Patshitinikutau Natukunisha Tshishennuat Uitshuau (a place for Elders to spend their last days in life): a qualitative study about Innu perspectives on end-of-life care.

BACKGROUND: Indigenous palliative persons and their families often have different values, spiritual traditions, and practices from Western culture and Canadian health systems. Additionally, many healthcare policies and practices have been established without adequate consultation of the Indigenous populations they are meant to serve. This can result in barriers to Innu receiving culturally safe end-of-life care. Innu community leaders from Sheshatshiu, Labrador, have identified a need for further research in this area. The purpose of this study is to: (1) describe the cultural and spiritual practices related to death and dying of the Innu in Sheshatshiu; (2) identify aspects of current end-of-life care delivery that serve and/or fail to meet the cultural and spiritual needs of the Innu in Sheshatshiu; and (3) explore ways to integrate current end-of-life care delivery practices with Innu cultural and spiritual practices to achieve culturally safer care delivery for the Innu. METHODS: This qualitative patient-oriented research study was co-led by Innu investigators and an Innu advisory committee to conduct semi-structured interviews of 5 healthcare providers and 6 decision-makers serving the community of Sheshatshiu and a focus group of 5 Innu Elders in Sheshatshiu. Data was analyzed thematically from verbatim transcripts. The codebook, preliminary themes, and final themes were all reviewed by Innu community members, and any further input from them was then incorporated. Quotations in this article are attributed to Innu Elders by name at the Elders' request. RESULTS: The findings are described using eight themes, which describe the following: relationships and visitation support a "peaceful death"; traditional locations of death and dying; the important role of friends and community in providing care; flexibility and communication regarding cultural practices; adequate and appropriate supports and services; culturally-informed policies and leadership; and Innu care providers and patient navigators. CONCLUSIONS: The Innu in Sheshatshiu have a rich culture that contributes to the health, care, and overall well-being of Innu people approaching end of life. Western medicine is often beneficial in the care that it provides; however, it becomes culturally unsafe when it fails to take Innu cultural and spiritual knowledge and traditions into account.

Community engagement by faculties of medicine: A scoping review of current practices and practical recommendations.

PURPOSE: Social accountability (SA) is the responsibility of faculties of medicine (FoMs) to address the health priorities of the communities they serve. Community engagement (CE) is a vital, but often ambiguous, component of SA. Practical guidance on how to engage community partners (CPs) is key for meaningful CE. We conducted a systematic scoping review of CE involving FoMs to map out how FoMs engage their communities, to provide practical recommendations for FoMs to take part in CE, and to highlight gaps in the literature. MATERIALS AND METHODS: We searched electronic databases for articles describing projects or programs involving FoMs and CPs. Descriptive information was analyzed thematically. RESULTS: Thirty-eight of 1406 articles were included, revealing three themes: (1) Partners (Who to Engage)-deciding who to engage establishes the basis for responsibility and creates space for communities to engage FoMs; (2) Partnerships (How to Engage)-fostering creative and authentic collaboration, enabling meaningful community contributions; and (3) Projects and Programs (With What to Engage)-identifying opportunities for communities to have a voice in many spaces within FoMs. Under these themes emerged 32 practical recommendations. CONCLUSION: Practical guidance facilitates meaningful commitments to communities. The literature is rich with examples of community-FoM partnerships. We provide recommendations for CE that are clear, evidence-based, and responsive.

Are general practitioners referring patients with low back pain for CTs appropriately according to the guidelines: a retrospective review of 3609 medical records in Newfoundland using routinely collected data.

