Perceived Access and Appropriateness: Comparison of Teaching and Resident Family Physicians' Patients.

BACKGROUND AND PURPOSE: Teaching clinics aim to provide patients with care that is comprehensive, high quality, and timely. Since resident presence at the clinic is irregular, timely access to care and continuity remain challenging. The two main objectives of our study were to compare the experience of timely access by patients of family residents vs staff and to determine if there was a difference between resident and staff patients in reported appropriateness and patient-centeredness of the visit. METHODS: This cross-sectional survey study was carried out in nine family medicine teaching clinics part of University of Montreal and McGill University Family Medicine Networks. Patients self-administered two anonymous questionnaires, before and after their consultation. RESULTS: We collected 1,979 preconsultation questionnaires. Teaching physician (staff) patients rated the usual wait time for an appointment as very good or excellent more frequently than resident patients (46% vs 35 %; P=.001). One out of five reported consulting another clinic in the last 12 months. Resident patients consulted elsewhere more often. In postconsultation questionnaires staff patients rated their visit experience better than resident physician patients and patients of second-year residents better than first-year residents. CONCLUSION: Although patients generally have a positive perception of access to care and adequacy of the consultations meet their needs, staff also face the challenge of providing better access to their patients. Finally, we found the patients' perceived visit-based patient centeredness was higher for visits of second-year than first-year resident physicians, supporting the impact of training efforts toward patient-centered best practices.

Are Family Medicine Clinics Improving Access to Care through Organizational Changes Driven by Healthcare Reform?

PURPOSE: This observational descriptive study reports organizational changes after the last reform in 18 family medicine units (FMUs) affiliated with the University of Montreal in Québec. METHOD: Two self-administered surveys on access to care were administered to FMU directors between December 2016 and January 2017, and in August 2018. RESULTS: Between surveys, the number of registered patients increased substantially. All clinics recruited new patients, and most offered walk-in services (89%) and moved toward an advanced access scheduling model (83%). For licensed practical nurses, there was a median increase from 0 to 3 and for nurse clinicians, from 2 to 3, that helped the development of collaborative teamwork. CONCLUSION: Despite the added teaching mission, the response of the FMU network has been dynamic, has adapted to the major changes and has continued to actively improve access to care for their communities. Challenges still remain regarding work on key priorities for improving access management.

Telehealth in Primary Healthcare: A Portrait of its Rapid Implementation during the COVID-19 Pandemic.

OBJECTIVE: This study documents the adoption of telehealth by various types of primary healthcare (PHC) providers working in teaching PHC clinics in Quebec during the COVID-19 pandemic. It also identifies the perceived advantages and disadvantages of telehealth. METHOD: A cross-sectional study was conducted between May and August 2020. The e-survey was completed by 48/50 teaching primary care clinics representing 603/1,357 (44%) PHC providers. RESULTS: Telephone use increased the most, becoming the principal virtual modality of consultation, during the pandemic. Video consultations increased, with variations by type of PHC provider: between 2% and 16% reported using it "sometimes." The main perceived advantages of telehealth were minimizing the patient's need to travel, improved efficiency and reduction in infection transmission risk. The main disadvantages were the lack of physical exam and difficulties connecting with some patients. CONCLUSION: The variation in telehealth adoption by type of PHC provider may inform strategies to maximize the potential of telehealth and help create guidelines for its use in more normal times.

Patients' missed appointments in academic family practices in Quebec.

OBJECTIVE: To determine the prevalence of no-show patients in 4 family medicine teaching units (FMTUs) and to investigate the reasons given by patients for past missed appointments in order to identify factors that could be acted on to improve access to care. DESIGN: Retrospective data collection through electronic medical records and a self-administered survey. SETTING: Four FMTUs at the University of Montreal in Quebec. PARTICIPANTS: Patients older than 18 years of age (or younger patients' guardians) who were able to read French and had visited the clinic at least once. MAIN OUTCOMES MEASURES: No-show prevalence among patients scheduled to see different types of health care professionals, and patients' reasons for past missed appointments and for not notifying the clinic before missing an appointment. RESULTS: The overall prevalence of no-show patients was 7.8% (2700 missed appointments of 34 619 scheduled appointments), ranging from 6.3% to 9.0% among the 4 FMTUs. The survey participation rate was 91.0% (1757 completed surveys of 1930 distributed surveys). A total of 19.1% of respondents acknowledged previous no-show behaviour. Resolved issues (22.9%) and work obligations (19.4%) were the most frequent personal reasons for missing an appointment, whereas inconvenient timing of the appointment (17.0%), delay before the appointment (14.6%), and lack of confirmation (13.7%) were the most frequent organizational reasons. The most frequent reason for not notifying the clinic of the absence was forgetting to call (55.2%). CONCLUSION: The no-show phenomenon, although not very prevalent in our clinics, is present and can potentially affect access to care. Reasons for missing an appointment without notifying the clinic are varied and point toward different potential solutions to reduce no-shows. Educating patients about the importance of informing the clinic when they cannot come, offering a wider range of appointment dates and times, systematically confirming appointments, improving telephone service, and offering different methods to communicate with the clinic could all be solutions to improve access to care.

