¿Hasta dónde?: Explorando los abordajes de problemáticas de salud mental por médiques generalistas en el Primer Nivel de Atención

Se partió de la pregunta problema, "¿Cómo es el abordaje de problemáticas vinculadas al malestar subjetivo y el padecimiento mental por médiques generalistas del Primer Nivel de Atención (PNA) del área programática del Hospital Piñero?", con el propósito de identificar recursos/herramientas/estrategias para su abordaje; reconocer cuáles se abordan; reconocer posibles escenarios de formación y aportar a la construcción de estrategias de abordaje. El objetivo se resume en caracterizar el abordaje de problemáticas vinculadas a la salud mental por generalistas del PNA. Metodología: se eligió el enfoque cualitativo mediante la realización de un Grupo Focal como técnica de recolección de información. Discusión: el abordaje de la salud mental se vuelve indivisible del abordaje de la salud integral. La definición de los problemas de salud mental, las herramientas y recursos, vacancias y formación, son todas dimensiones atravesadas por el intento de definir el campo de la Medicina General y Familiar y su desempeño en el abordaje de estas problemáticas. (AU)

Knowledge, attitudes, and practices towards epilepsy among general practitioners in rural Bolivia: Results before and after a training program on epilepsy.

INTRODUCTION: Epilepsy represents a major health problem in low- and middle-income countries where treatment gap (TG) levels are high. The reduction of epilepsy TG in the rural area of the Chaco region, Plurinational State of Bolivia, has been the aim of many projects based on the reinforcement of the primary care setting. To plan educational campaigns directed to the healthcare professionals, it is necessary to establish their baseline knowledge level. The objective of our study was to assess the baseline level of knowledge, attitudes, and practices (KAP) towards epilepsy among general practitioners (GPs) of the rural communities of the Chaco region. METHODS: The study was conducted in three departments of Bolivia. All the GPs living in these areas were invited to participate in the study consisting of two training modules six months apart from each other, each with two-day duration. They answered a validated questionnaire to evaluate the KAP towards epilepsy before and after the courses. RESULTS: Fifty GPs [30 men (60%); mean age: 32.1±5.8years] participated in the first training course. After six months, 31 GPs (62%) [19 men (61.3%); mean age: 33±5.0years] participated in the second module. Before the training, the majority of GPs declared a low level of satisfaction about their epilepsy knowledge, which improved after the courses. A change in practices was recorded after the training, with an increased confidence to manage antiepileptic treatment. CONCLUSION: Our study showed the significant impact of specific training programs on epilepsy among GPs.

Retrospective Multicenter Analysis of the Accuracy of Clinical Examination by Community Physicians in Diagnosing Developmental Dysplasia of the Hip.

OBJECTIVES: To determine among general practitioners (GPs) the most common clinical findings that raised concern for developmental dysplasia of the hip (DDH) and necessitated an orthopedic outpatient referral. In addition, we assessed the sensitivity and specificity of the most common of these clinical findings. STUDY DESIGN: We performed a multicenter retrospective review of all referrals by GPs to local orthopedic outpatient departments for DDH over a 12-month period. All patients had undergone pelvic radiographs, and the acetabular index (AI) was measured. The AI was used as a reference test to assess the accuracy of the clinical examination in diagnosing DDH. Sensitivity and specificity of each clinical sign was calculated. RESULTS: Twenty-six of 174 (14.9%) referred patients were diagnosed with DDH, defined as an AI score > 30. The most common indication for referral, per the GP letter was asymmetrical skin folds (97 patients, 45.8%), followed by hip click (42 patients, 19.8%), and limb shortening (34 patients, 16%). Sensitivities and specificities, respectively, among findings were asymmetric skin folds 46.2% (95% CI 26.6%-66.6%) and 42.6% (95% CI 34.5%-51.0%), hip click 23.1% (95% CI 9.0%-43.6%) and 75.7% (95% CI 67.9%-82.3%), limb shortening 30.8% (95% CI 14.3%-51.8%) and 82.4% (75.3%-88.2%), and reduced abduction 19.2% (95% CI 6.6%-39.4%) and 91.9% (95% CI 86.3%-95.7%). Using logistic regression analysis, no clinical sign was found to be a statistically significant indicator of an abnormal AI. CONCLUSIONS: Clinical examination by GPs does not reliably detect radiographically-defined DDH. None of the clinical findings by the GP showed an acceptable level of sensitivity. Absence of reduced abduction and limb shortening are relevant negatives given the high level of specificity of these signs.

