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.     

Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme

ObjectivesTo establish the effect of an educational intervention for general practitioners on the health behaviours and wellbeing of elderly patients.DesignRandomised controlled trial with 1 year follow up.SettingMetropolitan general practices in Melbourne, Australia.Subjects42 general practitioners and 267 of their patients aged over 65 years.InterventionEducational and clinical practice audit programme for general practitioners on health promotion for elderly people.ResultsPatients in the intervention group had increased (a) walking by an average of 88 minutes per fortnight, (b) frequency of pleasurable activities, and (c) self rated health compared with the control group. No change was seen in drug usage, rate of influenza vaccination, functional status, or psychological wellbeing as a result of the intervention. Extrapolations of the known effect of these changes in behaviour suggest mortality could be reduced by 22% if activity was sustained for 5 years.ConclusionsEducation of the general practitioners had a positive effect on health outcomes of their elderly patients. General practitioners may have considerable public health impact in promotion of health for elderly patients.

Key messages

• Few educational interventions for doctors have shown benefit to the health of patients
• Elderly people were identified in the UK health initiatives as in need of additional attention, and levels of health protective behaviours were low in community surveys
• A multifaceted educational intervention for general practitioners was effective in improving walking behaviour, self rated health status, and the frequency of social contacts in elderly patients
• General practitioners are effective in improving health and health behaviours in their elderly patients

     

Primary care management for optimized antithrombotic treatment [PICANT]: study protocol for a cluster-randomized controlled trial

ABSTRACT: BACKGROUND: Antithrombotic treatment is a continuous therapy that is often performed in general practice and requires careful safety management. The aim of this study is to investigate whether a best practice model that applies major elements of case management, including patient education, can improve antithrombotic management in primary health care in terms of reducing major thromboembolic and bleeding events. METHODS: This 24-month cluster-randomized trial will be performed in 690 adult patients from 46 practices. The trial intervention will be a complex intervention involving general practitioners, health care assistants and patients with an indication for oral anticoagulation. To assess adherence to medication and symptoms in patients, as well as to detect complications early, health care assistants will be trained in case management and will use the Coagulation-Monitoring-List (Co-MoL) to regularly monitor patients. Patients will receive information (leaflets and a video), treatment monitoring via the Co-MoL and be motivated to perform self-management. Patients in the control group will continue to receive treatment-as-usual from their general practitioners. The primary endpoint is the combined endpoint of all thromboembolic events requiring hospitalization, and all major bleeding complications. Secondary endpoints are mortality, hospitalization, strokes, major bleeding and thromboembolic complications, severe treatment interactions, the number of adverse events, quality of anticoagulation, health-related quality of life and costs. Further secondary objectives will be investigated to explain the mechanism by which the intervention is effective: patients' assessment of chronic illness care, self-reported adherence to medication, general practitioners' and health care assistants' knowledge, patients' knowledge and satisfaction with shared decision making. Practice recruitment is expected to take place between July and December 2012. Recruitment of eligible patients will start in July 2012. Assessment will occur at three time points: baseline (T0), follow-up after 12 (T1) and after 24 months (T2). DISCUSSION: The efficacy and effectiveness of individual elements of the intervention, such as antithrombotic interventions, self-management concepts in orally anticoagulated patients and the methodological tool, case-management, have already been extensively demonstrated. This project foresees the combination of several proven instruments, as a result of which we expect to profit from a reduction in the major complications associated with antithrombotic treatment.     

What Are the Effects of Teaching Evidence-Based Health Care (EBHC)? Overview of Systematic Reviews

Background

An evidence-based approach to health care is recognized internationally as a key competency for healthcare practitioners. This overview systematically evaluated and organized evidence from systematic reviews on teaching evidence-based health care (EBHC).

Methods/Findings

We searched for systematic reviews evaluating interventions for teaching EBHC to health professionals compared to no intervention or different strategies. Outcomes covered EBHC knowledge, skills, attitudes, practices and health outcomes. Comprehensive searches were conducted in April 2013. Two reviewers independently selected eligible reviews, extracted data and evaluated methodological quality. We included 16 systematic reviews, published between 1993 and 2013. There was considerable overlap across reviews. We found that 171 source studies included in the reviews related to 81 separate studies, of which 37 are in more than one review. Studies used various methodologies to evaluate educational interventions of varying content, format and duration in undergraduates, interns, residents and practicing health professionals. The evidence in the reviews showed that multifaceted, clinically integrated interventions, with assessment, led to improvements in knowledge, skills and attitudes. Interventions improved critical appraisal skills and integration of results into decisions, and improved knowledge, skills, attitudes and behaviour amongst practicing health professionals. Considering single interventions, EBHC knowledge and attitude were similar for lecture-based versus online teaching. Journal clubs appeared to increase clinical epidemiology and biostatistics knowledge and reading behavior, but not appraisal skills. EBHC courses improved appraisal skills and knowledge. Amongst practicing health professionals, interactive online courses with guided critical appraisal showed significant increase in knowledge and appraisal skills. A short workshop using problem-based approaches, compared to no intervention, increased knowledge but not appraisal skills.