Le stage en médecine familiale à l'externat et l'intention de s'inscrire en médecine de famille: Étude descriptive.

OBJECTIF: Identifier les facteurs propres au stage d'externat en médecine familiale (MF) pouvant être associés à un changement d'intention de s'inscrire en MF. TYPE D'ÉTUDE: Étude descriptive transversale. Un questionnaire autoadministré sur SurveyMonkey, distribué de septembre 2015 à avril 2016. CONTEXTE: Les milieux de stages en MF affiliés à l'Université de Montréal (Québec). PARTICIPANTS: Les externes qui effectuaient leur stage dans les milieux ayant accepté de participer et n'avaient pas encore fait leur choix de résidence. PRINCIPAUX PARAMÈTRES À L'ÉTUDE: Des facteurs spécifiques au stage ayant une influence sur le changement d'intention de s'inscrire en MF. RÉSULTATS: Dans l'échantillon, le stage en MF est généralement très apprécié, améliore l'image de cette spécialité et influence l'intention des étudiants de s'inscrire en MF. Plusieurs facteurs spécifiques au stage ont pu être associés à un changement positif de l'intention des étudiants de s'inscrire en MF. Le degré d'exposition à différents champs de pratique, la perception de l'ambiance générale, la rencontre d'un modèle de rôle et l'intérêt à revenir travailler dans le milieu de stage ont tous été associés, de façon modérée, au changement d'intention de s'inscrire en MF. Une association faible a été observée pour la perception de l'intérêt des médecins envers leur travail, le stage en milieu rural, l'appréciation du contact avec les médecins, la perception du niveau de difficulté du stage et le degré de satisfaction face à l'évaluation finale. Les résultats pour les autres facteurs sont non statistiquement significatifs. En ce qui concerne le changement négatif du rang de la MF, 2 facteurs ont été identifiés, soit l'absence de modèle de rôle et le manque d'intérêt à revenir travailler dans le milieu. De nouveaux facteurs positifs sont identifiés, soit la perception face à l'ambiance générale et l'intérêt à revenir travailler dans le milieu de stage. CONCLUSION: Plusieurs facteurs propres au stage en MF semblent agir comme moteurs de changement potentiel en faveur de la MF. Cela pourrait servir à la production d'un outil d'évaluation et d'amélioration du stage en MF.

Family medicine rotations and medical students' intention to pursue family medicine: Descriptive study.

OBJECTIVE: To identify specific factors occurring during family medicine (FM) rotations that were associated with a change in intention to pursue FM. DESIGN: Transversal descriptive study. A self-administered questionnaire was distributed on SurveyMonkey between September 2015 and April 2016. SETTING: Family medicine rotation sites affiliated with the University of Montreal in Quebec. PARTICIPANTS: Medical students who were conducting their rotations at participating sites and who had not yet chosen their residency specialty. MAIN OUTCOME MEASURES: Specific factors occurring during a rotation that influenced medical students' intention to pursue FM in residency. RESULTS: In the sample population, it was found that the FM rotation was generally highly appreciated by study participants, and that it improved the FM specialty's image while positively influencing the participants' intention to pursue FM. The degree of exposure to different areas of practice, overall atmosphere, the presence of role models, and the desire to return to the rotation site to practise were all moderately associated with a positive change in intention to pursue FM. There was a weak association between pursuing FM and participants' perception of physicians' interest in their work, rural rotation sites, positive interactions with physicians, perceptions of the rotation's level of difficulty, and degree of satisfaction with the final assessment. The results for other factors were not statistically significant. Concerning a negative change in the intention to pursue FM in residency, 2 factors were identified: the absence of a role model and lack of interest in returning to the rotation site. New positive factors were identified: overall atmosphere and the desire to return to the rotation site to practise. CONCLUSION: Several factors related to the FM rotations appeared to act as prime motivators for change toward pursuing FM. This could support the development of an assessment tool and the improvement of FM rotations.

To what extent do paramedics apply safe handling principles when transferring patients from stair chairs to stretchers?

