Family Medicine (family + medicine)

Distribution by Scientific Domains
Distribution within Medical Sciences

Selected Abstracts

Lack of management of cardiovascular risk factors in type 2 diabetic patients

K. E. Yun
Summary Effective management of diabetic patients includes comprehensive control for not only blood sugar, but also other cardiovascular risk factors. We assessed whether haemoglobin A1c (A1C) concentrations, blood pressure, low density lipoprotein (LDL) cholesterol levels and microalbuminuria were regularly measured in 281 patients with type 2 diabetes who received care for over 1 year in the Department of Family Medicine located in an urban area of Korea. Subsequently, in patients with A1C > 7%; blood pressure >130/80 mmHg; LDL cholesterol levels >100 mg/dl; or microalbuminuria, we evaluated the status of management for those cardiovascular risk factors. Physicians were most likely to measure A1C levels (98.6%), but less likely to measure microalbuminuria (56.2%), LDL cholesterol (73.7%), or blood pressure (74.4%). Patients whose A1C levels were above the goal (78.2%) were likely to receive optimal therapy. In contrast, only 21.1% of patients with uncontrolled blood pressure and 5.3% of patients with LDL cholesterol levels above the target range received optimal management. Of the 36 patients with microalbuminuria or overt proteinuria, 66.7% took angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Measurement of parameters indicating cardiovascular risk factors in type 2 diabetic patients was not optimal, particularly regular measurements for microalbuminuria and for controlling LDL-cholesterol and blood pressure. These findings indicate a need for greater education of comprehensive cardiovascular management in type 2 diabetic patients and their physicians. [source]

Socio-psychological stressors as risk factors for low back pain in Chinese middle-aged women

Yin-bing Yip BAppSc MPH PhD GDipEd RN
Socio-psychological stressors as risk factors for low back pain in Chinese middle-aged women Aim(s) of the study.,This study aims to explore the relationship between socio-psychological stress and low back pain (LBP) prevalence among Chinese middle-aged women. Background.,Women in mid-life experience increasing socio-psychological stress because of midlife transitions, stressful life events and housework or work factors. Encountering socio-psychological stress itself may result in the manifestation of LBP. Design.,A case,control study of Hong Kong community-based middle-aged women was conducted. The study subjects were either from the University Family Medicine Clinic or from a previous population-based cross-sectional study of middle-aged women conducted by Department of Community and Family Medicine. Among the 928 potential eligible subjects from both sources, a total of 182 cases and 235 controls participated in this study. Data were collected from face-to-face interviews and included demographic factors, menopausal status, socio-psychological stress and occurrence of LBP. Socio-psychological stress covered social factors, self-reported nature of housework/work, housework/work stress and stressful life events. Results.,Among the 182 cases who entered this study, 83 women (45·6%) had experienced 1,<14 days of LBP, and 99 women (54·4%) had at least 14 days of LBP in the previous 12 months. Those who reported that ,their family members, relatives or friends were very sick, died, needed her to take care of them or who they worried about in the past 12 months' had an increased risk of LBP of 67% (95% confidence interval (CI) 1·09,2·55). In addition women with a bad or ordinary relationship with cohabitants had an increased risk of LBP of 70% (95% CI 1·00,3·04). Lastly, women with a high housework or work stress had an increased risk of suffering both types of LBP of nearly two- and half-fold (95% CI 1·61,3·85). Conclusions.,The results indicate that an association exists between high socio-psychological stress and LBP prevalence. Alleviating the impact of housework or work related factors would, however, involve improving both the work and home environment. [source]

Guidelines Abstracted from the Department of Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Stroke Rehabilitation

