Family Doctors (family + doctor)

Distribution by Scientific Domains

Selected Abstracts

Patterns of Detection of Superficial Spreading and Nodular-Type Melanoma: A Multicenter Italian Study

Paolo Carli
Background. Nodular histotype represents the condition that is mostly associated with diagnosis of thick melanoma. Objective. The objectives were to evaluate variables associated with and pattern of detection of nodular melanomas and to investigate variables associated with early diagnosis in accordance with histotype (nodular vs. superficial spreading melanomas). Methods. From the original data set of 816 melanomas, all the invasive lesions classified as superficial spreading (n=500) and nodular (n=93) melanomas were considered for the study. A multivariate logistic analysis was performed. Results. Nodular melanomas did not significantly differ from superficial spreading melanomas regarding sex, anatomic site, number of whole-body nevi, and the presence of atypical nevi. As expected, nodular melanomas were represented by a higher percentage of thick (>2 mm) lesions compared to superficial spreading melanomas (64.5% vs. 9.6%, p<0.001). The pattern of detection significantly differed between nodular and superficial spreading melanomas, the former being more frequently self-detected (44.1% vs. 38.0%) or detected by the family doctor (34.4% vs. 11.4%). Female sex, high level of education, and detection made by a dermatologist had an independent, protective effect against late (>1 mm in thickness) diagnosis in superficial spreading melanomas. No protective variable associated with nodular melanomas was found. Conclusion. Patterns of detection for nodular melanomas significantly differ from those for superficial spreading melanomas. For superficial spreading, but not for nodular, melanomas, variables associated with protective effect against late diagnosis can be identified. [source]

Informed consent in direct access colonoscopy

Dev S Segarajasingam
Abstract Background and Aim:, Although direct access colonoscopy is a common practice, some consider the level of informed consent as inadequate, and therefore a medico-legal concern. The aim of this study was to assess the adequacy of informed consent from a patient perspective in a direct access colonoscopy service. Methods:, All patients having outpatient colonoscopy from May 2003 to February 2004 at a direct access colonoscopy service were considered for inclusion into the study. Information was obtained from patients by structured questionnaire administered either at the time of discharge from the day ward or mailed to their homes. Results:, Information was obtained from 346 direct access colonoscopy patients (172 male, 159 female; 226 , 50 years, 103 < 50 years), 80% of whom were referred by their family doctor. Colonoscopy was done for investigation of symptoms in 220 patients, and for screening and surveillance in 115 patients, with an indication not specified in 11 patients. The majority of patients were either very satisfied (70.5%) or satisfied (25.1%) with the consent process, with no demographic characteristics found to predict dissatisfaction. Thirty-seven patients expressed a preference to have seen a gastroenterologist prior to colonoscopy, and four of these patients reported the consent process to be unsatisfactory. Seventy (20.2%) patients reported that the most useful information about colonoscopy was received after they had completed bowel preparation. Conclusion:, No demographic characteristics were found to predict the small fraction of patients dissatisfied with the informed consent process. Further medico-legal risk reduction may be facilitated by enhancing the provision of information prior to bowel preparation. [source]

Decision-making needs of patients with depression: a descriptive study

D. STACEY rn mscn phd
The study's purpose was to explore the decision-making needs of patients considering treatment options for their depression. Semi-structured interviews were guided by the Ottawa Decision Support Framework. Of 94 participants, 67 were uncertain about their decision. Common decisions identified were whether or not to take medications, attend support groups, undergo electroconvulsive therapy, and location of care. Those feeling certain were more likely to have made a decision (RR 1.37; 95% CI: 1.05, 1.78). However, 40 patients who had ,made a decision' in the recent past were uncertain about their decision. Compared with those who were certain, the uncertain group felt less informed (2.65 vs. 1.64; P < 0.001), less supported (2.63 vs. 1.88; P < 0.001) and less clear about how they valued the benefits and risks of options (2.57 vs. 1.69; P < 0.001). Other influential factors included concerns about confidentiality, distress from depression, embarrassment, panic attacks and lack of energy. Few patients wanted to defer decision making to their physician (n = 8) or family (n = 1). To support decision making, participants identified the need for: discussions with their psychiatrist, nurse or family doctor; access to printed information; and information provided by health professionals and health societies. [source]

