUTCOME MEASURES: Evidence of additional training or certification in care of the elderly or practice activities relevant to the care of older adults. RESULTS: Of 14,123 FPs, 242 had evidence of additional scope to better support older adults. These FPs mainly practised in team-based care models, tended to provide comprehensive care, and billed for core primary care services. In an unadjusted analysis, factors statistically significantly associated with greater likelihood of having additional training or focused practices relevant to the care of older patients included physician demographic characteristics (eg, female sex, having completed medical school in Canada, residential instability at the community level), primary care practice model (ie, focused practice type), primary care activities (eg, more likely to provide consultations, practise in long-term care, refer patients to psychiatry and geriatrics, bill for complex house call assessments, bill for home care applications, and bill for long-term care health report forms), and patient characteristics (ie, older average age of patients). CONCLUSION: The FP workforce with additional training or focused practices in caring for older patients represents a small but specialized group of providers who contribute a portion of the total primary care activities for older adults. Health human resource planning should consider the contributions of all FPs who care for older adults, and enhancing geriatric competence across the family medicine workforce should be emphasized.

Chronic pain management in primary care: Using population-based data to examine family physician practice patterns.

OBJECTIVE: To examine trends in chronic pain (CP) practice patterns among community-based family physicians (FPs). DESIGN: Population-based descriptive study using health administrative data. SETTING: British Columbia from fiscal years 2008-2009 to 2017-2018. PARTICIPANTS: Patients with an algorithm-defined CP condition and community-based FPs, both registered with the British Columbia Medical Services Plan. MAIN OUTCOME MEASURES: Using British Columbia health administrative data and a CP algorithm adapted from a previous study, the following were compared between fiscal years 2008-2009 and 2017-2018: CP patient volumes, pain-related medication prescriptions, referrals to pain specialists, musculoskeletal imaging requests, and interventional procedures. RESULTS: In the fiscal year 2017-2018, among community-based family physicians (N=4796), an average of 32.5% of their patients had CP. Between 2008-2009 and 2017-2018, the proportion of CP patients per FP who were prescribed long-term opioids increased by an average absolute change of 0.56%; the proportion prescribed long-term neuropathic pain medications increased by 1.1%; and the proportion prescribed long-term nonsteroidal anti-inflammatory drugs decreased by 0.49%. The proportion of musculoskeletal imaging out of all imaging requests made by FPs increased by 2.0%; pain-related referrals increased by 1.73%; there was a 4.6% increase in the proportion of community-based FPs who performed 1 or more pain injections; and 10% more FPs performed 1 or more trigger point injections within a fiscal year. CONCLUSION: Findings show that the work of providing care to patients with CP increased while CP patient volumes per FP decreased. Workforce planning for community-based FPs should consider these increased demands and ensure FPs are adequately supported to provide CP care.

Mental distress and nutrition of family physicians, a European based cross-sectional study.

Family physicians are a pillar of the primary healthcare system, and their own mental well-being is integral to their performance. However, many studies have suggested a high prevalence of mental distress. The contributing factors include the emotional demands of the profession, work overload, budgetary constraints, loss of autonomy, and erosion of professional values. Outbreaks such as the COVID-19 pandemic exacerbate distress due to a greater risk of exposure to the virus, increased working hours, and fear of infecting families. Thus, it is crucial to assess risks and provide preventive measures. This study aimed to evaluate the association between the dietary patterns of family physicians and their mood. This study used a cross-sectional descriptive method and a validated Food-Mood Questionnaire (FMQ), shared via social networks across 10 European countries, to collect data from family physicians. Permission to use the FMQ was obtained. The breakfast-pattern subscale had the highest mean score (14.670 ±â€…4.305). The other subscale mean scores were as follows: health pattern (13.317 ±â€…5.388), mental distress pattern (11.184 ±â€…3.824), and western diet pattern (9.827 ±â€…3.604). According to Pearson correlation test there was a positive correlation between breakfast and Western diet patterns and between breakfast and health patterns. There was a negative correlation between health and mental distress pattern. Evidence suggests that mental distress may arise from different dietary deficiencies. Physicians' nutritional patterns have an impact on health indicators and are distributed in relation to sociodemographic factors, especially the regions they live in. Diet assessment is becoming a vital modifiable risk factor for mental health, but further research in this field is needed.