Miriam Rodin MD
OBJECTIVES: To assist facilities in identifying those evidence-based processes of poststroke care that enhance measurable patient outcomes. The guideline(s) should be used by facilities (hospitals, subacute-care units and providers of long-term care) to implement a structured approach to improve rehabilitative practices and by clinicians to determine best interventions to achieve improved patient outcomes. OPTIONS: The guideline considers five elements of poststroke rehabilitation care: interdisciplinary teams; use of standardized assessments; intensity, timing, and duration of therapy; involvement of patients' families and caregivers in decision-making; and educational interventions for patients, families, and caregivers. Evidence, benefits, harms, and recommendations for each of the five designated elements and specific annotated recommendations for poststroke managements are presented separately. OUTCOMES: The overall guideline considers improvement in functional status measures as the primary outcome. Achieving community-dwelling status and preventing complications, death, and rehospitalization are also important outcomes. Costs are not specifically addressed. PARTICIPANTS: The Department of Veterans Affairs/Department of Defense (VA/DoD) Stroke Rehabilitation Working Group consisted of 28, largely VA and military hospital, representatives of medical and allied professions concerned with stroke diagnosis, management, and rehabilitation. Nine additional members with similar credentials served as the editorial committee. Technical consultation was contracted from ACS Federal Health Care, Inc., and the Center for Evidence-Based Practice, State University of New York,Upstate Medical University, Department of Family Medicine conducted evidence appraisal. Consensus was achieved over several years of facilitated group discussion and iterative evaluation of draft documents and supporting evidence. SPONSOR: The guideline was prepared under the auspices of the VA/DoD. No other source of support was identified in the document, or supporting documents. [source]

Effectiveness of medical school admissions criteria in predicting residency ranking four years later

Christopher Peskun
Background, Medical schools across Canada expend great effort in selecting students from a large pool of qualified applicants. Non-cognitive assessments are conducted by most schools in an effort to ensure that medical students have the personal characteristics of importance in the practice of Medicine. We reviewed the ability of University of Toronto academic and non-academic admission assessments to predict ranking by Internal Medicine and Family Medicine residency programmes. Methods, The study sample consisted of students who had entered the University of Toronto between 1994 and 1998 inclusive, and had then applied through the Canadian resident matching programme to positions in Family or Internal Medicine at the University of Toronto in their graduating year. The value of admissions variables in predicting medical school performance and residency ranking was assessed. Results, Ranking in Internal Medicine correlated significantly with undergraduate grade point average (GPA) and the admissions non-cognitive assessment. It also correlated with 2-year objective structured clinical examination (OSCE) score, clerkship grade in Internal Medicine, and final grade in medical school. Ranking in Family Medicine correlated with the admissions interview score. It also correlated with 2nd-year OSCE score, clerkship grade in Family Medicine, clerkship ward evaluation in Internal Medicine and final grade in medical school. Discussion, The results of this study suggest that cognitive as well as non-cognitive factors evaluated during medical school admission are important in predicting future success in Medicine. The non-cognitive assessment provides additional value to standard academic criteria in predicting ranking by 2 residency programmes, and justifies its use as part of the admissions process. [source]

Role modelling: how does it influence teaching in Family Medicine?

Christopher Matthews
Objective To undertake a qualitative study to explore the influence of role modelling on teaching by comparing faculty members recollections of their teachers' behaviours with residents perceptions of the same behaviours in a family medicine residency programme in Saudi Arabia. Method Using semi-structured interviews of faculty and a questionnaire based on the issues arising from the interviews, faculty members' recollections of their medical teachers' behaviours were compared with residents' current perceptions of the same teaching behaviours. Setting Department of Family Medicine, King Fahad National Guard Hospital, Riyadh, Saudi Arabia. Subjects Faculty and residents. Results The four best-remembered teacher behaviours were: positive behaviour towards patients, negative behaviour towards junior colleagues, effective presentation of subject content and encouragement to participate in patient care. The residents perceived positive behaviour towards patients, positive behaviour towards junior colleagues, suboptimal skills of subject content presentation, and insufficient encouragement for trainees to actively participate in patient management. Although faculty retained many unhappy memories of teacher behaviour, it was encouraging that there was no evidence of perpetuation of the negatively perceived behaviours which provoked them. Conclusions Discernment of the value of technical teaching skills was not a predictor of later proficiency. [source]

Perceived need for emergency medicine training in Pakistan: A survey of medical education leadership