The efficiency of training programmes in handling designed to prevent injuries has rarely been demonstrated by studies in the workplace. This study aimed to identify factors that may favour or inhibit the application of safe handling principles by paramedics performing full-body transfers of patients from a stair chair to a stretcher. In an observational field study, handling methods used in 45 patient transfers from a stair chair to stretcher were characterised. Principles concerning the physical environment seem to be applied frequently, but those applicable during the transfer are neglected. Principles taught during training may not be applied due to the physical constraints of the workplace and the underestimation of risk exposure. The results suggest that training should be enhanced, not by focussing on handling techniques but by focussing on compromise and the capacity to adapt work techniques based on the working context and the team-mate.

Patients' experience of chronic illness care in a network of teaching settings.

OBJECTIVE: To evaluate chronic illness care delivery from the patient's perspective and to examine its main correlates. DESIGN: Cross-sectional, descriptive study using questionnaires and medical chart review. SETTING: Nine teaching family practices in Quebec. PARTICIPANTS: A total of 364 patients with diabetes, hypertension, or chronic obstructive pulmonary disease. MAIN OUTCOMES MEASURES: Score on the Patient Assessment of Chronic Illness Care (PACIC) questionnaire, which evaluates the patient's perspective on the care received based on the chronic care model (CCM); patients characteristics (sex, level of education, number of chronic illnesses); patient-physician relationship (relational continuity, interpersonal communication assessed from the patient's perspective); and interdisciplinary care and technical quality of care abstracted from patients' medical charts. RESULTS: The mean PACIC score obtained (2.8 out of 5) indicates that, on average, CCM-concordant care "generally did not occur" or occurred only "sometimes" in this network of teaching practices. However, with a mean technical quality-of-care score of nearly 80%, physicians in this network showed a high degree of adherence to clinical guidelines for the chronic illnesses under study. Patient education level lower than high school was negatively associated with PACIC scores, while positive associations were found with male sex, number of chronic illnesses, relational continuity, interpersonal communication, interdisciplinary care, and technical quality of care. CONCLUSION: Patients with less education reported receiving less CCM-concordant care. The patient-physician relationship was the strongest correlate of PACIC scores, while interdisciplinary care and technical quality of care had modest contributions.

The association between rural-urban continuum, maternal education and adverse birth outcomes in Québec, Canada.

CONTEXT: Rural relative to urban area and low socioeconomic status (SES) are associated with adverse birth outcomes. Whether a graded association of increasing magnitude is present across the urban-rural continuum, accounting for SES, is unclear. We examined the association between rural-urban continuum, SES and adverse birth outcomes. METHODS: Singleton births from 1999 to 2003 (n = 356,147) were linked to Québec municipalities ranked on a continuum of 3 urban and 4 rural areas based on population and economic base. Maternal education was used to represent SES. Odds ratios (OR) were calculated for preterm birth (PTB), low birth weight (LBW), and small-for-gestational-age (SGA) birth, accounting for municipality and individual-level covariates. We used stratified analyses to examine interaction between SES and rural-urban continuum. FINDINGS: Relative to metropolitan area residence, living in small urban or rural areas was associated with adverse birth outcomes. Living in rural areas was associated with SGA birth (OR 1.11, 95% CI 1.05-1.17) and LBW (OR 1.15, 95% CI 1.05-1.26), and living in small urban areas was associated with PTB (OR 1.14, 95% CI 1.08-1.20). Upon stratification by education, living in remote rural relative to metropolitan areas was associated with adverse birth outcomes among university educated mothers only, and living in small urban areas was associated with adverse birth outcomes among mothers with lesser but not higher education. An SES gradient was present in all rural-urban areas, particularly for SGA birth. CONCLUSION: Differences in perinatal health exist across the rural-urban continuum, and maternal education has a modifying influence.

Handling Techniques: The Influence of Weight and Height for Experts and Novices.

The purpose of this study was to evaluate the influence of the weight of the load (12 kg, 22 kg) and of the height of the grasp (high: 126 cm; middle: 64 cm and 95 cm; low: 33 cm) on the handling techniques adopted by six experienced handlers and six novices having only limited handling experience during a free box-handling task. Each subject had to transfer two sets of 16 boxes from a platform to a four-wheel cart. The observations dealt with the position of the subject at the beginning of transfer and at deposit (position of the back, knees and feet, pelvic orientation, position of the hands), his way of moving during the transfer (position of the feet), and his way of positioning and moving the box during handling (tilt of the box, impulse given to the box, grip change). The results show that the weight and the height of grasp/deposit had an influence on the techniques adopted by expert handlers and novices. Some of these variations are common to both groups but many of them are not, such as the position of the knees, the grips and the position of the box. This study suggests that there is not one method that is suitable for all situations, and that expert handlers may have learned how to adjust their methods to the working environment. A better understanding of the experts' techniques could help in redesigning efficient training programs.