Using disease risk estimates to guide risk factor interventions: field test of a patient workbook for self-assessing coronary risk

J. Michael Paterson MSc
Objective,To assess the feasibility and acceptability of a patient workbook for self-assessing coronary risk. Design,Pilot study, with post-study physician and patient interviews. Setting and subjects,Twenty southern Ontario family doctors and 40 patients for whom they would have used the workbook under normal practice conditions. Interventions,The study involved convening two sequential groups of family physicians: the first (n=10) attended focus group meetings to help develop the workbook (using algorithms from the Framingham Heart Study); the second (n=20) used the workbook in practice with 40 patients. Follow-up interviews were by interviewer-administered questionnaire. Main outcome measures,Physicians' and patients' opinions of the workbook's format, content, helpfulness, feasibility, and potential for broad application, as well as patients' perceived 10-year risk of a coronary event measured before and after using the workbook. Results,It took an average of 18 minutes of physician time to use the workbook: roughly 7 minutes to introduce it to patients, and about 11 minutes to discuss the results. Assessments of the workbook were generally favourable. Most patients were able to complete it on their own (78%), felt they had learned something (80%) and were willing to recommend it to someone else (98%). Similarly, 19 of 20 physicians found it helpful and would use it in practice with an average of 18% of their patients (range: 1,80%). The workbook helped to correct misperceptions patients had about their personal risk of a coronary event over the next 10 years (pre-workbook (mean (SD) %): 35.2 (16.9) vs. post-workbook: 17.3 (13.5), P < 0.0001; estimate according to algorithm: 10.6 (7.6)). Conclusions,Given a simple tool, patients can and will assess their own risk of CHD. Such tools could help inform otherwise healthy individuals that their risk is increased, allowing them to make more informed decisions about their behaviours and treatment. [source]

Interpreting three-dimensional structures from two-dimensional images: a web-based interactive 3D teaching model of surgical liver anatomy

HPB, Issue 6 2009
Jodi L. Crossingham
Abstract Background:, Given the increasing number of indications for liver surgery and the growing complexity of operations, many trainees in surgical, imaging and related subspecialties require a good working knowledge of the complex intrahepatic anatomy. Computed tomography (CT), the most commonly used liver imaging modality, enhances our understanding of liver anatomy, but comprises a two-dimensional (2D) representation of a complex 3D organ. It is challenging for trainees to acquire the necessary skills for converting these 2D images into 3D mental reconstructions because learning opportunities are limited and internal hepatic anatomy is complicated, asymmetrical and variable. We have created a website that uses interactive 3D models of the liver to assist trainees in understanding the complex spatial anatomy of the liver and to help them create a 3D mental interpretation of this anatomy when viewing CT scans. Methods:, Computed tomography scans were imported into DICOM imaging software (OsiriXÔ) to obtain 3D surface renderings of the liver and its internal structures. Using these 3D renderings as a reference, 3D models of the liver surface and the intrahepatic structures, portal veins, hepatic veins, hepatic arteries and the biliary system were created using 3D modelling software (Cinema 4DÔ). Results:, Using current best practices for creating multimedia tools, a unique, freely available, online learning resource has been developed, entitled Visual Interactive Resource for Teaching, Understanding And Learning Liver Anatomy (VIRTUAL Liver) ( This website uses interactive 3D models to provide trainees with a constructive resource for learning common liver anatomy and liver segmentation, and facilitates the development of the skills required to mentally reconstruct a 3D version of this anatomy from 2D CT scans. Discussion:, Although the intended audience for VIRTUAL Liver consists of residents in various medical and surgical specialties, the website will also be useful for other health care professionals (i.e. radiologists, nurses, hepatologists, radiation oncologists, family doctors) and educators because it provides a comprehensive resource for teaching liver anatomy. [source]