Junaid A Razzak
Abstract Objective: To assess the perception of leaders of the academic medical institutions regarding the need for specialty training in emergency medicine. Methods: A cross-sectional survey was conducted in all medical colleges of Pakistan in September 2005. Our sample included all academic leaders of recognized medical colleges in Pakistan. A questionnaire was designed and sent (mailed and faxed) to vice chancellors, deans, principals or medical directors of the institutions. Reminders were sent through faxes and emails wherever available, followed by phone calls if responses were not available after several attempts. Results: At the time of study, there were 39 medical colleges recognized by Pakistan Medical and Dental Council. Of these, responses were received from 26 teaching institutions in the country. A majority of the respondents (85%) were not satisfied with the care provided in the ED of their primary teaching hospital, and three-fourth (74%) thought that doctors specialized in other disciplines, like internal medicine and family medicine, cannot adequately manage all emergencies. When asked if Pakistan should have a separate residency training programme in emergency medicine, 96% responded in affirmative, and many (85%) thought that they will start a residency programme in emergency medicine if it was approved as a separate specialty. Conclusion: This survey shows significant support for a separate local training programme for emergency medicine in the country. [source]

Diagnosis Clusters for Emergency Medicine

Debbie A. Travers RN
Objectives: Aggregated emergency department (ED) data are useful for research, ED operations, and public health surveillance. Diagnosis data are widely available as The International Classification of Diseases, version, 9, Clinical Modification (ICD-9-CM) codes; however, there are over 24,000 ICD-9-CM code-descriptor pairs. Standardized groupings (clusters) of ICD-9-CM codes have been developed by other disciplines, including family medicine (FM), internal medicine (IM), inpatient care (Agency for Healthcare Research and Quality [AHRQ]), and vital statistics (NCHS). The purpose of this study was to evaluate the coverage of four existing ICD-9-CM cluster systems for emergency medicine. Methods: In this descriptive study, four cluster systems were used to group ICD-9-CM final diagnosis data from a southeastern university tertiary referral center. Included were diagnoses for all ED visits in July 2000 and January 2001. In the comparative analysis, the authors determined the coverage in the four cluster systems, defined as the proportion of final diagnosis codes that were placed into clusters and the frequencies of diagnosis codes in each cluster. Results: The final sample included 7,543 visits with 19,530 diagnoses. Coverage of the ICD-9-CM codes in the ED sample was: AHRQ, 99%; NCHS, 88%; FM, 71%; IM, 68%. Seventy-six percent of the AHRQ clusters were small, defined as grouping <1% of the diagnosis codes in the sample. Conclusions: The AHRQ system provided the best coverage of ED ICD-9-CM codes. However, most of the clusters were small and not significantly different from the raw data. [source]

Impact of Terminal Digit Preference by Family Physicians and Sphygmomanometer Calibration Errors on Blood Pressure Value: Implication for Hypertension Screening

Theophile Niyonsenga PhD
The accuracy of blood pressure (BP) measurement is important; systematic small errors can mislabel BP status in many persons. The objective of this study was to assess the impact of 2 types of measurement errors on the evaluation of BP in family medicine: errors associated with terminal digit preference and those associated with calibration errors of sphygmomanometers. Secondary data analyses from 2 different projects were used to derive empiric distributions of terminal digit and BP device errors. Taking into account both types of errors, the proportion of false positives (falsely high BP) and false negatives (falsely normal BP) varied between 0. 82% and 5.18% of the population of consulting family physicians. In the United States, false positives and false negatives in patients' BP evaluations might lead to overtreating or undertreating 1.15 million to 7.25 million patients. Results support the need for the development of systematic interventions for quality control of BP measurements and periodic retraining for health professionals. [source]

Changes in perceived effect of practice guidelines among primary care doctors

Lee Cheng MD MSc
Abstract Rationale, aims and objectives, Evidence suggests that when doctors use systematically developed clinical practice guidelines they have the potential to improve the safety, quality and value of health care. The purpose of this study was to evaluate recent changes in the perceptions of practice guidelines among US primary care doctors. Methods, Data were collected from the Community Tracking Survey 1996,97 and 2000,01. All results were weighted and adjusted to reflect the complex survey design. Results, Over the 5 years, the proportion of primary care doctors who said that practice guidelines had at least a moderate effect on their practice of medicine increased from 45.8% to 60.7%. This increase was nearly equal among primary care doctors of family medicine, internal medicine and paediatrics. In the 2001 survey, a higher perceived effect of practice guidelines was described by female doctors (OR = 1.39, 95% CI 1.19,1.63) and doctors who were practising in a large model group (OR = 1.73; 95% CI 1.04,2.89). Doctors who graduated from medical school within 10 years of the survey were more likely to report that practice guidelines had a positive effect on their practice of medicine than doctors who graduated 10 or more years before the survey. Conclusion, The perceived effect of practice guidelines on primary care doctors increased over time. Improved dissemination of guidelines and curriculum changes may have led recent primary care graduates to view practice guidelines as more important. [source]

