Anglo-Canadian Exchange in General Practice: British View of Canadian General Practice

The Canadian general practitioner is remunerated by an item-of-service system of payment which encourages servicing demands rather than needs, discourages delegation of work to paramedical workers, and involves his staff in a massive amount of paper work. He has an excellent hospital attachment, which unfortunately is overdone. His community facilities are piecemeal and his office organization is rudimentary. There are few incentives for good general practice in the community. He spends an inordinate amount of time examining well people. The university departments of general practice are extremely good and much should be heard from them very quickly. The patient''s attitude towards his doctor is quite different from the one prevailing currently in Britain.I returned happily to British general practice.     

Academic family medicine in Canada.

Fifty years ago family practice in Canada had no academic presence. Stimulated by a number of general practitioners and with the support of the Canadian Medical Association, the College of General Practitioners of Canada (CGPC) was founded in 1954. In 1962, conferences on education for general practice attended by the Association of Canadian Medical Colleges and the CGPC led to pilot postgraduate residencies in family practice supported by Department of National Health and Welfare. The first certification examination was held in 1969 and, by 1974, all Canadian medical schools had a family medicine residency program. Today departments of family medicine contribute substantially to undergraduate education in all 16 schools. In Canada, the medical profession, governments and the medical schools have demonstrated the importance they place on appropriate education for family physicians.     

The Adequacy of Education for General Practice: A Medical Educator's Viewpoint

The effect on medical education of the doubling of medical knowledge every 10 years is discussed. A brilliant student who might successfully master all the present facts and theories by graduation would be seriously out of date 10 years later, and hopelessly so by retirement age unless he continued his education while in practice. Lengthening the undergraduate course is not considered an effective solution, nor is increasing the general practice internship to two years. Emphasis should be placed on self-education by the medical student, on the inculcation of habits of study and motivation to encourage lifelong learning, and on the provision of more adequate programs of continuing education for the practising doctor. Teachers in medical schools require a better understanding of and interest in the learning processes of their students rather than concentrating on the exposition of their own knowledge.     

THE PLACE AND TRAINING OF THE GENERAL PRACTITIONER

Training for the medical student whose goal is general practice should aim at equipping him to maintain the close personal relationship with the patient which is considered the ideal basis for the treatment and prevention of disease. Preparation for general practice should anticipate graduate experience on a par with that which is currently considered necessary for the various specialties. Internship should be such as to fit the general practitioner to the peculiarities of the kind of community in which he will practice. Ability to recognize his own limitations and situations in which special consultation or referral are indicated should be developed in the student.The University of Colorado School of Medicine has adopted a course of training, from pre-medical education through internship, designed for the student who is to specialize in general practice.     

General practitioners' continuing medical education within and outside their practice.

To study continuing medical education 96 out of 101 general practitioners chosen at random from the list held by a family practitioner committee were interviewed. The results provided little evidence of regular attendance at local postgraduate centre meetings, though practice based educational meetings were common. Thirty one of the general practitioners worked in practices that held one or more practice based educational meetings each month at which the doctors provided the main educational content. Performance review was undertaken in the practices of 51 of the general practitioners, and 80 of the doctors recognised its value. The general practitioners considered that the most valuable educational activities occurred within the practice, the most valued being contact with partners. They asked for increased contact with hospital doctors. The development of general practitioners'' continuing medical education should be based on the content of the individual general practitioner''s day to day work and entail contact with his or her professional colleagues.     

A survey of postgraduate training for family practice.

The results of a survey of Canadian primary care physicians for the Canadian Medical Association (CMA''s) Task Force on Education for the Provision of Primary Care Services are reported. Recent Canadian medical school graduates in primary care practice reported that the three major training routes (rotating and mixed internships and family medicine residencies) each prepared them differently for practice. The graduates of 2-year family medicine residencies were more satisfied with their preparation than were the graduates of the other major training routes. A 2- or 3-year family medicine residency was preferred by 50% of the respondents, although only 33% of them had actually taken one of these routes. There was considerable agreement in the respondents'' assessments of the types of postgraduate education needed for primary care practice. The results of this survey were consistent with the recommendations in the final report of the CMA''s task force.     

Community Nurses' View of General Practice Attachment

An analysis of 98 health visitors and district nurses attached and non-attached to general practitioners in three local authority areas showed that most of them were aged over 40 and that many had entered domiciliary work because of the convenient hours or because of its intangible attractions. Adequate preparation for attachment was considered important, particularly a clear definition of the roles of the attached staff and their relationships to other workers in the practice.Attached staff were found to be much more satisfied with the information given by the general practitioner about their patients than were unattached staff, and the former usually had access to the patients'' medical records. The principal advantages of attachment were listed as access to family history; improved co-ordination within the practice and co-operation with the social services; favourable patient response; and increased mileage and work-load; the impossibility of crossing local authority boundaries; and having to deal with families registered with more than one doctor.     