Knowledge and attitudes about oral cancer among dentists in Spain

Pia López-Jornet PhD MD
Abstract Objectives, Detecting oral cancer (OC) at an early stage is the most effective means of improving survival and reducing morbility from disease. The objective was to study the knowledge, opinions and attitudes held by general dentists in Spain regarding aspects of OC in general clinic practice. Methods, A 44-item questionnaire relating to OC was randomly distributed by email to 1000 dentists in the different autonomous communities in Spain. Results, The response rate was 42.7%. Only 49.7% of the dentists who replied considered themselves to have up-to-date knowledge on OC. A total of 94.7% of those interviewed hold the opinion that it is the dentists who are qualified to carry out the oral examination. In addition, 41.8% felt that family doctors and 13.8% that dental hygienists were also capable of making this examination. We should highlight that dentists who rated their undergraduate OC training favourably were more likely to agree that their OC knowledge was current than those who rated their undergraduate training unfavourably [odds ratio (OR) = 4.1, 95% confidence interval (CI) = 1.1,4.2, P = 0.019). Respondents who performed oral cancer examinations on all patients 40 years of age or older were 1.8 times more likely to agree that their OC knowledge was current; however, the differences were not significant (OR = 1.3, 95% CI = 0.6,2.7, P = 0.392). Conclusions, Gaps in knowledge exist, strongly suggesting the need for continued courses of education detection and prevention of OC. [source]

Developing interdisciplinary maternity services policy in Canada.

Evaluation of a consensus workshop
Abstract Context, Four maternity/obstetrical care organizations, representing women, midwives, obstetricians and family doctors conducted interdisciplinary policy research under auspices of four key stakeholder groups. These projects teams and key stakeholders subsequently collaborated to develop consensus on strategies for improved maternity services in Ontario. Objectives, The objective of this study is to evaluate a 2-day research synthesis and consensus building conference to answer policy questions in relation to new models of interdisciplinary maternity care organizations in different settings in Ontario. Methods, The evaluation consisted of a scan of individual project activities and findings as were presented to an invited audience of key stakeholders at the consensus conference. This involved: participant observation with key informant consultation; a survey of attendees; pattern processing and sense making of project materials, consensus statements derived at the conference in the light of participant observation and survey material as pertaining to a complex system. The development of a systems framework for maternity care policy in Ontario was based on secondary analysis of the material. Findings, Conference participants were united on the importance of investment in maternity care for Ontario and the impending workforce crisis if adaptation of the workforce did not take place. The conference participants proposed reforming the current system that was seen as too rigid and inflexible in relation to the constraints of legislation, provider scope of practice and remuneration issues. However, not one model of interdisciplinary maternity/obstetrical care was endorsed. Consistency and coherence of models (rather than central standardization) through self-organization based on local needs was strongly endorsed. An understanding of primary maternity care models as subsystems of networked providers in complex health organizations and a wider social system emerged. The patterns identified were incorporated into a complexity framework to assist sense making to inform policy. Discussion, Coherence around core values, holism and synthesis with responsiveness to local needs and key stakeholders were themes that emerged consistent with complex adaptive systems principles. Respecting historical provider relationships and local history provided a background for change recognizing that systems evolve in part from where they have been. The building of functioning relationships was central through education and improved communication with ongoing feedback loops (positive and negative). Information systems and a flexible improved central and local organization of maternity services was endorsed. Education and improved communication through ongoing feedback loops (positive and negative) were central to building functioning relationships. Also, coordinated central organization with a flexible and adaptive local organization of maternity services was endorsed by participants. Conclusions, This evaluation used an approach comprising scoping, pattern processing and sense making. While the projects produced considerable typical research evidence, the key policy questions could not be addressed by this alone, and a process of synthesis and consensus building with stakeholder engagement was applied. An adaptive system with local needs driving a relationship based network of interdisciplinary groupings or teams with both bottom up and central leadership. A complexity framework enhanced sense making for the system approaches and understandings that emerged. [source]

Sharing specialist skills for diabetes in an inner city: A comparison of two primary care organisations over 4 years