Is there a relationship between attitudes of general practitioners/family doctors and attitudes of their patients regarding industry-sponsored clinical investigations? A cross-sectional survey in a convenience sample of doctors and patients across nine European countries.

AIM: To assess the relationship between the attitudes of general practitioners/family medicine doctors (GP/FD) and of their patients toward industry-sponsored clinical research. METHODS: A cross-sectional survey included volunteer GPs/FDs who then enrolled and interviewed their patients. Data were analyzed in hierarchical models (patients nested in GPs/FDs, nested in countries/regions). RESULTS: A total of 201 GPs/FDs from nine European countries responded to the invitation and enrolled 995 of their patients. We observed mild associations between some of the GPs/FDs' attitudes (general opinion on sponsored clinical studies, appreciation of the general values of such studies, views about the importance of participant protection/privacy) and some of the patients' attitudes (appreciation of the general values and of risks associated with sponsored clinical studies, importance assigned to potential personal benefits from participation). We observed no association between GPs/FDs' attitudes and patients' willingness to participate in such studies. However, willingness to participate increased with higher patients' appreciation of the general values of sponsored studies, decreased with higher patients' appreciation of associated risks, and showed a quadratic trend across the levels of importance assigned by patients to potential personal benefits (willingness was higher when the assigned importance was very low or very high). More importance to GP/FD's advice in this respect was assigned by patients who assigned more importance to potential personal benefits, who were better educated, and who resided in rural/suburban dwellings. CONCLUSIONS: In the present convenience sample, lay-person attitudes about and willingness to participate in industry-sponsored clinical studies were associated with the attitudes of their GPs/FDs.

The attitudes and knowledge of family physicians regarding malnutrition in the elderly: a call for action.

BACKGROUND: Malnutrition in the elderly places a significant burden on healthcare, social, and aged-care systems, yet it often remains undiagnosed and untreated. This study aims to evaluate family physicians' knowledge and attitudes towards the diagnosis and treatment of malnutrition in the elderly. METHODS: Based on a literature review, an online questionnaire was developed, comprised of seven knowledge-related items and eight attitude-related questions regarding malnutrition in elderly populations. We also assessed the feasibility of including two malnutrition screening questions in regular clinic visits for individuals aged ≥ 70 years. RESULTS: Surveys were completed by 126 physicians (35% response rate), mean age 47.2 ± 12.6 years; 15.6 ± 12.5 years of practice; 67% females; and 92% board-certified family physicians. Moreover, 77.6% agreed that diagnosing malnutrition is important in patients with decreased appetite. Most respondents demonstrated knowledge of nutritional screening principles (63.5%) and recognized that even obese elderly individuals could be malnourished (83.2%). There was partial agreement (60%) that normal BMI values in the elderly differ from those in younger populations. Almost complete agreement was seen for incorporating two nutritional status questions in medical visits (91%), with physicians expressing willingness to receive training in malnutrition identification and screening tools. Despite challenges such as time constraints and limited knowledge, participants were open to conducting biannual malnutrition risk screening for elderly patients. CONCLUSION: We recommend malnutrition screening in primary care followed by malnutrition diagnosis and referral of malnourished patients to the proper intervention.

Informing policy with health labour market analysis to improve availability of family doctors in Tajikistan.

