Factors associated with plans for early retirement among Ontario family physicians during the COVID-19 pandemic: a cross-sectional study.

BACKGROUND: Higher numbers of family physicians (FPs) stopped practicing or retired during the COVID-19 pandemic, worsening the family doctor shortage in Canada. Our study objective was to determine which factors were associated with FPs' plans to retire earlier during the COVID-19 pandemic. METHODS: We administered two cross-sectional online surveys to Ontario FPs asking whether they were "planning to retire earlier" as a result of the pandemic during the first and third COVID-19 pandemic waves (Apr-Jun 2020 and Mar-Jul 2021). We used logistic regression to determine which factors were associated with early retirement planning, adjusting for age. RESULTS: The age-adjusted proportion of FP respondents planning to retire earlier was 8.2% (of 393) in the first-wave and 20.5% (of 454) in the third-wave. Planning for earlier retirement during the third-wave was associated with age over 50 years (50-59 years odds ratio (OR) 5.37 (95% confidence interval (CI):2.33-12.31), 60 years and above OR 4.18 (95% CI: 1.90-10.23)), having difficulty handling increased non-clinical responsibilities (OR 2.95 (95% CI: 1.79-4.94)), feeling unsupported to work virtually (OR 1.96 (95% CI: 1.19-3.23)) or in-person (OR 2.70 (95% CI: 1.67-4.55)), feeling unable to provide good care (OR 1.82 (95% CI: 1.10-3.03)), feeling work was not valued (OR 1.92 (95% CI: 1.15-3.23)), feeling frightened of dealing with COVID-19 (OR 2.01 (95% CI: 1.19-3.38)), caring for an elderly relative (OR 2.36 (95% CI: 1.69-3.97)), having difficulty obtaining personal protective equipment (OR 2.00 (95% CI: 1.16-3.43)) or difficulty implementing infection control practices in clinic (OR 2.10 (95% CI: 1.12-3.89)). CONCLUSIONS: Over 20% of Ontario FP respondents were considering retiring earlier by the third-wave of the COVID-19 pandemic. Supporting FPs in their clinical and non-clinical roles, such that they feel able to provide good care and that their work is valued, reducing non-clinical (e.g., administrative) responsibilities, dealing with pandemic-related fears, and supporting infection control practices and personal protective equipment acquisition in clinic, particularly in those aged 50 years or older may help increase family physician retention during future pandemics.

The Effects of Hot Yoga on Kidney Function: An Observational Pilot and Feasibility Study.

Yoga has been shown to have health benefits, whereas exercising in a hot environment has deleterious effects on kidney function. There are no long-term studies on the physiological effects of hot yoga. The purpose of this study was to investigate changes in renal function acutely and over time between practitioners of hot and non-hot yoga. Urine and capillary samples were collected for urinalysis, albumin-creatinine ratio, and serum creatinine at yoga studios preand postexercise over 1 year. Thirty-two participants in non-hot yoga and 19 participants in hot yoga were recruited. Difference in blood capillary creatinine (post-yoga minus pre-yoga) showed a 7.52 µmol/L (SD 11.46) increase for practitioners of hot yoga and a 4.07 µmol/L (SD 9.94) increase for practitioners of non-hot yoga, with a between-group difference of 3.45 µmol/L (95% CI -0.42, 7.32; p = 0.08). Over 1 year, the mean difference in blood capillary creatinine for the hot group increased by 0.91 µmol/L (SD 11.00) and by 3.08 µmol/L (SD 9.96) for the non-hot group, with a between-group difference of -2.17 µmol/L (95% CI -10.20, 5.86; p = 0.58). Over 1 year, the mean difference in albumin-creatinine ratio for the hot group was -0.16 mg/mmol creatinine (SD = 0.74); for the non-hot group the difference was -0.20 mg/µmol (SD = 0.80). The difference in difference between the hot and non-hot groups was 0.04 mg/µmol (95% CI -0.60, 0.68; p = 0.90). Urine collected for urinalysis could not be analyzed due to too many 0 values. This pragmatic observational study did not find a statistically significant change in renal function between participants in non-hot and hot yoga either acutely or over 1 year. A larger and longer study focusing on blood creatinine over time would help to inform the long-term effects of hot yoga on the kidneys.

