Development of the approaches to work and workplace climate questionnaires for physicians.

Two questionnaires were developed to investigate the workplace learning of physicians. The Approaches to Work Questionnaire for Physicians and the Workplace Climate Questionnaire for Physicians were adapted from general measures developed by Kirby, Knapper, Evans, Carty, and Gadula. These questionnaires were administered to a random sample of Ontario physicians. Consistent with the results of Kirby et al., three dimensions of approaches to work were observed: Deep. Surface-Rational, and Surface-Disorganized. Three dimensions of workplace climate were also found, Supportive-Receptive, Choice-Independence, and Workload. Results indicate that physicians adopt primarily a Deep approach to work, but that there is a smaller tendency toward Surface-Disorganized learning, one that is strongly correlated with perceptions of heavy workload. The Deep approach was associated with work environments perceived to be Supportive-Receptive and offer Choice-Independence. The use of these questionnaires in research and practice is discussed.

Postal survey of approaches to learning among Ontario physicians: implications for continuing medical education.

OBJECTIVES: To understand the approaches to learning of practising physicians in their workplace and to assess the relation of these approaches to their motivation for, preferred methods of, and perceived barriers to continuing medical education. DESIGN: Postal survey of 800 Ontario physicians. PARTICIPANTS: 373 physicians who responded. MAIN OUTCOME MEASURES: Correlations of approaches to learning and perceptions of workplace climate with methods, motives, and barriers to continuing medical education. RESULTS: Perceived heavy workload was significantly associated with the surface disorganised (r=0.463, P<0.01) and surface rational approach (r=0.135, P<0.05) to learning. The deep approach to learning was significantly correlated with a perception of choice-independence and a supportive-receptive climate at work (r=0.341 and 0.237, P<0.01). Physicians who adopt a deep approach to learning seem to be internally motivated to learn, whereas external motivation is associated with surface approaches to learning. Heavy workload and a surface disorganised approach to learning were correlated with every listed barrier to continuing medical education. The deep approach to learning was associated with independent learning activities and no barriers. CONCLUSIONS: Perception of the workplace climate affects physicians' approaches to learning at work and their motivation for and perceived barriers to continuing medical education. Younger, rural, family physicians may be most vulnerable to feeling overworked and adopting less effective approaches to learning. Further work is required to determine if changing the workplace environment will help physicians learn more effectively.

Recommendations for the management of irritable bowel syndrome in family practice. IBS Consensus Conference Participants.

To help family physicians manage patients with irritable bowel syndrome (IBS), a consensus conference was convened in June 1997 at which 5 internationally recognized experts in IBS presented position papers on selected topics previously circulated to the conference participants. Five working groups comprising family physicians, gastroenterologists and allied health care professionals from across Canada were then charged with developing recommendations for the diagnosis, patient education, psychosocial management, dietary advice and pharmacotherapy, respectively. An evidence-based approach was used where possible; otherwise, recommendations were made by consensus. The participants concluded that family physicians can make a positive diagnosis of IBS using symptom criteria. The pathophysiology is poorly understood, but motility and sensory disturbances appear to play a role. Neither psychological nor specific dietary factors cause IBS, but both can trigger symptoms. Drug therapy is not recommended for the routine treatment of IBS, but short-term trials of drug therapy may be targeted to predominant symptoms in selected patients. A step-wise, patient-centred approach to management is outlined.

Chinese herbal medicine and acupuncture. How do patients who consult family physicians use these therapies?

OBJECTIVE: To determine how a population of Chinese patients consulting family physicians in Vancouver use traditional Chinese medicine (TCM), specifically Chinese herbal medicine and acupuncture. DESIGN: Bilingual survey (English and Chinese). SETTING: Four family practices with predominantly Chinese patients in metropolitan Vancouver. PARTICIPANTS: The 932 patients or family members who visited one of the practices. MAIN OUTCOME MEASURES: Demographic characteristics; frequency and reason for visiting a family physician, Chinese herbalist, or acupuncturist; choice of practitioner if affected by one of 16 common conditions. RESULTS: The study population was mostly Chinese and immigrant to Canada. Chinese herbal medicine was currently used by 28% (262/930) of respondents (more than one visit in the last year), and another 18% (172/930) were past users. Acupuncture was currently used by 7% (64/927) and had been used in the past by another 8% (71/927). Use of Chinese herbal medicine varied significantly (P < .01) according to age, sex, immigrant status, and ethnicity. Acupuncture use varied significantly only by age. The main reasons for consulting Chinese herbalists were infection (41%, 157/382), respiratory problems (11%, 42/382), and rheumatologic problems (10%, 38/382), whereas acupuncturists were consulted almost exclusively for rheumatologic problems (80%, 45/56). CONCLUSIONS: Using TCM in conjunction with visiting family physicians was very popular among this predominantly Chinese study population. Patients with acute conditions, such as influenza, consulted both their family physicians and Chinese herbalists in quick succession. On the other hand, those suffering from more chronic conditions, such as rheumatologic diseases, were more likely to start using TCM after repeated visits to their family physicians.