Abdu Mohiddin MFPHM Lecturer
Abstract Objective, To evaluate the effects of organizational change and sharing of specialist skills and information technology for diabetes in two primary care groups (PCGs) over 4 years. Methods, In PCG-A, an intervention comprised dedicated specialist sessions in primary care, clinical guidelines, educational meetings for professionals and a shared diabetes electronic patient record (EPR). Comparison was made with the neighbouring PCG-B as control. In intervention and control PCGs, practice development work was undertaken for a new contract for family doctors. Data were collected for clinical measures, practice organizational characteristics and professional and patient views. Results, Data were analysed for 26 general practices including 17 in PCG-A and nine in PCG-B. The median practice-specific proportions of patients with HbA1c recorded annually increased in both areas: PCG-A from median 65% to 77%, while PCG-B from 53% to 84%. For cholesterol recording, PCG-A increased from 50% to 76%, and PCG-B from 56% to 80%. Organizational changes in both PCGs included the establishment of recall systems, dedicated clinics and educational sessions for patients. In both PCGs, practices performing poorly at baseline showed the greatest improvements in organization and clinical practice. Primary care professionals' satisfaction with access and communication with diabetes specialist doctors and nurses increased, more so in the intervention PCG. Only 16% of primary care professional respondents used the diabetes EPR at least monthly. Patient satisfaction and knowledge did not change. Conclusions, Improvements in practices' organizational arrangements were associated with improvements in clinical care in both PCGs. Sharing specialist skills in one PCG was associated with increased professional satisfaction but no net improvement in clinical measures. A shared diabetes EPR is unlikely to be used, unless integrated with practice information systems. [source]

Testing an empirically derived mental health training model featuring small groups, distributed practice and patient discussion

Rachael C Murrihy
Objectives, Internationally, family doctors seeking to enhance their skills in evidence-based mental health treatment are attending brief training workshops, despite clear evidence in the literature that short-term, massed formats are not likely to improve skills in this complex area. Reviews of the educational literature suggest that an optimal model of training would incorporate distributed practice techniques; repeated practice over a lengthy time period, small-group interactive learning, mentoring relationships, skills-based training and an ongoing discussion of actual patients. This study investigates the potential role of group-based training incorporating multiple aspects of good pedagogy for training doctors in basic competencies in brief cognitive behaviour therapy (BCBT). Methods, Six groups of family doctors (n = 32) completed eight 2-hour sessions of BCBT group training over a 6-month period. A baseline control design was utilised with pre- and post-training measures of doctors' BCBT skills, knowledge and engagement in BCBT treatment. Results, Family doctors' knowledge, skills in and actual use of BCBT with patients improved significantly over the course of training compared with the control period. Conclusions, This research demonstrates preliminary support for the efficacy of an empirically derived group training model for family doctors. Brief CBT group-based training could prove to be an effective and viable model for future doctor training. [source]

Challenges in multisource feedback: intended and unintended outcomes

Joan Sargeant
Context, Multisource feedback (MSF) is a type of formative assessment intended to guide learning and performance change. However, in earlier research, some doctors questioned its validity and did not use it for improvement, raising questions about its consequential validity (i.e. its ability to produce intended outcomes related to learning and change). The purpose of this qualitative study was to increase understanding of the consequential validity of MSF by exploring how doctors used their feedback and the conditions influencing this use. Methods, We used interviews with open-ended questions. We purposefully recruited volunteer participants from 2 groups of family doctors who participated in a pilot assessment of MSF: those who received high (n = 25) and those who received average/lower (n = 44) scores. Results, Respondents included 12 in the higher- and 16 in the average/lower-scoring groups. Fifteen interpreted their feedback as positive (i.e. confirming current practice) and did not make changes. Thirteen interpreted feedback as negative in 1 or more domains (i.e. not confirming their practice and indicating need for change). Seven reported making changes. The most common changes were in patient and team communication; the least common were in clinical competence. Positive influences upon change included receiving specific feedback consistent with other sources of feedback from credible reviewers who were able to observe the subjects. These reviewers were most frequently patients. Discussion, Findings suggest circumstances that may contribute to low consequential validity of MSF for doctors. Implications for practice include enhancing procedural credibility by ensuring reviewers' ability to observe respective behaviours, enhancing feedback usefulness by increasing its specificity, and considering the use of more objective measures of clinical competence. [source]