Integrating shared decision-making into primary care: lessons learned from a multi-centre feasibility randomized controlled trial.

BACKGROUND: MyDiabetesPlan is a web-based, interactive patient decision aid that facilitates patient-centred, diabetes-specific, goal-setting and shared decision-making (SDM) with interprofessional health care teams. OBJECTIVE: Assess the feasibility of (1) conducting a cluster randomized controlled trial (RCT) and (2) integrating MyDiabetesPlan into interprofessional primary care clinics. METHODS: We conducted a cluster RCT in 10 interprofessional primary care clinics with patients living with diabetes and at least two other comorbidities; half of the clinics were assigned to MyDiabetesPlan and half were assigned to usual care. To assess recruitment, retention, and resource use, we used RCT conduct logs and financial account summaries. To assess intervention fidelity, we used RCT conduct logs and website usage logs. To identify barriers and facilitators to integration of MyDiabetesPlan into clinical care across the IP team, we used audiotapes of clinical encounters in the intervention groups. RESULTS: One thousand five hundred and ninety-seven potentially eligible patients were identified through searches of electronic medical records, of which 1113 patients met the eligibility criteria upon detailed chart review. A total of 425 patients were randomly selected; of these, 213 were able to participate and were allocated (intervention: n = 102; control: n = 111), for a recruitment rate of 50.1%. One hundred and fifty-one patients completed the study, for a retention rate of 70.9%. A total of 5745 personnel-hours and $6104 CAD were attributed to recruitment and retention activities. A total of 179 appointments occurred (out of 204 expected appointments-two per participant over the 12-month study period; 87.7%). Forty (36%), 25 (23%), and 32 (29%) patients completed MyDiabetesPlan at least twice, once, and zero times, respectively. Mean time for completion of MyDiabetesPlan by the clinician and the patient during initial appointments was 37 min. From the clinical encounter transcripts, we identified diverse strategies used by clinicians and patients to integrate MyDiabetesPlan into the appointment, characterized by rapport building and individualization. Barriers to use included clinician-related, patient-related, and technical factors. CONCLUSION: An interprofessional approach to SDM using a decision aid was feasible. Lower than expected numbers of diabetes-specific appointments and use of MyDiabetesPlan were observed. Addressing facilitators and barriers identified in this study will promote more seamless integration into clinical care. Trial registration Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: February 11, 2015. Protocol version: Version 1; February 26, 2015.

Exploring the primary care experiences of adult patients with eating disorders: a qualitative analysis.

Eating disorders (EDs) are severe psychological conditions, often requiring specialized treatment. Patients with EDs generally first present in primary care before being referred to tertiary centres. Evidence suggests that family physicians do not identify most patients with clinical EDs. The objective of this study was to explore the primary care experiences of adult patients with EDs. Ten individual, semi-structured interviews with adult women with an ED were conducted. A qualitative descriptive approach was adopted using thematic analysis. The researchers identified codes, which were categorized into five major themes: 1) disparate patient experiences in primary care, 2) delayed diagnosis, 3) key family physician qualities for ED care, 4) individual and systemic barriers to recovery, and 5) patient needs in primary care. Most participants reported that their diagnosis was not timely, suggesting a need for improved screening and diagnostic procedures. Inconsistent treatment practices imply that family physicians would benefit from the development of standardized guidelines for ED diagnosis and treatment in primary care as well as additional training in ED care. Family physicians being empathic and nonjudgmental and facilitating access to resources are of particular importance to this patient population.

Development and Psychometric Evaluation of the Preconception Health Knowledge Questionnaire.