Predicting doctor performance outcomes of curriculum interventions: problem-based learning and continuing competence

Geoffrey R Norman
Context, Problem-based learning (PBL) is an educational strategy designed to enhance self-assessment, self-directed learning and lifelong learning. The present study examines a peer review programme to determine whether the impact of PBL on continuing competence can be detected in practice. Objectives, This study aimed to establish whether McMaster graduates who graduated between 1972 and 1991 were any less likely to be identified as having issues of competence by a systematic peer review programme than graduates of other Ontario medical schools. Methods, We identified a total of 1166 doctors who had graduated after 1972 and had completed a mandated peer review programme. Of these, 108 had graduated from McMaster and 857 from other Canadian schools. School of graduation was cross-tabulated against peer rating. A secondary analysis examined predictors of ratings using multiple regression. Results, We found that 4% of McMaster graduates and 5% of other graduates were deemed to demonstrate cause for concern or serious concern, and that 24% of McMaster doctors and 28% of other doctors were rated as excellent. These differences were not significant. Multiple regression indicated that certification by family medicine or a specialty, female gender and younger age were all predictors of practice outcomes, but school of graduation was not. Conclusions, There is no evidence from this study that PBL graduates are better able to maintain competence than graduates of conventional schools. The study highlights potential problems in attempting to link undergraduate educational interventions to doctor performance outcomes. [source]

Community family medicine teachers' perceptions of their teaching role

Karen V Mann
Objectives Our study explored community preceptors' perceptions of their teaching role, to better understand effective ambulatory and community-based teaching. Methods Bandura's social cognitive theory and Schön's notion of reflective practice guided conceptual development of an interview exploring preceptors' views of their role, teaching goals, teaching techniques, student assessment practices, factors affecting teaching and learning, and balance of patient and student needs. Preceptors reflected also on a significant personal teaching experience. A total of 17 highly student-rated preceptors participated. A trained interviewer conducted each interview; all were transcribed and subjected to content analysis. Results Preceptors (male, 14; female, 3) described learner-centred approaches, setting goals jointly with the student. Demonstration, guided practice, observation and feedback were integral to the experience. Preceptors saw student comfort in the environment as key to effective learning; they attempted to maximize students' learning and breadth of experience. They wanted students to understand content, ,know-how' and ,being a family physician'. Patients remained the primary responsibility, but learners' needs were viewed as compatible with that responsibility. Many preceptors perceived a professional responsibility as ,role models'. Conclusions Preceptors recognized the dynamic environment in which they taught students, and they described strategies which demonstrated how they adapted their teaching to meet the needs of the learner in that environment. These teachers combined learner-centred approaches with sound educational practices, broad learning experiences, attention to student learning and concern for development of professional expertise and judgement. These findings may assist faculty development in family medicine, and other disciplines, in providing effective ambulatory care teaching. [source]