BACKGROUND: Tajikistan has embarked on health reforms to orient the health system towards primary health care (PHC). The health labour market analysis (HLMA) was initiated by the Ministry of Health with the World Health Organization (WHO) on policy questions related to the PHC workforce team. This article presents the results with focus on family doctors as a critical part of the PHC team, providing lessons for strengthening family medicine and PHC in the European Region and central Asia. METHODS: The HLMA framework was used to guide the analysis. The data for analysis were provided by the Ministry of Health and Social Protection of the Population of the Republic of Tajikistan. Descriptive means were used to analyse the data. A Technical Working Group guided the process. RESULTS: There has been an increase in the number of health workers in the country over the last 7 years. However, there is a huge shortage of family doctors when compared with norms, with decreasing family doctor densities over the last 7 years. Family doctors have the highest vacancy rates among specialists and also constitute the highest proportion of specialists who migrate. There is inequitable distribution of doctors across the regions. Overall number of enrolments and graduates in family medicine are declining. Although salaries in PHC are higher than in hospitals, the overall health workforce salaries are lower than the national average. While there have been efforts to retain and attract doctors to PHC in rural and remote regions, challenges exist. The attraction of doctors to narrow specialties may be leading to undermining PHC and family medicine. While the optimal skill-mix and availability of nurses provide an opportunity to strengthen multi-disciplinary teams at the PHC level, shortages and unequal distribution of doctors are affecting health services coverage and health indicators. CONCLUSIONS: Application of the HLMA framework has helped identify the bottlenecks in the health labour market flows and the possible explanations for them. The policy considerations emerging out of the HLMA have contributed to improving evidence-based planning for retention and recruitment of the PHC workforce, improvements in medical and nursing education, and higher investments in the PHC workforce and particularly in family doctors. Implementation of the Action Plan will require political commitment, financial resources, strong inter-sectoral collaboration, stakeholder management, and cross-country learning of best practices. Through this process, Tajikistan has shown the way forward in implementing the Central Roadmap for health and well-being in Central Asia and the Framework for Action on the Health and Care Workforce in the WHO European Region.

Does contracting family doctor promote primary healthcare utilization among older adults? - evidence from a difference-in-differences analysis.

INTRODUCTION: In 2016, the Chinese government officially scaled up family doctor contracted services (FDCS) scheme to guide patients' health seeking behavior from tertiary hospitals to primary health facilities. METHODS: This study evaluated the overall gate-keeping effects of this scheme on healthcare utilization of rural residents by using a difference-in-differences (DiD) design. The analysis was based on Shandong Rural Elderly Health Cohort 2019 and 2020. Participants who contracted FDCS in second round and were not contracted with a family doctor in the first round were regarded as treatment group. In total, 310 respondents who have used medical care were incorporated for final study. RESULTS: Participants who contracted FDCS (treatment group) experienced a significant decline in the mean level of first-contact health-care facilities, decreasing from 2.204 to 1.981. In contrast, participants who did not contract FDCS (control group), showed an increasing trend in the mean level of first-contact health-care facilities, rising from 2.128 to 2.445. Our results showed that contracting FDCS is associated with approximately 0.54 extra lower mean level of first-contact health-care facilities (P = 0.03, 95% CI: -1.03 to 0.05), which suggests an approximately 24.5% reduction in the mean first-contact health-care facility level for participants compared with contracted FDCS than those who did not. CONCLUSIONS: The study suggested primary healthcare quality should be strengthened and restrictive first point of contact policy should be enacted to establish ordered healthcare seeking behavior among rural residents.

A knowledge-based decision support system to support family doctors in personalizing type-2 diabetes mellitus medical nutrition therapy.