PURPOSE: To develop and psychometrically test a comprehensive measure of preconception health knowledge. DESIGN: Cross-sectional survey, in May and June, 2019. SETTING: Alberta, Ontario, and Québec, Canada. SAMPLE: One thousand seven hundred seventy-seven women and men with ≥1 children born in the last 5 years or planning a pregnancy in the next 5 years. MEASURES: Using prior literature and input from public health nurses and physicians, the Preconception Health Knowledge Questionnaire (PHKQ) was developed and comprised 25 multiple choice questions on reproductive history, sexual health, infectious diseases, chronic medical conditions, mental health, medications, immunizations, lifestyle behaviors, psychosocial stressors, and environmental exposures. ANALYSIS: Psychometric testing was undertaken to evaluate item difficulty, discrimination, quality of response alternatives, internal consistency, and construct validity. RESULTS: Participants had a mean total score of 15.8/25 (SD = 3.9); women and men had mean total scores of 16.2 (SD = 3.6) and 13.8 (SD = 4.7), respectively. Most items were neither too difficult nor too easy, discriminated well between participants with high and low knowledge, and had appropriate response alternatives. High internal consistency (KR-20 = 0.87) and construct validity, shown via significant correlations with education level and previous preconception care receipt, were demonstrated. CONCLUSION: The PHKQ is a reliable and valid tool for measuring preconception health knowledge and may be useful in identification of high-risk groups in need of preconception health education and evaluation of preconception health interventions.

Impact of MyDiabetesPlan, a Web-Based Patient Decision Aid on Decisional Conflict, Diabetes Distress, Quality of Life, and Chronic Illness Care in Patients With Diabetes: Cluster Randomized Controlled Trial.

BACKGROUND: Person-centered care is critical for delivering high-quality diabetes care. Shared decision making (SDM) is central to person-centered care, and in diabetes care, it can improve decision quality, patient knowledge, and patient risk perception. Delivery of person-centered care can be facilitated with the use of patient decision aids (PtDAs). We developed MyDiabetesPlan, an interactive SDM and goal-setting PtDA designed to help individualize care priorities and support an interprofessional approach to SDM. OBJECTIVE: This study aims to assess the impact of MyDiabetesPlan on decisional conflict, diabetes distress, health-related quality of life, and patient assessment of chronic illness care at the individual patient level. METHODS: A two-step, parallel, 10-site cluster randomized controlled trial (first step: provider-directed implementation only; second step: both provider- and patient-directed implementation 6 months later) was conducted. Participants were adults 18 years and older with diabetes and 2 other comorbidities at 10 family health teams (FHTs) in Southwestern Ontario. FHTs were randomly assigned to MyDiabetesPlan (n=5) or control (n=5) through a computer-generated algorithm. MyDiabetesPlan was integrated into intervention practices, and clinicians (first step) followed by patients (second step) were trained on its use. Control participants received static generic Diabetes Canada resources. Patients were not blinded. Participants completed validated questionnaires at baseline, 6 months, and 12 months. The primary outcome at the individual patient level was decisional conflict; secondary outcomes were diabetes distress, health-related quality of life, chronic illness care, and clinician intention to practice interprofessional SDM. Multilevel hierarchical regression models were used. RESULTS: At the end of the study, the intervention group (5 clusters, n=111) had a modest reduction in total decisional conflicts compared with the control group (5 clusters, n=102; -3.5, 95% CI -7.4 to 0.42). Although there was no difference in diabetes distress or health-related quality of life, there was an increase in patient assessment of chronic illness care (0.7, 95% CI 0.4 to 1.0). CONCLUSIONS: Use of goal-setting decision aids modestly improved decision quality and chronic illness care but not quality of life. Our findings may be due to a gap between goal setting and attainment, suggesting a role for optimizing patient engagement and behavioral support. The next steps include clarifying the mechanisms by which decision aids impact outcomes and revising MyDiabetesPlan and its delivery. TRIAL REGISTRATION: ClinicalTrials.gov NCT02379078; https://clinicaltrials.gov/ct2/show/NCT02379078.

Pilot Randomized Controlled Trial of an Interconception Intervention Provided by Public Health Nurses.