The risks and benefits of being a young female adolescent standardised patient

KD Blake
Objective, To follow the progress of young female adolescents, as risk-taking standardised patients (SPs), and to monitor for adverse affects that role-playing may have on the adolescents. Methods, A prospective design was used in which 11 female adolescents, aged 13,15 years, were recruited from 2 schools. The adolescents were trained to portray risk-taking individuals with a medical condition and were interviewed with their SP mother by final-year medical students 1,3 times a month over 6,14 months. A control group was selected from both schools (n = 6). Main outcome measures were pre- and post-interviews using standardised questionnaires [Achenbach's Youth Self-Report (YSR) and Piers Harris Children's Self Concept Scale (SCS),] and focus groups. Results, The adolescent group simulated 111 interviews (mean per adolescent 10.1, SD = 6.2) each lasting 60,70 minutes. Quantitative data, The pre- and post-scores from the YSR and SCS demonstrated no significant differences within the SP study participants or between the control group vs. the study group. Focus group findings, The initial focus group acted as a debriefing exercise and prompted the adolescents to request that they come out of their role when giving feedback. Subsequent focus group discussion was around the medical student performance and their family doctors. Conclusion, Adolescent females showed no adverse effects when used extensively to portray risk-taking SPs. The focus groups provided the adolescents with an opportunity to debrief together. The adolescent SPs reported benefiting from this study but requested unanimously that they come ,out of character' when giving feedback to the medical students. [source]

Assessment in the context of uncertainty: how many members are needed on the panel of reference of a script concordance test?

R Gagnon
Purpose, The script concordance test (SCT) assesses clinical reasoning in the context of uncertainty. Because there is no single correct answer, scoring is based on a comparison of answers provided by examinees with those provided by members of a panel of reference made up of experienced practitioners. This study aims to determine how many members are needed on the panel to obtain reliable scores to compare against the scores of examinees. Methods, A group of 80 residents were tested on 73 items (Cronbach's ,: 0.76). A total of 38 family doctors made up the pool of experienced practitioners, from which 1000 random panels of reference of increasing sizes (5, 10, 15, 20, 25 and 30) were generated with a resampling procedure. Residents' scores were computed for each panel sample. Units of analysis were means of residents' score, test reliability coefficient and correlation coefficient between scores obtained with a given panel of reference versus the scores obtained with the full panel of 38. Statistics were averaged across the 1000 samples for each panel size for the mean and test reliability computations, and across 100 samples for the correlation computation. Results, For sample variability, there was a 3-fold increase in standard deviation of means between a sample panel size of 5 (SD = 1.57) and a panel size of 30 (SD = 0.50). For reliability, there was a large difference in precision between a panel size of 5 (0.62) and a panel size of 10 (0.70). When the panel size was over 20, the gain became negligible (0.74 for 20 and 0.76 for 38). For correlation, the mean correlation coefficient values were 0.90 with 5 panel members, 0.95 with 10 members and 0.98 with 20 members. Conclusion, Any number over 10 is associated with acceptable reliability and good correlation between the samples versus the full panel of 38. For high stake examinations, using a panel of 20 members is recommended. Recruiting more than 20 panel members shows only a marginal benefit in terms of psychometric properties. [source]

Why do doctors attend traditional CME events if they don't change what they do in their surgeries?

Evaluation of doctors' reasons for attending a traditional CME programme
Objective ,This study aimed to discover what the family doctors who attended an annual refresher course wished to obtain from participating in the event and what their response was to evidence that doctor behaviour is not changed by such programmes. Design ,The study used the qualitative method of in-depth interviews. Setting ,Ottawa, Ontario, Canada and the surrounding area. Participants The informants for the study were a sample of 6 family doctors who attended the 50th Annual Refresher Course for Family Physicians, held in April 2001 in Ottawa, Ontario, Canada. Method ,In-depth interviews with the participants were conducted before and after they attended the annual refresher course. The doctors had pre-registered for the 3-day course. They were purposely selected to obtain diversity of gender, year of graduation from medical school and practice location. Results ,The doctors interviewed had 3 main reasons for attending the refresher course: to obtain information or to be updated; to be reassured that their practice behaviour was within accepted guidelines, and to hear from and interact with the specialists who gave presentations. All the participants in the study were able to name changes they had made as the result of attending a similar type of programme in the past and were sceptical of findings that practice behaviour did not change as a result of traditional continuing medical education (CME). Conclusions ,Despite current support for interactive and practice-linked educational activities, the doctors in this study valued the input of the experts who lectured at the course. These doctors were not prepared to accept the currently held precept that their behaviour did not change as a result of attendance at traditional CME programmes. [source]