BACKGROUND: Type-2 Diabetes Mellitus (T2D) is a growing concern worldwide, and family doctors are called to help diabetic patients manage this chronic disease, also with Medical Nutrition Therapy (MNT). However, MNT for Diabetes is usually standardized, while it would be much more effective if tailored to the patient. There is a gap in patient-tailored MNT which, if addressed, could support family doctors in delivering effective recommendations. In this context, decision support systems (DSSs) are valuable tools for physicians to support MNT for T2D patients - as long as DSSs are transparent to humans in their decision-making process. Indeed, the lack of transparency in data-driven DSS might hinder their adoption in clinical practice, thus leaving family physicians to adopt general nutrition guidelines provided by the national healthcare systems. METHOD: This work presents a prototypical ontology-based clinical Decision Support System (OnT2D- DSS) aimed at assisting general practice doctors in managing T2D patients, specifically in creating a tailored dietary plan, leveraging clinical expert knowledge. OnT2D-DSS exploits clinical expert knowledge formalized as a domain ontology to identify a patient's phenotype and potential comorbidities, providing personalized MNT recommendations for macro- and micro-nutrient intake. The system can be accessed via a prototypical interface. RESULTS: Two preliminary experiments are conducted to assess both the quality and correctness of the inferences provided by the system and the usability and acceptance of the OnT2D-DSS (conducted with nutrition experts and family doctors, respectively). CONCLUSIONS: Overall, the system is deemed accurate by the nutrition experts and valuable by the family doctors, with minor suggestions for future improvements collected during the experiments.

How to overcome information and communication barriers in Human Papillomavirus vaccination? A SWOT analysis based on the opinions of European family doctors in contact with young people and their parents.

BACKGROUND: Family doctors (FDs)/General practitioners (GPs) are the key contact points for young people and their parents regarding Human Papillomavirus (HPV) vaccination. However, their recommendations are influenced by communication skills. OBJECTIVES: Under the EU4Health project, PROTECT-EUROPE, WONCA Europe led a task to identify and analyse strategies for clinicians' interpersonal communication skills when discussing HPV and its vaccination with young people and their parents. METHODS: Strengths, Weaknesses, Opportunities, Threats (SWOT) analysis using qualitative data focused on HPV vaccine acceptance and communication with the target population. FDs/GPs, members of WONCA Europe, were recruited using convenience and snowball sampling through surveys at conferences and emails. RESULTS: 223 FDs/GPs from 36 countries participated. Strengths included face-to-face communication, extensively used to promote the HPV vaccine. Weaknesses involved financial constraints, limited knowledge about gender-neutral vaccination, safety concerns, and time pressure during the consultations. Opportunities included confidentiality, open dialogue, trusting relationship between FDs/GPs and the target population, continuing medical education, school training, and questions & answers sessions to increase vaccine communication. Threats included social norms and cultures, stigmas against HPV, and anti-vaccination movements hindering discussions on HPV vaccination. CONCLUSION: It is crucial to train FDs/GPs to address knowledge gaps, enhance communication skills, and maintain a trusting relationship with patients when discussing HPV vaccination. Overcoming financial barriers and ensuring gender-neutral vaccination programs are accessible across Europe are also essential. Providing accurate information through the web- and school-based channels and developing community-oriented approaches targeting sociocultural factors and different needs to eliminate HPV vaccine stigmas should be considered when recommending the vaccine.

Face-to-face, trust-based communication is a strength and opportunity for FDs/GPs to promote the HPV vaccine in all countries.The lack of free-of-charge, nationally implemented gender-neutral vaccination represents a policy weakness needing improvement.Stigma and vaccine hesitancy pose major threats, which FDs/GPs must proactively address, supported by robust public health policies.

Self-Reported Panel Size Among Family Physicians Declined by Over 25% Over a Decade (2013-2022).

Underinvestment in primary care and erosion of the primary care physician workforce are resulting in patients across the US experiencing growing difficulty in obtaining access to primary care. Compounding this access problem, we find that the average patient panel size among US family physicians may have decreased by 25% over the past decade (2013 to 2022). Reversing the decline in access to primary care in the face of decreasing panel sizes requires both better supporting family physicians to manage larger panels, such as by expanding primary care teams, and substantially increasing the supply of family physicians.

Why Are Family Physicians' Panels Shrinking?