OBJECTIVES: Preconception health impacts perinatal outcomes, but the difficulty in engaging reproductive-aged individuals in health promotion activities is a barrier to effective implementation of preconception interventions. Since most women have more than one pregnancy and many risk factors repeat across pregnancies, the time between pregnancies-the interconception period-may be an opportune time to improve health. Our objective was to examine the feasibility and acceptability of an interconception intervention delivered by public health nurses. METHODS: We conducted a pilot randomized controlled trial in three small urban and rural public health units in Ontario, Canada, in 2017-2018 among women who were ≥ 18 years of age and between 2 and 12 months postpartum after a first birth. Women randomly allocated to the intervention group received a preconception risk assessment, tailored health education, and referral for clinical follow-up as needed, while those in the control group received standard care. Primary outcomes were intervention feasibility, adherence, and acceptability. RESULTS: Of 66 eligible women, 61% agreed to participate and were randomized to the intervention (n = 16) or control (n = 24) groups. The follow-up rate was 78% at 1 month and 71% at 3 months. Most women (83%) were satisfied with the intervention, including the number and length of sessions and content of recommendations. CONCLUSIONS FOR PRACTICE: Results demonstrate the potential feasibility and acceptability of an interconception intervention delivered in a public health setting. The short- and long-term impacts of the intervention on knowledge, behavior, and health should be tested in a larger sample.

Informing Integration of Genomic Medicine Into Primary Care: An Assessment of Current Practice, Attitudes, and Desired Resources.

Introduction: Preparing primary care providers for genomic medicine (GM) first requires assessment of their educational needs in order to provide clear, purposeful direction and justify educational activities. More understanding is needed about primary care providers' perspectives on their role in newer areas of GM and what resources would be helpful in practice. Our objective was to determine family physicians' (FP) current involvement and confidence in GM, attitudes regarding its clinical value, suggestions for integration of GM into practice, and resources and education required. Methods: A self-complete anonymous questionnaire was mailed to a random sample of 2,000 FPs in Ontario, Canada in September 2012. Results: Adjusted response rate was 26% (361/1,365), mean age was 51, and 53% were male. FPs reported many aspects of traditional GM as part of current practice (eliciting family history: 93%; deciding who to refer to genetics: 94%; but few reported confidence (44%, 32% respectively). Newer areas of GM were not part of most FPs' current practice and confidence was low (pharmacogenetics: 28% part of practice, 5% confident; direct-to-consumer genetic testing: 14%/2%; whole genome sequencing: 8%/2%). Attitudes were mixed with 59% agreeing that GM would improve patient health outcomes, 41% seeing benefits to genetic testing, but only 36% agreeing it was their responsibility to incorporate GM into practice. Few could identify useful sources of genetic information (22%) or find information about genetic tests (21%). Educational resources participants anticipated would be useful included contact information for local genetics clinics (89%), summaries of genetic disorders (86%), and genetic referral (85%) and testing (86%) criteria. About 58% were interested in learning about new genetic technologies. Most (76%) wanted to learn through in-person teaching (lectures, seminars etc.), 66% wanted contact with a local genetic counselor to answer questions, and 59% were interested in a genetics education website. Conclusion: FPs lack confidence in GM skills needed for practice, particularly in emerging areas of GM. They see their role as making appropriate referrals, are somewhat optimistic about the contribution GM may make to patient care, but express caution about its current clinical benefits. There is a need for evidence-based educational resources integrated into primary care and improved communication with genetic specialists.

Measurement of Preconception Health Knowledge: A Systematic Review.

OBJECTIVE: Preconception health is an important determinant of maternal, paternal, and infant outcomes. Knowledge is commonly used to evaluate the effectiveness of interventions to promote preconception health. Our objective was to examine how preconception health knowledge has been measured in the existing literature and to identify measurement gaps, biases, and logistical challenges. DATA SOURCE: MEDLINE, EMBASE, PsycINFO, CINAHL, the Cochrane Database of Systematic Reviews, and gray literature were searched from database inception to January 2018. STUDY INCLUSION AND EXCLUSION CRITERIA: Studies were included if they measured preconception or interconception health knowledge and included reproductive-aged women and/or men. DATA EXTRACTION: Two independent reviewers completed data extraction and quality appraisal using standardized instruments. DATA SYNTHESIS: Due to measurement heterogeneity, a narrative synthesis was performed. RESULTS: The review included 34 studies from 14 countries with data collected in 2000 to 2017. Most studies used cross-sectional (n = 24) or prepost designs (n = 7). Studies primarily sampled women (n = 25), and methodological quality was rated largely as weak (n = 18) or moderate (n = 14). Preconception health knowledge tools focused on fertility, folic acid, and alcohol, with few questions pertaining to men's health, mental health, or the interconception period. Only 19 (56%) studies reported psychometric properties of their knowledge tools. CONCLUSIONS: This systematic review revealed the need for a valid and reliable knowledge tool that reflects a holistic conceptualization of preconception health.