Conclusions

EBHC teaching and learning strategies should focus on implementing multifaceted, clinically integrated approaches with assessment. Future rigorous research should evaluate minimum components for multifaceted interventions, assessment of medium to long-term outcomes, and implementation of these interventions.     

The Chronic CARe for diAbeTes study (CARAT): a cluster randomized controlled trial

Background

Diabetes is a major challenge for the health care system and especially for the primary care provider. The Chronic Care Model represents an evidence-based framework for the care for chronically ill. An increasing number of studies showed that implementing elements of the Chronic Care Model improves patient relevant outcomes and process parameters. However, most of these findings have been performed in settings different from the Swiss health care system which is dominated by single handed practices.

Methods/Design

CARAT is a cluster randomized controlled trial with general practitioners as the unit of randomization (trial registration: ISRCTN05947538). The study challenges the hypothesis that implementing several elements of the Chronic Care Model via a specially trained practice nurse improves the HbA1c level of diabetes type II patients significantly after one year (primary outcome). Furthermore, we assume that the intervention increases the proportion of patients who achieve the recommended targets regarding blood pressure (<130/80), HbA1c (=<6.5%) and low-density lipoprotein-cholesterol (<2.6 mmol/l), increases patients' quality of life (SF-36) and several evidence-based quality indicators for diabetes care. These improvements in care will be experienced by the patients (PACIC-5A) as well as by the practice team (ACIC). According to the power calculation, 28 general practitioners will be randomized either to the intervention group or to the control group. Each general practitioner will include 12 patients suffering from diabetes type II. In the intervention group the general practitioner as well as the practice nurse will be trained to perform care for diabetes patients according to the Chronic Care Model in teamwork. In the control group no intervention will be applied at all and patients will be treated as usual. Measurements (pre-data-collection) will take place in months II-IV, starting in February 2010. Follow-up data will be collected after 1 year.

Discussion

This study challenges the hypothesis that the Chronic Care Model can be easily implemented by a practice nurse focused approach. If our results will confirm this hypothesis the suggestion arises whether this approach should be implemented in other chronic diseases and multimorbid patients and how to redesign care in Switzerland.

     

The Effect of an Individualized Practice-Based CME Program on Physician Performance and Patient Outcomes

The Professional Competence Assurance Program (PROCAP) is an individualized educational program that examines physicians'' performance in ambulatory practice. It uses medical record review to identify deficiencies in the care process that guides development of the educational intervention. Medical care is reassessed one year later. This program was used with 51 private practitioners to assess the care of 1,229 hypertensive patients. The educational program included a computer printout comparing one physician''s performance with that of peers, readings targeted to management problems, and a conference call or group seminar with an expert stressing issues relevant to each physician''s performance. Postintervention assessment showed that physicians prescribed beta-blockers (P<.01) and vasodilators (P<.01) more often. Improvement (P<.05) occurred in the control of diastolic blood pressure (≤90 mm of mercury) and in several other criteria. These results show that well-designed, individualized continuing medical education addressing specific deficiencies can change physicians'' performance and patients'' intermediate outcome.     

The consultant's role in continuing medical education of general practitioners: the case of rheumatology.

Consultant rheumatologists were surveyed by questionnaire about their contribution to the continuing education of general practitioners, and 84% (203/243) replied. Altogether 157 respondents had participated in some form of teaching, 147 in collective teaching sessions such as lectures and 99 in the teaching of small groups. Arthritis comprised 44% of the rheumatological topics taught; there was a noticeable lack of teaching on problems commonly encountered in general practice, such as soft tissue rheumatism and injury and back pain, and on clinical skills including examination and injection of joints. Eighty eight respondents made comments and suggestions. The favoured educational strategies were small group teaching, apprenticeship schemes, and interchange between general practitioners and consultants about shared cases. This contrasts with what was typically done--namely, formal lectures on rheumatoid arthritis in postgraduate medical centres. These findings raise questions about the continuing education of consultants themselves as well as about the consultants'' role in teaching others.     

Nurse practitioners in primary care I. The McMaster University educational program

In 1971 McMaster University offered an educational program for nurse practitioners sponsored jointly by the Faculty of Medicine and the School of Nursing. Priority in the pilot program was given to nurses employed in family practice settings and to those participating in related McMaster studies. Because of the implications of a change in role for both nurse and physician, one requirement for acceptance of a nurse in the program was participation of the physician-associate in the educational program.The program prepares registered nurses to extend their responsibilities in primary health care activities for the assessment and management of patients in family practice. The current evaluations of the pilot-study results suggest that such programs can contribute effective resources towards meeting expectations of ready access to primary care by the people of Canada.     