BACKGROUND: CT Imaging is often requested for patients with low back pain (LBP) by their general practitioners. It is currently unknown what reasons are common for these referrals and if CT images are ordered according to guidelines in one province in Canada, which has high rates of CT imaging. The objective of this study is to categorise lumbar spine CT referrals into serious spinal pathology, radicular syndrome, and non-specific LBP and evaluate the appropriateness of CT imaging referrals from general practitioners for patients with LBP. METHODS: A retrospective medical record review of electronic health records was performed in one health region in Newfoundland and Labrador, Canada. Inclusion criteria were lumbar spine CT referrals ordered by general practitioners for adults ≥18 years, and performed between January 1st-December 31st, 2016. Each CT referral was identified from linked databases (Meditech and PACS). To the study authors' knowledge, guidelines regarding when to refer patients with low back pain for CT imaging had not been actively disseminated to general practitioners or implemented at clinics/hospitals during this time period. Data were manually extracted and categorised into three groups: red flag conditions (judged to be an appropriate referral), radicular syndrome (judged be unclear appropriateness), or nonspecific LBP (determined to be inappropriate). RESULTS: Three thousand six hundred nine lumbar spine CTs were included from 2016. The mean age of participants was 54.7 (SD 14 years), with females comprising 54.6% of referrals. 1.9% of lumbar CT referrals were missing/unclear, 6.5% of CTs were ordered on a red-flag suspicion, 75.6% for radicular syndromes, and 16.0% for non-specific LBP; only 6.5% of referrals were clearly appropriate. Key information including patient history and clinical exams performed at appointment were often missing from referrals. CONCLUSION: This audit found high proportions of inappropriate or questionable referrals for lumbar spine CT and many were missing information needed to categorise. Further research to understand the drivers of inappropriate imaging and cost to the healthcare system would be beneficial.

A global picture of family medicine: the view from a WONCA Storybooth.

BACKGROUND: Family Medicine is a novel discipline in many countries, where the motivation for training and value added to communities is not well-described. Our purpose was to understand the reason behind the choice of Family Medicine as a profession, the impact of Family Medicine on communities, and Family Medicine's characterizing qualities, as perceived by family doctors around the world. METHODS: One-question video interviews were conducted using an appreciative inquiry approach, with volunteer participants at the 2016 World Organization of Family Doctors conference in Rio de Janeiro. Qualitative data analysis applied the thematic, framework method. RESULTS: 135 family doctors from 55 countries participated in this study. Three overarching themes emerged: 1) key attributes of Family Medicine, 2) core Family Medicine values and 3) shared traits of family doctors. Family Medicine attributes and values were the key expressed motivators to join Family Medicine as a profession and were also among expressed factors that contributed to the impact of Family Medicine globally. Major sub-themes included the principles of comprehensive care, holistic care, continuity of care, patient centeredness, and the patient-provider relationship. Participants emphasized the importance of universal care, human rights, social justice and health equity. CONCLUSION: Family doctors around the world shared stories about their profession, presenting a heterogeneous picture of global Family Medicine unified by its attributes and values. These stories may inspire and serve as positive examples for Family Medicine programs, prospective students, advocates and other stakeholders.

Mortality in Innu communities in Labrador, 1993-2018: a cross-sectional study of causes and location of death.

In Canada, most people prefer to die at home. However, the proportion of deaths that occur in hospital has increased over time. This study examined mortality rates and proportionate mortality in Innu communities in Labrador, and compared patterns to other communities in Labrador and Newfoundland. We conducted a cross-sectional ecological study with mortality data from the vital statistics system. This included information about all deaths in Newfoundland and Labrador from 1993 to 2018. We used descriptive statistics and rates to examine patterns by age, sex, cause and location. During the 2003 to 2018 period the leading cause of death in the Innu communities (excluding external causes) was cancer, followed by circulatory disease and respiratory disease. Between 1993 and 2018, there was a lower percentage of hospital deaths and a higher percentage of at home deaths in Innu communities than in the rest of the province. The majority of deaths among Innu were due to cancer and chronic diseases. We found a higher percentage of at home deaths in Innu communities compared to the rest of the province.

International health experiences in postgraduate medical education: A meta-analysis of their effect on graduates' clinical practice among underserved populationsExpériences internationales de soins de santé en formation médicale post-doctorale : une méta-analyse des effets sur la pratique clinique des diplômés au sein des populations mal desservies.

BACKGROUND: International health experiences (IHEs) are popular among medical learners and provide a valuable learning experience. IHE participants have demonstrated an increased intention to care for underserved populations in the future, but what is its actual impact on practice? This study evaluates the effect of postgraduate IHE participation on the future careers of clinicians regarding their work among underserved populations. METHODS: We conducted a systematic review and meta-analysis of peer-reviewed articles comparing the populations served by physicians who had participated in an IHE with those of physicians who had not participated in an IHE. RESULTS: 764 titles were scanned, 28 articles were reviewed, with an eventual 3 studies of fair-good or good quality identified. These addressed physicians' service to domestic underserved populations, and also addressed future service in a low- or middle-income country (LMIC). Meta-analysis demonstrated a statistically-significant increase in service by IHE graduates to domestic underserved populations (OR = 2.12; CI = 95%; P = 0.03). The certainty of the evidence was low due to limitations in study design (non-randomised studies) and inconsistency in effects. CONCLUSION: Participation in an IHE may cause an increase in care for domestic underserved populations in future clinical practice, though further research from high quality randomised trials is needed to increase the certainty of the effect. Further study is needed to establish whether there is a similar effect with increased future service in a LMIC setting.