Association Between Adherence to Cancer Screening and Knowledge of Screening Guidelines: Feasibility Study Linking Self-Reported Survey Data With Medical Records.

BACKGROUND: It is possible that patients who are more aware of cancer screening guidelines may be more likely to adhere to them. OBJECTIVE: The aim of this study was to determine whether screening knowledge was associated with the documented screening participation. We also assessed the feasibility and acceptability of linking electronic survey data with clinical data in the primary care setting. METHODS: We conducted an electronic survey at 2 sites in Toronto, Canada. At one site, eligible patients were approached in the waiting room to complete the survey; at the second site, eligible patients were sent an email inviting them to participate. All participants were asked to consent to the linkage of their survey results with their electronic medical record. RESULTS: Overall, 1683 participants responded to the survey-247 responded in the waiting room (response rate, 247/366, 67.5%), whereas 1436 responded through email (response rate, 1436/5779, 24.8%). More than 80% (199/247 and 1245/1436) of participants consented to linking their survey data to their medical record. Knowledge of cancer screening guidelines was generally low. Although the majority of participants were able to identify the recommended tests for breast and cervical screening, very few participants correctly identified the recommended age and frequency of screening, with a maximum of 22% (21/95) of screen-eligible women correctly answering all 3 questions for breast cancer screening. However, this low level of knowledge among patients was not significantly associated with screening uptake, particularly after adjustment for sociodemographic characteristics. CONCLUSIONS: Although knowledge of screening guidelines was low among patients in our study, this was not associated with screening participation. Participants were willing to link self-reported data with their medical record data, which has substantial implications for future research.

Preconception health interventions delivered in public health and community settings: A systematic review.

OBJECTIVES: The objective of this systematic review was to assess the effects of preconception health interventions, delivered to individuals of reproductive age in public health and community settings, on reproductive, maternal, and child health outcomes. METHODS: A search of Ovid MEDLINE, CINAHL, EMBASE, PsychINFO, Scopus, Gender Studies Database, and SocINDEX from July 1999 through July 2016 was performed. We included studies that reported original data, used an interventional study design, included reproductive-aged women or men, were written in English, and were published in peer-reviewed journals. Two reviewers independently used standardized instruments for data extraction and quality assessment. A narrative synthesis was performed. SYNTHESIS: Twelve studies met the inclusion criteria. These studies included randomized controlled trials and quasi-experimental, pre-post, and time-series designs. Most studies were conducted in the United States; all but one study included only women. Interventions were mainly educational initiatives focused on nutrition, immunization, and lifestyle behaviours and were delivered in a single contact. The studies reported positive effects on health knowledge (n = 9), behaviour change (n = 4), and health outcomes (n = 1). Study quality was weak (n = 11) or moderate (n = 1), with limitations related to selection bias, blinding, data collection methods, and participant attrition. CONCLUSION: To develop a comprehensive, standardized approach to preconception health promotion and care in Canada, there is a clear need for high-quality research evaluating the effectiveness of preconception health interventions. Studies should use a health equity lens that includes all individuals of reproductive age and addresses the broad determinants of preconception health.

Teaching Primary Care Genetics: A Randomized Controlled Trial Comparison.