General practitioners' attitudes to professional reaccreditation.

OBJECTIVE--To determine the views of general practitioners about professional reaccreditation. DESIGN--Postal questionnaire. SUBJECTS--All 278 general practitioner principals working in Cleveland. MAIN OUTCOME MEASURES--General practitioner characteristics; attitudes to reaccreditation; and views on the development, conduct, content, and format of reaccreditation. RESULTS--210 out of 278 (76%) general practitioners responded to the questionnaire. 128 (61%) agreed that general practitioners should undergo reaccreditation. 149 (72%) thought the General Medical Services Committee and local medical committees were appropriate bodies to lead its development. 120 respondents suggested that reaccreditation should be carried out by assessors appointed by the doctor''s own local medical committee. The most favoured interval between reaccreditation episodes was 10 or more years. 152 doctors thought that doctors who failed reaccreditation should be advised on education and reassessed soon afterwards. Clinical knowledge (82%), clinical skill (82%), prescribing practices (67%), standards of medical record keeping (60%), and consultation behaviour (58%) were the most popular subjects for scrutiny. 138 (67%) respondents felt that reaccreditation should be part of continuing medical education. CONCLUSION--Most general practitioners support professional reaccreditation. They believe the process should be led by the profession, be educational, and take account of a range of professional activities.     

Anesthesia training for family practitioners

The 1988 CMA report on anesthesia training for general practitioners/family physicians outlined recommendations about the provision of anesthesia services, the educational process for the family practitioner anesthetist, including educational objectives, as well as comments on continuing medical education and maintenance of competence.     

Obesity reduction black intervention trial (ORBIT): six-month results

The Obesity Reduction Black Intervention Trial (ORBIT) is a randomized controlled trial designed to assess the efficacy of a culturally proficient 6-month weight loss intervention followed by a 1-year maintenance intervention. This article describes the results of the 6-month weight loss intervention. Two hundred thirteen obese black women aged 30-65 years were randomized to the intervention group or a general health control group. The intervention consisted of a 6-month culturally adapted weight loss program that targeted changes in diet and physical activity patterns. Weight, dietary intake, and physical activity were measured at baseline and 6 months. A total of 198 women (93%) completed both the baseline and postintervention assessments. Women in the intervention group lost significantly more weight than women in the control group (P < 0.001). However, weight change was variable within the intervention group, with a maximum weight loss of 19.4% of initial body weight and a maximum weight gain of 6.4% of initial body weight. Women in the intervention group also showed significant improvements in fruit intake (P < 0.01), Healthy Eating Index score (P < 0.001), and moderate (P = 0.05), and vigorous (P < 0.001) physical activity compared to women in the control group. This study demonstrates that a culturally adapted program can successfully promote weight loss in obese black women. However, average weight loss was relatively modest, and weight change varied widely within the intervention group. Further research is needed in order to develop programs that will allow more black women to achieve their weight loss goals..     

Mobilizing physicians to conduct clinical intervention in tobacco use through a medical-association program: 5 years' experience in British Columbia.

During the last 5 years, a program run by the medical association in British Columbia has recruited 23% of the province''s general practitioners (GPs) to take an active, systematic approach to clinical intervention in tobacco use. Another 9% of GPs (considered "semi-active") regularly use the program''s educational materials for patients, and another 25% have been trained in intervention or have been given intervention materials or both. If the cessation rate (rate of patients who quit smoking who would not otherwise have done so) was 4% among physicians actively involved in intervention and 2% among physicians considered semi-active, in 1995 an estimated 4700 smokers quit and were followed by their GPs as a result of the program. Another 135,000 smokers received brief counselling from their GPs and were also followed. This article reviews the strategies and methods used in this program to mobilize physicians.     

医学检验专业实践教学改革与毕业生质量评价

目的：寻求医学检验专业教学改革新方案。方法：以我校检验专业2000、2001届毕业生为对照组,以2002、2003届毕业生为实验组,对实验组进行实践教学改革。毕业前分别进行综合实践技能考核,并对部分毕业生进行了追踪调查。结果：实验组的技能考核成绩明显高于对照组,毕业生质量明显提高。结论：实践教学改革有利于提高医学检验专业教学质量。     

B.M.A. Planning Unit Survey of General Practice 1969

A postal survey of 776 principals representative of general practice in Britain is described. Doctors working in health centres are compared both with colleagues in other group practices and with doctors who have no group practice allowance. Young doctors are mainly in group practice, especially health centres; the proportion of doctors who are not in groups is diminishing steadily, and they are mainly older. With some notable exceptions health centres provide most space, equipment, and staff; group practitioners in privately-owned premises spend more of their money on their practices, more often use appointment systems, and tend to make more efficient use of premises and staff. Overall, however, the picture is still one of general practice geared to the needs of practitioners working alone. Premises with space for sophisticated organization and for future teaching needs are unusual.Scotland, the North of England, and Wales have fewer young doctors. Average lists are higher in the North of England, and less money is invested in practice premises.Young doctors look for modern premises and the tools and staff for the job. If their career expectations are to be met the tremendous improvements made in some practices must be extended rapidly to the remainder.     