The average panel for family physicians dropped from about 2400 to about 1800 patients from 2013 to 2022. Likely reasons for this decline: 1) fewer people seeking primary care, and 2) fewer people receiving their care through a long-term continuity relationship with a primary care clinician.

Electronic Health Record Usability, Satisfaction, and Burnout for Family Physicians.

Importance: Electronic health record (EHR) work has been associated with decreased physician well-being. Understanding the association between EHR usability and physician satisfaction and burnout, and whether team and technology strategies moderate this association, is critical to informing efforts to address EHR-associated physician burnout. Objectives: To measure family physician satisfaction with their EHR and EHR usability across functions and evaluate the association of EHR usability with satisfaction and burnout, as well as the moderating association of 4 team and technology EHR efficiency strategies. Design, Setting, and Participants: This study uses data from a cross-sectional survey conducted from December 12, 2021, to October 17, 2022, of all family physicians seeking American Board of Family Medicine recertification in 2022. Exposure: Physicians perceived EHR usability across 6 domains, as well as adoption of 4 EHR efficiency strategies: scribes, support from other staff, templated text, and voice recognition or transcription. Main Outcomes and Measures: Physician EHR satisfaction and frequency of experiencing burnout measured with a single survey item ("I feel burned out from my work"), with answers ranging from "never" to "every day." Results: Of the 2067 physicians (1246 [60.3%] younger than 50 years; 1051 men [50.9%]; and 1729 [86.0%] practicing in an urban area) who responded to the survey, 562 (27.2%) were very satisfied and 775 (37.5%) were somewhat satisfied, while 346 (16.7%) were somewhat dissatisfied and 198 (9.6%) were very dissatisfied with their EHR. Readability of information had the highest usability, with 543 physicians (26.3%) rating it as excellent, while usefulness of alerts had the lowest usability, with 262 physicians (12.7%) rating it as excellent. In multivariable models, good or excellent usability for entering data (ß = 0.09 [95% CI, 0.05-0.14]; P < .001), alignment with workflow processes (ß = 0.11 [95% CI, 0.06-0.16]; P < .001), ease of finding information (ß = 0.14 [95% CI, 0.09-0.19]; P < .001), and usefulness of alerts (ß = 0.11 [95% CI, 0.06-0.16]; P < .001) were associated with physicians being very satisfied with their EHR. In addition, being very satisfied with the EHR was associated with reduced frequency of burnout (ß = -0.64 [95% CI, -1.06 to -0.22]; P < .001). In moderation analysis, only physicians with highly usable EHRs saw improvements in satisfaction from adopting efficiency strategies. Conclusions and Relevance: In this survey study of physician EHR usability and satisfaction, approximately one-fourth of family physicians reported being very satisfied with their EHR, while another one-fourth reported being somewhat or very dissatisfied, a concerning finding amplified by the inverse association between EHR satisfaction and burnout. Electronic health record-based alerts had the lowest reported usability, suggesting EHR vendors should focus their efforts on improving alerts. Electronic health record efficiency strategies were broadly adopted, but only physicians with highly usable EHRs realized gains in EHR satisfaction from using these strategies, suggesting that EHR burden-reduction interventions are likely to have heterogenous associations across physicians with different EHRs.

Advice to future family physicians: findings from qualitative interviews with family medicine residents and early-career family physicians.