BACKGROUND AND OBJECTIVE: Given the increasing discussions of the impact of genetic medicine within family medicine, it is important to determine the most effective way of teaching this material to family medicine residents (FMRs). The objective of this study was to evaluate and compare the impact of three methods of delivering primary care genetic content to FMRs. METHODS: Curriculum materials and assessment tools were created to teach and evaluate knowledge, skills, and attitudes around four core competencies in primary care genetics, with a focus on hereditary colorectal cancer (CRC). Participants were randomly allocated to four learning conditions: (1) no intervention (control), (2) web-based module outlining genetic concepts applied to CRC, (3) live presentation of the web-based material, (4) live presentation and subsequent standardized patient (SP) encounter. Three months later, all participants completed a written knowledge test, attitude survey, and a standardized patient-based performance assessment. RESULTS: Sixty FMRs completed the study. All three educational interventions resulted in significantly improved outcome measures in knowledge and skills but not attitudes, compared to control. There was no significant difference in outcomes between intervention groups. CONCLUSION: FMRs acquired knowledge and improved skills in genetic medicine with three educational methods. Resources such as faculty expertise in genetic medicine and cost should guide decisions on curricular development for this rapidly expanding field. This may be especially relevant for programs with distributed teaching sites.

Academic family health teams: Part 2: patient perceptions of access.

OBJECTIVE: To explore patients' perceptions of primary care (PC) in the early development of academic family health teams (aFHTs)--interprofessional PC teams delivering care where family medicine and other health professional learners are trained--focusing on patients' perceptions of access and patients' satisfaction with services. DESIGN: Self-administered survey. SETTING: Six aFHTs in Ontario. PARTICIPANTS: Adult patients attending appointments and administrators at each of the aFHTs. MAIN OUTCOME MEASURES: Answers to questions about access from the Primary Care Assessment Tool Adult Expanded Version, the Primary Care Assessment Survey, and research team questions. RESULTS: The response rate was 47.3% (1026 of 2167). The mean (SD) Primary Care Assessment Tool first-contact accessibility score was 2.28 (0.36) out of 4, with 96.5% of patients rating access less than 3, which was the minimum expected level of care. Two-thirds (66.6%) indicated someone from their aFHTs would definitely or probably see them the same day if they were sick, 56.8% could definitely or probably get advice quickly by telephone, and 14.5% indicated it was definitely or probably difficult to be seen by their primary health care provider (HCP). Additionally, 46.9% indicated they would like to get medical advice by e-mail. For a routine or follow-up visit, 73.4% would be willing to see another aFHT physician if their regular provider were unavailable, while only 48.3% would see a nonphysician HCP. If sick, 88.2% would see another aFHT physician and 55.2% would see a nonphysician HCP. Most (75.3%) were satisfied with access to their regular HCP. CONCLUSION: Although patients are generally satisfied with care, there is room for improvement in access. Strategies are needed to enhance access to care, including addressing appropriate roles and scopes of practice for nonphysician HCPs. The accessibility challenges for aFHTs will likely affect new family physicians and other HCPs training in these practices and their approach to future practice.

Academic family health teams: Part 1: patient perceptions of core primary care domains.

OBJECTIVE: To explore patients' perceptions of primary care (PC) in the early development of academic family health teams (aFHTs)--interprofessional PC teams delivering care where family medicine and other health professional learners are trained--focusing on the 4 core domains of PC. DESIGN: Self-administered survey using the Primary Care Assessment Tool Adult Expanded Version (PCAT), which addresses 4 core domains of PC (first contact, continuity, comprehensiveness, and coordination). The PCAT uses a 4-point Likert scale (from definitely not to definitely) to capture patients' responses about the occurrence of components of care. SETTING: Six aFHTs in Ontario. PARTICIPANTS: Adult patients attending appointments and administrators at each of the aFHTs. MAIN OUTCOME MEASURES: Mean PCAT domain scores, with a score of 3 chosen as the minimum expected level of care. Multivariate log binomial regression models were used to estimate the adjusted relative risks of PCAT score levels as functions of patient- and clinic-level characteristics. RESULTS: The response rate was 47.3% (1026 of 2167). The mean age of respondents was 49.6 years, and most respondents were female (71.6%). The overall PC score (2.92) was just below the minimum expected care level. Scores for first contact (2.28 [accessibility]), coordination of information systems (2.67), and comprehensiveness of care (2.83 [service available] and 2.36 [service provided]) were below the minimum. Findings suggest some patient groups might not be optimally served by aFHTs, particularly recent immigrants. Characteristics of aFHTs, including a large number of physicians, were not associated with high performance on PC domains. Distributed practices across multiple sites were negatively associated with high performance for some domains. The presence of electronic medical records was not associated with improved performance on coordination of information systems. CONCLUSION: Patients of these aFHTs rated several core domains of PC highly, but results indicate room for improvement in several domains, particularly first-contact accessibility. A future study will determine what changes were implemented in these aFHTs and if patient ratings have improved. This reflective process is essential to ensuring that aFHTs provide effective models of PC to learners of all disciplines.