Bases teóricas para el desarrollo de la habilidad de aplicación de atención médica integral en el médico general en formación inicial / Theoretical basis for the development of the ability of application of comprehensive medical care in general practitioner in initial formation

La preparación del médico general en formación inicial para la atención integral a la salud del adulto se sustenta en el desarrollo de la habilidad clínica de aplicar atención médica integral al adulto. El propósito de este artículo es la fundamentación teórica del desarrollo de dicha habilidad a partir de indagaciones sobre el tema. En su desarrollo, se reconoce la significación de asumir bases teóricas desde la Pedagogía de la Educación Superior, enriquecidas por los aportes de la Filosofía y la Sociología de la Educación, así como desde la Medicina. El desarrollo de la antedicha habilidad clínica no es posible lograrlo escindido de la actividad del futuro médico general en los escenarios de la práctica médica, de su interacción comunicativa y colaborativa con todos los participantes en el proceso de atención médica y con el contexto de formación-actuación y, a tenor, de sus motivaciones e intereses(AU)

The preparation of the general practitioner in initial formation in comprehensive care to adult health is based on the development of clinical skills to implement comprehensive care to adult. The purpose of this paper is the theoretical foundation for the development of this ability from inquiries on the subject. In its development, the significance of taking theoretical bases from the Pedagogy of Higher Education, enriched by the contributions of Philosophy and Sociology of Education, as well as from Medicine is recognized. The development of the above clinical skill is not possible to achieve cleaved activity of GP future scenarios of medical practice, their communicative and collaborative interaction with all participants in the process of care and the context of formation-performance and tenor, their motivations and interests(AU)

The payment for performance model and its influence on British general practitioners' principles and practice.

This article explores some effects of the British payment for performance model on general practitioners' principles and practice, which may contribute to issues related to financial incentive modalities and quality of primary healthcare services in low and middle-income countries. Aiming to investigate what general practitioners have to say about the effect of the British payment for performance on their professional ethos we carried out semi-structured interviews with 13 general practitioner educators and leaders working in academic medicine across the UK. The results show a shift towards a more biomedical practice model and fragmented care with nurse practitioners and other health care staff focused more on specific disease conditions. There has also been an increased medicalisation of the patient experience both through labelling and the tendency to prescribe medications rather than non-pharmacological interventions. Thus, the British payment for performance has gradually strengthened a scientific-bureaucratic model of medical practice which has had profound effects on the way family medicine is practiced in the UK.

The payment for performance model and its influence on British general practitioners' principles and practice / O modelo de pagamento por desempenho e sua influencia nos principios e pratica dos medicos generalistas britanicos / El modelo de pago por desempeno y su influencia en los principios y practica de los medicos generales britanicos

This article explores some effects of the British payment for performance model on general practitioners’ principles and practice, which may contribute to issues related to financial incentive modalities and quality of primary healthcare services in low and middle-income countries. Aiming to investigate what general practitioners have to say about the effect of the British payment for performance on their professional ethos we carried out semi-structured interviews with 13 general practitioner educators and leaders working in academic medicine across the UK. The results show a shift towards a more biomedical practice model and fragmented care with nurse practitioners and other health care staff focused more on specific disease conditions. There has also been an increased medicalisation of the patient experience both through labelling and the tendency to prescribe medications rather than non-pharmacological interventions. Thus, the British payment for performance has gradually strengthened a scientific-bureaucratic model of medical practice which has had profound effects on the way family medicine is practiced in the UK.

Este artigo explora alguns efeitos do modelo de pagamento por desempenho nos princípios e prática dos médicos generalistas britânicos, podendo contribuir para o debate sobre a relação entre modalidades de incentivos financeiros e qualidade dos serviços na atenção primária à saúde em países de moderada e baixa renda. Objetivando investigar o que os médicos generalistas têm a dizer dos efeitos do pagamento por desempenho britânico sobre seu ethos profissional, conduzimos entrevistas semiestruturadas com 13 médicos generalistas, educadores e líderes no meio acadêmico da medicina no Reino Unido. Os resultados apontam um modelo de prática mais biomédica e fragmentação do cuidado, com enfermeiras e outros profissionais mais focados em doenças específicas. Houve também um aumento da medicalização da vivência dos pacientes, pela rotulação e tendência a prescrever mais medicação e menor uso de intervenções não farmacológicas. Assim, o pagamento por desempenho britânico tem gradualmente fortalecido um modelo científico-burocrático de prática médica que teve efeitos profundos sobre a forma como a medicina de família vem sendo praticada no Reino Unido.

Este artículo explora algunos efectos del modelo británico de pago por desempeño en los principios y práctica de médicos generales que pueden contribuir a cuestiones relacionadas con modalidades de incentivos financieros y calidad de servicios de atención primaria en países de bajos y medios ingresos. La investigación tuvo por objetivo lo que los médicos tienden a decir sobre el efecto del pago por desempeño británico en su ethos profesional; se realizaron entrevistas semi-estructuradas con 13 médicos generales, educadores y líderes en medicina académica del Reino Unido. Los resultados muestran cambios hacia un modelo de práctica más biomédica y atención fragmentada con enfermeras y otros profesionales enfocados en enfermedades específicas. También produjo un aumento en medicalización de la experiencia del paciente a través de rotulaciones y tendencia a prescribir medicamentos en lugar de intervenciones no farmacológicas. Así, el pago por desempeño británico ha reforzado gradualmente un modelo científico-burocrático de práctica que ha tenido profundos efectos en la forma en la que la medicina familiar está siendo practicada en el Reino Unido.

The broken branch: Darwin's evolutionary tree and the progress of medicine, the evolution of specialism and generalism.

The landscape of medical practice and health care has been transformed by specialization over the past Century. There has been an extraordinary acceleration in the proliferation of specialty practice, coincident with rapid growth in technological devices and their clinical applications during the past fifty years. Medicine and medical care are evolving rapidly, a process that has similarities to biologic evolution. Medical educators, policy makers, and practitioners might find a Darwinian overview of medicine and health care of interest.