BACKGROUND: Canadians continue to report challenges accessing primary care. Practice choices made by primary care providers shape services available to Canadians. Although there is literature observing family medicine practice trends, there is less clarity on the reasoning underlying primary care providers' practice intentions. Advice offered by residents and early-career family physicians may reveal challenges they have experienced, how they have adapted to them, and strategies for new residents. In this paper, we examine advice family medicine residents and early-career family physicians would give to new family medicine residents. METHODS: Sixty early-career family physicians and thirty residents were interviewed as part of a mixed-methods study of practice patterns of family medicine providers in Canada. During qualitative interviews, participants were asked, "what advice would you give [a new family medicine resident] about planning their career as a family physician?" We inductively analyzed responses to this question. RESULTS: Advice consisted of understanding the current climate of family medicine (need for specialization, business management burden, physician burnout) and revealed reasons behind said challenges (lack of support for comprehensive clinic care, practical limitations of different practice models, and how payment models influence work-life balance). Subtheme analyses showed early-career family physicians being more vocal on understanding practical aspects of the field including practice logistics and achieving job security. CONCLUSION: Most advice mirrored current changes and challenges as well as revealing strategies on how primary care providers are handling the realities of practicing family medicine. Multi-modal systemic interventions may be needed to support family physicians throughout the changing reality of family medicine and ensure family medicine is an appealing specialty.

Military Family Physicians' Readiness to Provide Gender-Affirming Care: A Serial Cross-Sectional Study.

PURPOSE: Family physicians are increasingly more likely to encounter transgender and gender-diverse (TGD) patients requesting gender-affirming care. Given the significant health inequities faced by the TGD community, this study aimed to assess changes in military-affiliated clinicians' perspectives toward gender-affirming care over time. METHODS: Using a serial cross-sectional survey design of physicians at the 2016 and 2023 Uniformed Services Academy of Family Physicians conferences, we studied participants' perception of, comfort with, and education on gender-affirming care using Fisher's Exact tests and logistic regression. RESULTS: Response rates were 68% (n = 180) and 69% (n = 386) in 2016 and 2023, respectively. Compared to 2016, clinicians in 2023 were significantly more likely to report receiving relevant education during training, providing care to >1 patient with gender dysphoria, and being able to provide nonjudgmental care. In 2023, 26% reported an unwillingness to prescribe gender-affirming hormones (GAH) to adults due to ethical concerns. In univariable analysis, female-identifying participants were more likely to report willingness to prescribe GAH (OR = 2.6, 95%CI = 1.7-4.1) than male-identifying participants. Willingness to prescribe was also associated with ≥4 h of education (OR = 2.2, 95%CI = 1.1-4.2) compared to those with fewer than 4 h, and those who reported the ability to provide nonjudgmental care compared to those who were neutral (OR = 0.09, 95%CI = 0.04-0.2) or disagreed (OR = 0.11, 95%CI = 0.03-0.39). Female-identifying clinicians were more likely to agree additional training would benefit their practice (OR = 5.3, 95%CI = 3.3-8.5). CONCLUSIONS: Although military-affiliated family physicians endorsed more experience with and willingness to provide nonjudgmental gender-affirming care in 2023 than 2016, profound gaps in patient experience may remain based on the assigned clinician. Additional training opportunities should be available, and clinicians unable to provide gender-affirming care should ensure timely referrals. Future research should explore trends across clinical specialties.

Performance trend of the family physician referral system before and during the COVID-19 pandemic: a study in northern Iran.

BACKGROUND: Considering the challenges of the referral system in the family physician program and the impact of COVID-19 pandemic on the performance of the relevant ministry's programs, it is necessary to assess the performance of the referral system. This study was conducted with the aim of investigating the performance of the family physician referral system before and during COVID-19 in Golestan province. METHODS: The present repeated cross-sectional study was conducted on secondary data Recorded of 786,603 cases referred and cared by family physicians (including information on physicians' and midwives' visits, percentage of prescriptions and other information) in Golestan province from 2017 to 2022 in a census and retrospective manner. Data were collected using the reference ratio checklist and analyzed with SPSS 23 software at a significance level of less than 0.05. RESULTS: Referral to 10 types of medical specialties and 10 indicators of family physicians referral before and during COVID-19 were investigated. The highest and lowest percentages of referrals by family physicians were belonged to the surgical (17.6%) and infectious (2%) specialists before COVID-19, and internal medicine (15.07%) and urology (3%) specialists during COVID-19, respectively. Referral due to physician's diagnosis increased by 19.3% compared to before Covid-19, target group increased by 0.86%, care decreased by 2.69% and reverse referral decreased by 36.1%. The amount of population covered by rural insurance, the amount of visits to midwives, the percentage of electronic appointments in the post-Covid-19 years have changed significantly compared to before.it (P-Value < 0.05). CONCLUSION: The present study showed that the COVID-19 pandemic had a significant impact on family physician referral indicators, such as the process of referral to specialists, drug prescriptions, insurance coverage, one-time service population, and patient care, which can be used to eliminate the weaknesses and Strengthening the strengths of the programs being implemented in the face of possible pandemics is very useful and effective and can be used in the country. Finally, the results obtained from this research provide evidence to discuss the importance of the family physicians care and referral system in the face of special conditions for quality control in health policies.