Impact of an interprofessional shared decision-making and goal-setting decision aid for patients with diabetes on decisional conflict--study protocol for a randomized controlled trial.

BACKGROUND: Competing health concerns present real obstacles to people living with diabetes and other chronic diseases as well as to their primary care providers. Guideline implementation interventions rarely acknowledge this, leaving both patients and providers feeling overwhelmed by the volume of recommended actions. Interprofessional (IP) shared decision-making (SDM) with the use of decision aids may help to set treatment priorities. We developed an evidence-based SDM intervention for patients with diabetes and other conditions that was framed by the IP-SDM model and followed a user-centered approach. Our objective in the present study is to pilot an IP-SDM and goal-setting toolkit following the Knowledge-to-Action Framework to assess (1) intervention fidelity and the feasibility of conducting a larger trial and (2) impact on decisional conflict, diabetes distress, health-related quality of life and patient assessment of chronic illness care. METHODS/DESIGN: A two-step, parallel-group, clustered randomized controlled trial (RCT) will be conducted, with the primary goal being to assess intervention fidelity and the feasibility of conducting a larger RCT. The first step is a provider-directed implementation only; the second (after a 6-month delay) involves both provider- and patient-directed implementation. Half of the clusters will be assigned to receive the IP-SDM toolkit, and the other will be assigned to be mailed a diabetes guidelines summary. Individual interviews with patients, their family members and health care providers will be conducted upon trial completion to explore toolkit use. A secondary purpose of this trial is to gather estimates of the toolkit's impact on decisional conflict. Secondary outcomes include diabetes distress, quality of life and chronic illness care, which will be assessed on the basis of patient-completed questionnaires of validated scales at baseline and at 6 and 12 months. Multilevel hierarchical regression models will be used to account for the clustered nature of the data. DISCUSSION: An individualized approach to patients with multiple chronic conditions using SDM and goal setting is a desirable strategy for achieving guideline-concordant treatment in a patient-centered fashion. Our pilot trial will provide insights regarding strategies for the routine implementation of such interventions in clinical practice, and it will offer an assessment of the impact of this approach. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: 11 February 2015.

Examining the teaching roles and experiences of non-physician health care providers in family medicine education: a qualitative study.

BACKGROUND: Primary Care reform in Canada and globally has encouraged the development of interprofessional primary care initiatives. This has led to significant involvement of non-physician Health Care Providers (NPHCPs) in the teaching of medical trainees. The objective of this study was to understand the experiences, supports and challenges facing non-physician health care providers in Family Medicine education. METHODS: Four focus groups were conducted using a semi-structured interview guide with twenty one NPHCPs involved in teaching at the University of Toronto, Department of Family & Community Medicine. The focus groups were transcribed and analyzed for recurrent themes. The multi-disciplinary research team held several meetings to discuss themes. RESULTS: NPHCPs were highly involved in Family Medicine education, formally and informally. NPHCPs felt valued as teachers, but this often did not occur until after learners understood their educator role through increased time and exposure. NPHCPs expressed a lack of advance information of learner knowledge level and expectations, and missed opportunities to give feedback or receive teaching evaluations. Adequate preparation time, teaching space and financial compensation were important to NPHCPs, yet were often lacking. There was low awareness but high interest in faculty status and professional development opportunities. CONCLUSIONS: Sharing learner goals and objectives and offering NPHCPs feedback and evaluation would help to formalize NPHCP roles and optimize their capacity for cross-professional teaching. Preparation time and dedicated space for teaching are also necessary. NPHCPs should be encouraged to pursue faculty appointments and to access ongoing Professional Development opportunities.