Defense of Breast Cancer Malpractice Claims

FACOG, Samuel Zylstra MD
Abstract: The goal of this study was to determine whether factors associated with the successful defense and cost of malpractice cases involving the failure to diagnose breast cancer could be identified in medical and legal records. Secondary goals were to develop a multidisciplinary clinical algorithm utilizing National Comprehensive Cancer Network (NCCN) practice guidelines with practitioner risk management strategies. Physician deviations from these guidelines were tracked to identify high-risk areas in the diagnosis of breast cancer. A multidisciplinary clinical algorithm was introduced and practitioner risk management issues were addressed. In this study specific medical, legal, and cost factors were retrospectively abstracted and analyzed to identify associations between medical and legal factors and medicolegal outcome. ProMutual handled 156 malpractice cases involving breast cancer between January 22, 1986, and November 20, 1997. Of the total, 124 cases involving 212 defendants were closed. The closed cases were analyzed, using multivariable stepwise logistic and linear regression, to identify associations between clinical factors and case outcome. Women's health practitioners (WHPs), including obstetrician-gynecologists (OB-GYNs), family medicine, and internal medicine clinicians, were the largest group of defendants (97). Others included radiologists (43), surgeons (33), and pathologists (3). OB-GYNs accounted for 31% of these defendants, with a cost of more than $16 million. The greatest number of specialists represented in the open cases were radiologists, with 38% of the total. The defense model predicts that the probability of successful defense is lessened with inadequate record keeping, a patient that has metastasis and is alive, and a delay in diagnosis of 12 months or more. The overall indemnity model predicts a higher indemnity with the spread of disease at the time of evaluation, a patient who has metastasis and is alive, and a date of occurence closer to the present. Indemnity is less in patients who have had a lymph node dissection, who have died, or who are alive without metastasis. The WHP model predicts an increased overall indemnity with the spread of disease at the time of evaluation and the presence of a mass without pain. Indemnity decreases with a history of pregnancy, absence of presenting symptoms, or presentation with pain with or without a mass, and the performance of a lymph node dissection. [source]

Do International Medical Graduates (IMGs) "Fill the Gap" in Rural Primary Care in the United States?

A National Study
ABSTRACT:,Context: The contribution that international medical graduates (IMGs) make to reducing the rural-urban maldistribution of physicians in the United States is unclear. Quantifying the extent of such "gap filling" has significant implications for planning IMG workforce needs as well as other state and federal initiatives to increase the numbers of rural providers. Purpose: To compare the practice location of IMGs and US medical graduates (USMGs) practicing in primary care specialties. Methods: We used the 2002 AMA physician file to determine the practice location of all 205,063 primary care physicians in the United States. Practice locations were linked to the Rural-Urban Commuting Areas, and aggregated into urban, large rural, small rural, and isolated small rural areas. We determined the difference between the percentage of IMGs and percentage of USMGs in each type of geographic area. This was repeated for each Census Division and state. Findings: One quarter (24.8% or 50,804) of primary care physicians in the United States are IMGs. IMGs are significantly more likely to be female (31.9% vs 29.9%, P < .0001), older (mean ages 49.7 and 47.1 year, P < .0001), and less likely to practice family medicine (19.0% vs 38%, P < .0001) than USMGs. We found only two Census Divisions in which IMGs were relatively more likely than USMGs to practice in rural areas (East South Central and West North Central). However, we found 18 states in which IMGs were more likely, and 16 in which they were less likely to practice in rural areas than USMGs. Conclusions: IMGs fill gaps in the primary care workforce in many rural areas, but this varies widely between states. Policies aimed to redress the rural-urban physician maldistribution in the United States should take into account the vital role of IMGs. [source]

Recruitment and Retention of Rural Physicians: Outcomes From the Rural Physician Associate Program of Minnesota

Gwen Wagstrom Halaas MD
ABSTRACT:,Context: Founded in 1971 with state funding to increase the number of primary care physicians in rural Minnesota, the Rural Physician Associate Program (RPAP) has graduated 1,175 students. Third-year medical students are assigned to primary care physicians in rural communities for 9 months where they experience the realities of rural practice with hands-on participation, mentoring, and one-to-one teaching. Students complete an online curriculum, participate in online discussion with fellow students, and meet face-to-face with RPAP faculty 6 times during the 9-month rotation. Projects designed to bring value to the community, including an evidence-based practice and community health assessment, are completed. Purpose: To examine RPAP outcomes in recruiting and retaining rural primary care physicians. Methods: The RPAP database, including moves and current practice settings, was examined using descriptive statistics. Findings: On average, 82% of RPAP graduates have chosen primary care, and 68% family medicine. Of those currently in practice, 44% have practiced in a rural setting all of the time, 42% in a metropolitan setting and 14% have chosen both, with more than 50% of their time in rural practice. Rural origin has only a small association with choosing rural practice. Conclusion: RPAP data suggest that the 9-month longitudinal experience in a rural community increases the number of students choosing primary care practice, especially family medicine, in a rural setting. [source]