[One after the other: factors influencing the abandonment of Family and Community Medicine practice in young family physicians. A qualitative study]. / Uno detrás de otro: Factores que influyen en el abandono del ejercicio de la Medicina Familiar y Comunitaria en jóvenes médicos y médicas de familia. Un estudio cualitativo.

OBJECTIVE: A strong Primary Care has beneficial health effects. Its more beneficial attribute is longitudinality, which requires job stability in order to occur. In addition, Primary Care is facing a crisis due to the number of retirements it expects. The permanence of young professionals in Primary Care could contribute to improve longitudinality and the generational turnover of professionals. Therefore, this study explored the reasons that influence the abandonment of Family Medicine among young family physicians. METHODS: A qualitative descriptive-interpretative study was carried out in Granada and Madrid in 2022. By means of purposive snowball sampling, young family physicians who had left their job were recruited, with whom in-depth interviews and a triangular group were carried out. The information was coded inductively and analyzed according to the thematic content analysis method. RESULTS: Young family physicians left Family Medicine due to the frustration of not being able to practice as they would like to, job dissatisfaction and a pessimistic view of their future as workers. The decision to leave by these young professionals had been favored by the worsening of working conditions after the pandemic and by the values they have regarding work. CONCLUSIONS: The decision of young family physicians to leave the practice of Family Medicine is complex. To contribute to their permanence in Primary Care, it's necessary to improve their working conditions and increase the prestige of Family Medicine.

OBJECTIVE: Una Atención Primaria fuerte tiene efectos beneficiosos para la salud. El atributo de la misma con mayores beneficios es la longitudinalidad, que requiere de estabilidad laboral para poder producirse. Además, la Atención Primaria se enfrenta a una crisis por el número de jubilaciones que espera. Conseguir la permanencia de los profesionales jóvenes en Atención Primaria podría contribuir a mejorar la longitudinalidad y al recambio generacional de los profesionales. Por ello, en este estudio se exploraron los motivos que influyen en el abandono de la Medicina Familiar y Comunitaria entre jóvenes médicos y médicas de familia. METHODS: Se realizó un estudio cualitativo descriptivo-interpretativo en Granada y Madrid durante 2022. Mediante un muestreo intencionado por bola de nieve se reclutaron jóvenes médicos y médicas de familia que habían abandonado su trabajo, a los que se realizaron entrevistas en profundidad, además de un grupo triangular. La información se codificó de forma inductiva y se analizó según el método de análisis de contenido temático. RESULTS: Los jóvenes médicos y médicas de familia abandonaban la Medicina Familiar y Comunitaria por la frustración de no poder ejercer como les gustaría, por insatisfacción laboral y por una visión pesimista de su futuro como trabajadores/as. La decisión de abandonar de estos jóvenes profesionales se vio favorecido por el empeoramiento de las condiciones laborales tras la pandemia y sus valores respecto al trabajo. CONCLUSIONS: La decisión de jóvenes médicos y médicas de familia de abandonar la Medicina Familiar y Comunitaria es compleja. Para contribuir a su permanencia es necesario mejorar sus condiciones laborales y represtigiar la especialidad.