Attachment of Community Nurses to General Practices. A Follow-up Study

A follow-up survey has shown that in a two-year period the number of community nurses working in general practice attachment schemes rose from 11 to 24% (32% in counties, 13% in county boroughs, and 12% in London boroughs). The proportion of health visitors and home nurses rose from 15 to 29% and from 9 to 25% respectively. Reasons given for the 23 attachment schemes which were discontinued included administrative and personality problems. Careful preparation and continuing support, for both the general practitioners and the community nurses, are stressed for the success of these schemes.     

三甲综合医院住院医师职业倦怠现状调查与影响因素分析

目的:探究三甲综合医院住院医师职业倦怠的发生现状及其影响因素,为预防三甲综合医院住院医师发生职业倦怠提供依据。方法:选择三甲综合医院各临床住院医师218名为研究对象,采用问卷调查住院医师性别、年龄、文化程度、职务、婚姻状况、职称、工作时间、编制及身体健康情况等基线资料及职业倦怠程度,采用logistics回归分析住院医师职业倦怠的影响因素。结果:218例三甲住院医师中119例人(54.59%)发生职业倦怠,其中轻度倦怠者60人(27.52%),中度倦怠者49人(22.48%),重度倦怠者10人(4.59%);身体健康状况一般、差(OR=1.547,5.342;P0.05)是住院医师发生职业倦怠的危险因素,职称为初级、中级、副高及以上(OR=0.893,0.827,0.736;P0.05)是住院医师发生职业倦怠的保护因素。结论:三甲住院医师职业倦怠发生的现状不容乐观,无编制、身体健康状况一般、差是住院医师发生职业倦怠的危险因素,职称为初级、中级、副高及以上是住院医师发生职业倦怠的保护因素。     

Postgraduate clinical education — the Canadian experience

To obtain a quantitative measure of the extent to which graduate education and qualification for specialty practice have become an integral part of the total educational experience, samples of the graduating classes of 1960, 1964, 1968 and 1970 of Canadian medical schools were tracked through postgraduate educational training and into specialty certification. From the 1960 cohort 65% chose a career recognized by special certifying exams in Canada and/or the United States, entered a residency, completed it and achieved certification of special competence. From the 1970 cohort, by the end of 1972 approximately 50% had entered a recognized specialty training program leading to certification. The diminishing trend toward specialty practice is demonstrated by reviewing the comparative figures in the 1964 and 1968 cohorts. Evidence garnered in this study indicates a continuing strong motivation for specialty practice although family medicine and/or general practice appear increasingly attractive as career choices. Strong provincial educational forces as well as social and other forces will probably continue to modify career selection and may lead an increasing number of Canadian medical graduates into family practice.     

Psychiatry in General Practice

Psychiatrists should include the family doctor in their plans for future psychiatric services. The general practitioner now treats most of the patients who seek help for psychiatric disorder and he could not give up his psychiatric practice even if he wanted to. Furthermore, there are not now nor will there ever be enough psychiatrists to take over all patients with mental ills. Most emotionally disturbed patients can be better handled by their family physicians than by a specialist.To provide the best care for emotionally disturbed people the communication between family doctors and psychiatrists must be improved. The specialist must acknowledge the importance of the general practitioner''s role in psychiatric diagnosis and treatment and give him more help. Medical schools must provide better undergraduate and postgraduate psychiatric training for the students who will become family doctors. Health plans and other prepayment agencies should properly compensate the general practitioner for giving psychiatric treatment. The specialist in psychiatry should consult more readily with the general practitioner and help him carry out some of the therapy. General hospitals should permit family doctors to admit mental patients to psychiatric wards in a general hospital and to carry out psychiatric treatment with the help of the specialist in psychiatry.     

Canadian Medical Student Interest in General Practice and the Specialties

The interest of 1900 Canadian medical students in the various fields of medical practice was measured by a questionnaire. The students were asked to rank the various fields in order of their interest in them. It was found that general practice, internal medicine and surgery were the fields which consistently captured most interest among the students. Few students ranked dermatology, administration, teaching and research in the first three ranks.Striking differences in the interest preferences of male and female students were demonstrated, with the women ranking pediatrics and psychiatry higher than the men. Significantly more men, however, expressed a prime interest in surgery.Interest in general practice increases with the senior years in medical school, but it was shown that this increase is associated with marital status and with the number of children rather than with the year of training alone.Interest in the fields of medical practice varied between medical schools, with general practice ranking highest at British Columbia and relatively low at McGill and Manitoba. Significant differences between the students of the schools were displayed in the case of neurology, obstetrics, pediatrics and psychiatry.     