CONTEXTE: Les expériences internationales de soins de santé sont populaires auprès des étudiants en médecine et fournissent une expérience d'apprentissage enrichissante. Les participants aux expériences internationales de soins de santé démontrent une intention accrue de prodiguer des soins aux populations mal desservies dans leur future pratique,; mais quelle est l'incidence réelle sur la pratique ? Cette étude évalue l'effet de la participation des résidents aux expériences internationales de soins de santé sur leur carrière future au sein des populations mal desservies. MÉTHODES: Nous avons réalisé une revue systématique et une méta-analyse des articles évalués par des pairs comparant les populations desservies par les médecins ayant participé aux expériences internationales de soins de santé et celles desservies par des médecins n'ayant pas participé à celles-ci. RÉSULTATS: 764 titres ont été analysés et 28 articles ont été révisés pour arriver à identifier trois études de qualité passable à bonne. Ces études portaient sur les services médicaux aux populations locales mal desservies, et de la pratique future dans un pays à revenu faible ou intermédiaire. La méta-analyse a démontré une augmentation statistiquement significative des soins aux populations locales mal desservies fournis par les diplômés avant participé à des expériences internationales de soins de santé (RC = 2,12; IC = 95 %; valeur p = 0,03). Le degré de certitude des preuves était plutôt bas en raison des limites associées aux devis (études non randomisées) et des tailles d'effet inconstantes. CONCLUSIONS: La participation aux expériences internationales de soins de santé peut augmenter les soins médicaux aux populations locales mal desservies dans une future pratique clinique, mais des recherches supplémentaires à partir d'essais randomisés de haute qualité doivent être menées pour établir la certitude de l'effet. D'autres études sont nécessaires pour savoir s'il existe un effet similaire lié à l'augmentation de la pratique future dans un pays à revenu faible ou intermédiaire.

Status of global health fellowship training in the United States and Canada.

BACKGROUND: Increasing numbers of residency graduates desire global health (GH) fellowship training. However, the full extent of training options is not clear. OBJECTIVE: To identify clinical GH fellowships in all specialties in the U.S. and Canada and to describe their demographics, innovative features, and challenges. METHODS: The authors surveyed program directors or designees from GH fellowships with a web-based tool in 2017. RESULTS: The authors identified 85 programs. Fifty-four programs (63.5%) responded confirming 50 fellowships. One- third of fellowships accepted graduates from more than one specialty, and the most common single-specialty programs were Emergency Medicine and Family Medicine. Fellowships most commonly were 24 months in duration with a median size of one fellow per year. Funding and lack of qualified applicants were significant challenges. Most programs were funded through fellow billing for patient care or other self-support. CONCLUSION: The number of U.S. and Canadian GH fellowship programs has nearly doubled since 2010. Challenges include lack of funding and qualified applicants. Further work is needed to understand how best to identify and disseminate fellowship best practices to meet the diverse needs of international partners, fellows, and the patients they serve and to determine if consensus regarding training requirements would be beneficial.

