Prenatal care: a comparative evaluation of nurse-midwives and family physicians.

We evaluated the prenatal care provided to 44 low-risk women by nurse-midwives (NMs) at a special clinic of a large obstetric referral hospital and a sample of 88 low-risk women attended by family physicians (FPs) in their offices. The women were matched on the basis of date of delivery, age, parity, number of previous miscarriages, gravidity, socioeconomic status and delivery after 32 weeks'' gestation. The Burlington Randomized Controlled Trial criteria, which reflect community standards of care, were updated and used to assess the information, which was provided on standard provincial prenatal care forms. Scoring was carried out blindly, and interrater reliability was high. A highly significant difference was found in the proportions of NM and FP charts that were rated adequate, superior or inadequate: 77% v. 24%, 7% v. 16% and 16% v. 60% respectively. The rate at which procedures were omitted (leading to an inadequate score) in the categories of initial assessment, monitoring and management also varied between the two patient groups. These findings, even when considered in terms of several biases that may have resulted in the high proportion of NM charts rated at least adequate, suggest that NMs provide prenatal care to low-risk women that is comparable, if not superior, to the care provided by FPs.     

A smoking cessation intervention program for family physicians.

Family physicians are able to approach many patients who smoke but are often hesitant to help them quit. Lack of knowledge about effective interventions is a major reason for this hesitancy. The important components that have been tested in physician-initiated smoking cessation interventions are advice to quit, information about the risks of smoking and techniques for quitting, nicotine gum, setting a date for quitting and offers of supportive follow-up visits. We describe a cessation program developed for family physicians that incorporates these factors into three types of visits over a 2-month period: the challenge visit, which occurs during a regular office visit and focuses on advice and setting a date to quit; the quit-date visit, which involves instructing patients on the proper use of nicotine gum, if applicable, and confirming their desire to quit; and four supportive follow-up visits, which provide continuing encouragement for 2 months and allow physicians to monitor withdrawal symptoms, relapses and other problems. Such a program can be effectively incorporated into a general practice.     

Prenatal care: a comparative evaluation of nurse-midwives and family physicians

We review various organ procurement strategies from ethical and practical perspectives to understand why these strategies have been relatively unsuccessful. We propose that the CMA recommend the implementation of a required-request policy in hospitals. We also propose a possible new approach in which people from the age of 18 years would voluntarily enrol in an organ donation program, agreeing to permit all usable organs to be taken for transplantation at the time of death. In return they would have priority for receiving organs made available by the program. We believe that this program would save lives, respect the donor''s autonomy and satisfy the principles of justice and beneficence.     

Participation of Colorado pediatricians and family physicians in the Medicaid program.

The Pediatric Health Policy Group of the University of Colorado Health Sciences Center (Denver) surveyed 650 family physicians and 296 pediatricians in 1988, with 50% of family physicians and 48% of pediatricians responding. Half of the pediatricians in private practice and 35% of family physicians in private practice accepted all children who were Medicaid beneficiaries into their practice; 42% of pediatricians and 50% of family physicians accepted all non-Medicaid patients but only some new Medicaid patients; and 8% of pediatricians and 15% of family physicians accepted new non-Medicaid patients but no Medicaid patients. Practice location was associated with the level of Medicaid participation for these primary care physicians: Significantly more rural pediatricians and family physicians than those with urban practices accepted Medicaid patients. The average reimbursement level for these physicians was shown to be an important determinant of whether physicians would accept Medicaid patients. Nonparticipatory physicians were more concerned about excessive paperwork compared with physicians with limited participation. Among physicians with limited participation, family physicians and pediatricians both cited problems of excessive paperwork, reimbursement delays, and retroactive denials of payment as important deterrents to accepting Medicaid patients.     

Family physician anesthetists: continuing education,observations, evaluation

A method is described whereby continuing education for family practitioner anesthetists is taken to community hospitals, where patterns of practice, local problems and facilities are different from those of larger urban areas. Five Ontario communities were visited for 4½ days each, by invitation, providing the visiting clinician with an opportunity to observe the quality of anesthesia services and to measure, through a self-evaluation test, the deficiencies in applied basic and clinical knowledge thought to be necessary for modern, safe practice. These programs were well received and thought to be of real benefit to the participants. Similar programs could be provided in general medicine, cardiology, gastroenterology, pediatrics and psychiatry.     

Muscle relaxation techniques: a therapeutic tool for family physicians.

Muscle relaxation techniques are important adjunctive therapy for anxiety-related conditions. Family physicians can learn to teach the techniques so as to try helping anxious patients themselves rather than automatically referring them to a psychiatrist. The exercises are generally acceptable to patients, are easy to learn and do not require expensive equipment. They are beneficial in insomnia and tension headache, of some value in chronic anxiety states and a useful adjunct in hypertension. In this paper the evidence supporting the value of muscle relaxation therapy is briefly reviewed, methods of teaching and of practising the techniques are described in detail, and answers to some of the questions and problems that may arise are presented.