Primary care for nontraumatic illness at the emergency department and the family physician's office.

A total of 1117 visits by patients to two hospital emergency departments and 15 family physicians'' offices for nontraumatic complaints over two 2-week periods were studied. Patients visiting the two settings fell into two distinct subgroups, and they appeared to select where to seek care by the acuteness and duration of the complaint. Several highly significant differences were noted between the two groups: those who visited an emergency department had complaints of shorter duration, underwent more investigations (which more often gave abnormal results), were more likely to undergo investigation for mental symptoms, had more consultations, received counselling and drug therapy less often (but intramuscular injections more often), were admitted to hospital more often, returned for further care for the same complaint less often, complied with disposal instructions less often, were more likely to receive fewer than 5 days'' care and were less likely to receive more than 31 days'' care; those without a family physician more often received additional care (were referred, admitted or asked to return).     

Endometrial carcinoma: feasibility of case-finding in a family physician's office.

To study the feasibility of endometrial sampling in a family physician''s office we examined 42 asymptomatic women 50 years of age or older with the use of a Milan-Markley helix to obtain cytopathologic material. Nine procedures could not be completed because of stenosis of the introitus or cervix. The procedure took less than 3 minutes to complete for 30 women, and there was no technical difficulty for 27. Adequate amounts of tissue for diagnosis were obtained from 32 women. One or more risk factors for endometrial carcinoma were present in 34 women. Nine samples showed atypical hyperplasia. Although 37 women experienced discomfort and 19 experienced spotting, 35 were willing to have the procedure repeated annually or as indicated by their physician.     

Cross-cultural communication in the physician's office.

Physicians are increasingly called on to provide care for patients whose cultures differ from their own. I describe strategies, attitudes, and investigative methods that will enhance the experience of cross-cultural medicine for both patients and physicians.     

Violence in the emergency department: a survey of health care workers

BACKGROUND: Violence in the workplace is an ill-defined and underreported concern for health care workers. The objectives of this study were to examine perceived levels of violence in the emergency department, to obtain health care workers'' definitions of violence, to determine the effect of violence on health care workers and to determine coping mechanisms and potential preventive strategies. METHODS: A retrospective written survey of all 163 emergency department employees working in 1996 at an urban inner-city tertiary care centre in Vancouver. The survey elicited demographic information, personal definition of violence, severity of violence, degree of stress as a result of violence and estimate of the number of encounters with violence in the workplace in 1996. The authors examined the effects of violence on job performance and job satisfaction, and reviewed coping and potential preventive strategies. RESULTS: Of the 163 staff, 106 (65%) completed the survey. A total of 68% (70/103) reported an increased frequency of violence over time, and 60% (64/106) reported an increased severity. Most of the respondents felt that violence included witnessing verbal abuse (76%) and witnessing physical threats or assaults (86%). Sixty respondents (57%) were physically assaulted in 1996. Overall, 51 respondents (48%) reported impaired job performance for the rest of the shift or the rest of the week after an incident of violence. Seventy-seven respondents (73%) were afraid of patients as a result of violence, almost half (49%) hid their identities from patients, and 78 (74%) had reduced job satisfaction. Over one-fourth of the respondents (27/101) took days off because of violence. Of the 18 respondents no longer working in the emergency department, 12 (67%) reported that they had left the job at least partly owing to violence. Twenty-four-hour security and a workshop on violence prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the company of family and friends were the most frequent coping strategies. INTERPRETATION: Violence in the emergency department is frequent and has a substantial effect on staff well-being and job satisfaction.     

The role of deputizing agencies in the delivery of primary health care services.

When not available to their patients, family practitioners in large cities can "sign out" to deputizing agencies, which coordinate the activities of part-time physicians on call. The physicians making use of one such agency in Toronto appeared to be representative of family practitioners in the region. One thousand of their patients seen consecutively by one physician were asked a series of questions. The majority of the 811 evaluable patients were considered to have problems justifying an after-hours call, although 16% of the problems were of a trivial nature. However, almost half of the patients with trivial problems would have gone to the local emergency room, as would 85% of all the patients. Although virtually all (94%) of the visits with the elderly were justified, 34% of the patients in this age group said they probably or definitely would not have sought emergency room care if a physician had not been available. The use of deputizing agencies should reduce the overuse of emergency room facilities and provide optimal after-hours primary medical care.     

Developing primary health care.

Primary health care is best provided by a primary health care team of general practitioners, community nurses, and other staff working together from good premises and looking after the population registered with the practice. It encourages personal and continuing care of patients and good communication among the members of the team. Efforts should be made to foster this model of primary care where possible and also to evaluate its effectiveness. Community services that are not provided by primary care teams should be organised on a defined geographical basis, and the boundaries of these services should coincide as much as possible. Such arrangements would facilitate effective community care and health promotion and can be organised to work well with primary care teams. The patient''s right to freedom of choice of a doctor, however, should be retained, as it adds flexibility to the rigidity of fixed geographically based services.     

Improving the care of patients with major trauma in the accident and emergency department.

OBJECTIVE--To determine whether improvement in the care of victims of major trauma could be made by using the revised trauma score as a triage tool to help junior accident and emergency doctors rapidly identify seriously injured patients and thereby call a senior accident and emergency specialist to supervise their resuscitation. DESIGN--Comparison of results of audit of management of all seriously injured patients before and after these measures were introduced. SETTING--Accident and emergency department in an urban hospital. PATIENTS--All seriously injured patients (injury severity score greater than 15) admitted to the department six months before and one year after introduction of the measures. RESULTS--Management errors were reduced from 58% (21/36) to 30% (16/54) (p less than 0.01). Correct treatment rather than improvement in diagnosis or investigation accounted for almost all the improvement. CONCLUSIONS--The management of seriously injured patients in the accident and emergency department can be improved by introducing two simple measures: using the revised trauma score as a triage tool to help junior doctors in the accident and emergency department rapidly identify seriously injured patients, and calling a senior accident and emergency specialist to supervise the resuscitation of all seriously injured patients. IMPLICATIONS--Care of patients in accident and emergency departments can be improved considerably at no additional expense by introducing two simple measures.     

Integration of child mental health services to primary care: challenges and opportunities

In the first decade of this new millennium, health professionals are faced with a rapidly increasing need for child mental health services and changing models of service provision. This gives us a unique opportunity to make provision for services where it has not been available before, or to improve upon the existing services. This paper examines the challenges and opportunities while attempting to integrate child mental health services to primary care.     

Community participation in primary health care.

A two and a half year''s experience of a community participation group has shown that this can have a valuable role in suggesting practicable improvements in a group practice. Topics discussed by the group (which is composed of one representative from every known organization in the area) have included problems of receptionists; the role of the individual ancillary worker; and teaching in general practice. The high attendance rate at the group''s meetings testifies to the community''s interest in primary health care services.