Paediatric training for family doctors: principals and practice

C Melville
Background There is controversy as to how best to train general practitioners for the paediatric challenges they will meet in practice, in particular what should be included in training, what should be left out and how long should it last? Subjects and methods All 615 general practice principals referring to 6 hospitals were surveyed (40% response rate). Setting West Midlands region of England. Study design Postal questionnaire. Statistics Quantitative and qualitative assessment of responses. Quantitative responses were analysed by hospital, decade of qualification, and duration of paediatric training. Qualitative responses were analysed using grounded theory. Results Satisfaction with training was directly related to its duration, with low levels of satisfaction for less than 6 months paediatrics, moderate levels for 6,11 months, and high levels with 12 months or more. The most important item of training was recognition of the sick child. Acute and chronic paediatrics was generally well covered. Psychosocial aspects, public health and immunisation were poorly addressed. Neonatal resuscitation and first day checks were seen as relevant, but neonatal intensive care was not. Conclusions At least 6 months of paediatrics is necessary for GPs in training, but longer paediatric exposure further increases their satisfaction with training. GPs have a biopsychosocial rather than biomedical approach to their child patients, suggesting potential benefits from a greater emphasis on psychosocial and public health aspects at the expense of neonatal intensive care. Recognition of the sick child is essential, and acute and chronic organic illness should be covered in breadth. Possible future models for GP training in paediatrics are discussed. [source]

Descriptive epidemiology of Down's syndrome in Estonia

Tiia Reimand
Summary The aim of the study was to investigate the livebirth prevalence of Down's syndrome (DS) in Estonia during the past 14 years, create a DS database and observe the effectiveness of prenatal screening. This is a population-based descriptive study. The study subjects were children with DS diagnosis born between the years 1990 and 2003. We collected data from genetic centres in Estonia, from the databases of DS support groups, from institutions for disabled children and from the registers of family doctors/paediatricians. Prenatal screening for chromosomal anomalies for women aged ,35 years was started in Estonia in 1995. Therefore, we divided the DS children into two groups: 112 born between 1990 and 1994 comprise group I, and 127 born between 1995 and 2003 comprise group II. Group II was further divided into two subgroups: IIa, from 1995 to 1998, when screening of advanced maternal age (,35 years) commenced, and IIb, from 1999 to 2003, when screening of second trimester maternal serum for younger women commenced. Prenatally, 68 cases of DS were diagnosed between 1995 and 2003 in the whole of Estonia, and all of these pregnancies were terminated. This represents 34.9% of all delivered and prenatally detected DS cases from this period. The overall livebirth prevalence was 1.17 per 1000 livebirths. The livebirth prevalence in group I was 1.25 and in group II was 1.09 per 1000 livebirths. The second trimester maternal serum screening with advanced maternal age screening was more effective than advanced maternal age screening alone. The livebirth prevalence in group IIa was 1.22 and in group IIb 0.99 per 1000 livebirths. Overall, regular trisomy was found in 90.4%, translocation in 6.3% and mosaicism in 2.9%. The overall male to female sex ratio of DS was 1.09. [source]

Knowledge and Behavior of Tourists to Manu National Park, Peru, in Relation to Leishmaniasis

Irmgard L. Bauer
Background: Tourists have been infected with Leishmania braziliensis and the lack of appropriate travel information on the disease has been documented. The aim of this study was to describe the knowledge and behavior of tourists booked on a trip to Manu National Park in Peru in relation to leishmaniasis and its prevention. Methods: The clients of two tour operators in Cusco, Peru, represented the experimental and control group. The experimental group completed a questionnaire after the tour briefing the night before the trip and received the information leaflet. A second questionnaire was completed just before returning from the park. The clients in the control group did not receive the leaflet. Results: Three hundred and seventy-three questionnaire pairs were collected (173 experimental, 200 control). Only 24 (6%) of all participants claimed to have heard of leishmaniasis. Of the 92.5% of tourists who read the leaflet, 156 (97.5%) found it informative, although 50 (32.5%) wanted more information. It was suggested that the leaflet should be distributed by tour operators (56.9%), general practitioners/family doctors (49%), and travel agents (47.1%). There was no significant difference in the use of preventive measures between the groups. One-third of the experimental group claimed to have paid more attention to protection due to the information given in the leaflet. Conclusions: There is generally a lack of knowledge on leishmaniasis with a great feeling of need for more and detailed information. Correct and complete information on leishmaniasis should be included in the health advice for travelers to endemic areas. [source]