The American General Practitioner in Hospital

In the U.S.A. and Canada full access of general practitioners to hospital beds and facilities is regarded as an essential privilege of their work. All hospital constitutions require a review of the credentials of staff applicants and continuing evaluation of their performance. Staff appointment carries administrative as well as clinical responsibilities and hospital work occupies a considerable proportion of the general practitioner''s day. The disciplinary machinery for safeguarding standards is strict by comparison with British hospital practice.This system produces an obvious excellence of clinical standards, postgraduate education, and communication between specialist and general practitioner and is attractive to the more able young British graduate. A pilot experiment of hospital staffing on North American lines in one of our new district general hospitals would be a worthwhile proposition.     

An American's view of Canadian medical education.

Undergraduate medical education in Canada and the United States is remarkably similar, except for the fact that Canadian medical schools are supported by their provincial governments. However, the systems diverge sharply at the postgraduate level. In Canada, the number and specialty mix of residents are negotiated by medical schools in response to educational and social needs; in the United States, these factors are largely determined by hospital service needs. The Canadian systems of accreditation, certification and payment for medical education after graduation are much simpler than those of the United States, and the accreditation and certification systems are more objective. In addition, the US system promotes subspecialization and a costly specialty imbalance, whereas Canada''s system has achieved an appropriate balance of specialists and generalists. In general, Canadian medical education appears to be simpler, more accountable and more socially responsive.     

Patient autonomy, assessment of competence and surrogate decision-making: a call for reasonableness in deciding for others

In this paper, I address some of the shortcomings of established clinical ethics centring on personal autonomy and consent and what I label the Doctrine of Respecting Personal Autonomy in Healthcare. I discuss two implications of this doctrine: 1) the practice for treating patients who are considered to have borderline decision-making competence and 2) the practice of surrogate decision-making in general. I argue that none of these practices are currently aligned with respectful treatment of vulnerable individuals. Because of 'structural arbitrariness' in the whole process of how we assess decision-making competence, this area is open to disrespectful treatment of people. The practice of surrogate decision- making on the basis of a single person's judgment is arguably not consistent with ethical and political requirements derived from the doctrine itself. In response to the inadequacies of the doctrine, I suggest a framework for reasonableness in surrogate decision-making which might allow practice to avoid the problems above. I conclude by suggesting an extended concept of Patient Autonomy which integrates both personal autonomy and the regulative idea of morality that is required by reasonableness in deciding for non-competent others.     

What Is So Special About a Family Physician?

Around a core of common, acute and chronic, recurrent health problems, a family physician must marshall the traditional episodic management for both inpatient and outpatient illness. He must also be especially adept at recently emerging routines of prevention and early detection. He provides individual and familial psychologic support and counselling, for both its therapeutic and preventive values. In addition, he must relate the individual care of his patient and the patient''s family to the community as a whole. In doing this he will use not only his own skills but those of lay health volunteers, trained allied health care professionals and skilled subspecialists in the limited medical disciplines.The proper preparation of family physicians for this complicated role has far-reaching implications for change in both medical education and medical practice.     

General and Family Practice: Chlamydia trachomatis Infections

The Scientific Board of the California Medical Association presents the following inventory of items of progress in general and family practice. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, research workers of scholars to stay abreast of these items of progress in general and family practice that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on General and Family Practice of the California Medical Association and the summaries were prepared under its direction.     

The general practitioner in industrial medicine

Most industrial injuries are treated by physicians who have a general practice in addition to their industrial work. Because of the increasing number and seriousness of industrial injuries, better preparation for treatment is required in the patient's interest and for reasonable economy. The trend toward centralization of industrial medical facilities, increasing before and during World War II, has been somewhat reversed; the general practitioner now has an opportunity to take a useful place in the care of injured employees.A physician dealing with industrial cases must be prepared to give immediate emergency treatment, to comply with the procedures of insurance carriers, and to refer cases which he is not skilled or equipped to handle. As a personal physician having the confidence of the patient he can secure greater cooperation from all parties concerned in industrial disability and can sometimes promote a more rapid recovery.     

General and Family Practice: New Guidelines to Prevent Atherosclerosis

The Scientific Board of the California Medical Association presents the following inventory of items of progress in general and family practice. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, or scholars to stay abreast of these items of progress in general and family practice that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another.The items of progress listed below were selected by the Advisory Panel to the Section on General and Family Practice of the California Medical Association, and the summaries were prepared under its direction.