Travel medicine and general practice: a suitable case for audit?

Travel medicine becomes more important with the continual expansion of international travel and the increased popularity of exotic holiday destinations. In the United Kingdom general practitioners provide the bulk of travel health advice and immunisation and there is growing interest in providing these services. While their armamentarium has been expanded with attractive but expensive new vaccines, the need for health service advice has never been more vital, with the risks of HIV infection and drug resistant malaria. Advantages of a general practice based travel medicine service include maintaining continuity of care for the patient, but a disadvantage might be that the general practitioner sees too few patients to acquire enough skill in the subject. Furthermore, there may be a conflict of interest between time devoted to the "vaccination ritual" and giving health advice. Overall there seems to be a case for both audit and support by the health authorities.     

General practitioner training in paediatrics in the Trent region.

A total of 259 postal questionnaires were sent to all final year vocational trainees and new principals in general practice in the Trent region to find out how much training in paediatrics they had had. Questionnaires were returned by 105 trainees and 139 principals (244; 94%). Overall 72% (175) had taken up a hospital post in paediatrics during training, but among the 138 doctors who were on or had completed a three year vocational training scheme the proportion was slightly higher (82%; 115) (p = 0.01). Among the 175 who had had a post in paediatrics 108 (62%) had been given teaching sessions every week, and for half of these doctors the sessions lasted over one hour a week. Seventy five (54%) of the 139 principals reported that in their training in a general practice they had received no teaching about child health and a fifth said that they had not attended a clinic for children; 47 (34%) had received no training on procedures for dealing with cases of child abuse. The doctors who had held posts as senior house officers in paediatrics were more likely to report that they had adequate skills in paediatrics than those who had not, but overall only 62 (44%) reported that they could run a preschool child health surveillance programme. Extra paediatric posts in hospital are needed, but in the mean time improvements can be made to the teaching content in hospital and in the general practice attachment and postgraduate training in paediatrics provided for all general practitioners.     

Promoting state health department evidence-based cancer and chronic disease prevention: a multi-phase dissemination study with a cluster randomized trial component

Background

Cancer and other chronic diseases reduce quality and length of life and productivity, and represent a significant financial burden to society. Evidence-based public health approaches to prevent cancer and other chronic diseases have been identified in recent decades and have the potential for high impact. Yet, barriers to implement prevention approaches persist as a result of multiple factors including lack of organizational support, limited resources, competing emerging priorities and crises, and limited skill among the public health workforce. The purpose of this study is to learn how best to promote the adoption of evidence based public health practice related to chronic disease prevention.

Methods/design

This paper describes the methods for a multi-phase dissemination study with a cluster randomized trial component that will evaluate the dissemination of public health knowledge about evidence-based prevention of cancer and other chronic diseases. Phase one involves development of measures of practitioner views on and organizational supports for evidence-based public health and data collection using a national online survey involving state health department chronic disease practitioners. In phase two, a cluster randomized trial design will be conducted to test receptivity and usefulness of dissemination strategies directed toward state health department chronic disease practitioners to enhance capacity and organizational support for evidence-based chronic disease prevention. Twelve state health department chronic disease units will be randomly selected and assigned to intervention or control. State health department staff and the university-based study team will jointly identify, refine, and select dissemination strategies within intervention units. Intervention (dissemination) strategies may include multi-day in-person training workshops, electronic information exchange modalities, and remote technical assistance. Evaluation methods include pre-post surveys, structured qualitative phone interviews, and abstraction of state-level chronic disease prevention program plans and progress reports.

Trial registration

clinicaltrials.gov:NCT01978054.

     

PSYCHIATRIC UNITS IN GENERAL HOSPITALS—Problems in Development and Efficient Operation

An adequate 25-bed psychiatric unit can be housed in a wing of a general hospital. Even more important than physical facilities are competent personnel, to be headed by a chief psychiatrist and a psychiatric nurse supervisor, for the unit. Incorporating teaching facilities into the unit helps to integrate psychiatry into the other disciplines of medicine in a continuing educational program.Having psychiatric units in general hospitals enables many voluntary patients to be treated in early stages of the disorder, with a high proportion of recoveries.Medicolegal aspects and the lack of adequate coverage of mental disorders by voluntary prepayment health plans are serious problems in the economy of a unit. Improved hospital administration, expanded training programs, educational work by local mental health societies and modification of laws on malpractice and commitment will go far to help solve these problems.