CONTEXTE: Un nombre croissant de diplômés des programmes de résidence optent pour une formation complémentaire en santé mondiale. Cependant, la pleine mesure des possibilités de formation n'est pas claire. OBJECTIF: Identifier les formations cliniques complémentaires en santé mondiale pour toutes les spécialités aux États- Unis et au Canada et décrire leur démographie, leurs caractéristiques novatrices, et leurs défis. MÉTHODES: En 2017, les auteurs ont interrogé les directeurs de programmes de formation complémentaire en santé mondiale ou leur représentant à l'aide d'un outil en ligne. RÉSULTATS: Les auteurs ont identifié 85 programmes. 54 programmes (63,5 %) ont répondu et confirmé 50 programmes de formation. Un tiers des programmes acceptaient des diplômés provenant de plusieurs spécialités, et les programmes offerts à des spécialités uniques étaient plus fréquemment ceux en médecine d'urgence et en médecine familiale. Les programmes étaient généralement d'une durée de 24 mois avec une capacité d'accueil d'un moniteur (fellow) par année. Le financement et le manque de candidats qualifiés étaient des défis de taille. La plupart des programmes étaient financés par la rémunération des moniteurs (fellows) pour les soins qu'ils prodiguaient aux patients ou via d'autres aides financières individuelles. CONCLUSIONS: Le nombre de programmes de formation complémentaire en santé mondiale a presque doublé depuis 2010. Les défis sont notamment le manque de financement et de candidats qualifiés. Il est nécessaire de poursuivre le travail pour pouvoir bien identifier et transmettre les meilleures pratiques en matière de formation complémentaire afin de répondre aux divers besoins des partenaires internationaux, des moniteurs (fellows) et des patients qu'ils soignent, et déterminer si un consensus concernant les exigences de formation serait bénéfique.

Indira's story.

Indira is an independent woman who does not live a traditional Nepali life. She rescues abandoned and abused young women from sexual exploitation and provides them with love, support, and education. Her story highlights the key role of the social determinants of health in caring for marginalized populations. Challenges and benefits of attempting to learn from another's personal narrative are also considered.

Enhanced skills in global health and health equity: Guidelines for curriculum development.

INTRODUCTION: Global health addresses health inequities in the care of underserved populations, both domestic and international. Given that health systems with a strong primary care foundation are the most equitable, effective and efficient, family medicine is uniquely positioned to engage in global health. However, there are no nationally recognized standards in Canada for postgraduate family medicine training in global health. OBJECTIVE: To generate consensus on the essential components of a Global Health/Health Equity Enhanced Skills Program in family medicine. METHODS: A panel comprised of 34 experts in global health education and practice completed three rounds of a Delphi small group process. RESULTS: Consensus (defined as ≥ 75% agreement) was achieved on program length (12 months), inclusion of both domestic and international components, importance of mentorship, methods of learner assessment (in-training evaluation report, portfolio), four program objectives (advocacy, sustainability, social justice, and an inclusive view of global health), importance of core content, and six specific core topics (social determinants of health, principles and ethics of health equity/global health, cultural humility and competency, pre and post-departure training, health systems, policy, and advocacy for change, and community engagement). CONCLUSION: Panellists agreed on a number of program components forming the initial foundation for an evidence-informed, competency-based Global Health/Health Equity Enhanced Skills Program in family medicine.

Cesarean delivery rates among family physicians versus obstetricians: a population-based cohort study using instrumental variable methods.

BACKGROUND: Previous research suggests that family physicians have rates of cesarean delivery that are lower than or equivalent to those for obstetricians, but adjustments for risk differences in these analyses may have been inadequate. We used an econometric method to adjust for observed and unobserved factors affecting the risk of cesarean delivery among women attended by family physicians versus obstetricians. METHODS: This retrospective population-based cohort study included all Canadian (except Quebec) hospital deliveries by family physicians and obstetricians between Apr. 1, 2006, and Mar. 31, 2009. We excluded women with multiple gestations, and newborns with a birth weight less than 500 g or gestational age less than 20 weeks. We estimated the relative risk of cesarean delivery using instrumental-variable-adjusted and logistic regression. RESULTS: The final cohort included 776 299 women who gave birth in 390 hospitals. The risk of cesarean delivery was 27.3%, and the mean proportion of deliveries by family physicians was 26.9% (standard deviation 23.8%). The relative risk of cesarean delivery for family physicians versus obstetricians was 0.48 (95% confidence interval [CI] 0.41-0.56) with logistic regression and 1.27 (95% CI 1.02-1.57) with instrumental-variable-adjusted regression. INTERPRETATION: Our conventional analyses suggest that family physicians have a lower rate of cesarean delivery than obstetricians, but instrumental variable analyses suggest the opposite. Because instrumental variable methods adjust for unmeasured factors and traditional methods do not, the large discrepancy between these estimates of risk suggests that clinical and/or sociocultural factors affecting the decision to perform cesarean delivery may not be accounted for in our database.