Men and women residents' experiences with women's health care in a family medicine center.

PURPOSE: To address the experience in women's health care available at the Queen's University Faculty of Medicine family residency program and to compare the amounts and types of experiences of men and women residents. METHOD: A retrospective analysis was made of 70,805 patient encounters with family medicine residents at the Queen's University Family Medicine Centre over a five-year period (June 1988-May 1993). Patient-encounter files contained patient, staff, and resident information, as well as service and diagnostic codes. Statistical analysis was done using a two-tailed Student's t-test to compare the mean numbers of encounters with the women patients for the men and women residents in ten service and diagnostic categories. RESULTS: Of the 70,805 patients, 65.1% were women. The mean numbers of patients seen by the 45 men residents (534) and the 90 women residents (519) did not differ significantly. The percentages of the women patients seen by the men and the women residents (58.6% and 68.4%, respectively), however, differed significantly. The mean ages of the women patients seen by the men and the women residents (44.5 years and 39.2 years, respectively) also differed significantly. The women had significantly more encounters with the women patients in five of the ten categories studied. CONCLUSION: The differences between the men and women residents' experiences was significant in several areas. A potentially confounding factor is that the women may have been preferentially placed in team areas with all women staff physicians and the men placed in team areas with all men staff physicians. As family medicine programs aim for levels of exposure that are sufficient and similar for men and women residents, it is important that they evaluate the clinical opportunities for residents in women's health and work to ensure that both men and women residents receive adequate exposure in this area. One step in this direction might be gender-balanced patient populations, which might be obtained by ensuring gender-balanced clinical teams.

A comparison of family physicians' and obstetricians' intrapartum management of low-risk pregnancies.

BACKGROUND: We hypothesized that family physicians' style of intrapartum management was less interventional than the management style of obstetricians, and that this would not adversely affect maternal or neonatal outcomes. METHODS: A retrospective, matched-pair study design was used to compare low-risk women cared for by community family physicians with those cared for by obstetricians at a small teaching hospital. The subjects were matched on the basis of age and parity. We compared the rates of intervention between family physicians and obstetricians. RESULTS: We studied 351 matched pairs of women. The demographic characteristics of patients were similar as were the rates for most labor and delivery procedures. Family physicians had lower rates for induction, external and internal fetal monitoring, narcotic analgesia use, and postpartum oxytocin use. Women cared for by family physicians spent less time in the hospital, both during labor and postpartum. CONCLUSION: This study supports the hypothesis that at our center family physicians intervene less than obstetricians in intrapartum management. Comparisons with similar studies conducted at other academic centers illustrate differences in styles of practice between institutions, not just between specialties.

Is this problem urgent? Attitudes in a community hospital emergency room.

As health care resources become increasingly scarce, some suggest that emergency rooms are misused or overused. This study examined whether patients believe their problems are urgent, whether health care providers agree, and what factors influence these decisions. In many cases, using less expensive alternative care is appropriate. Widespread education to change patients' attitudes about the urgency of their medical concerns could reduce inappropriate hospital visits.

Personal journal writing in a communication skills course for first-year medical students.

Student journals are used at all levels of education to facilitate academic and personal learning. This paper describes the experience of journal writing from both a student and teacher perspective, in a communication skills course for first-year medical students at Queen's University, Kingston, Ontario, Canada. As one of the requirements of the course, students described their individual reactions to each weekly session in a journal. Teachers responded to each journal entry. Guidelines for journal usage in this course are described. The content of the journals includes topic-related information, comments concerning the student's individual experience of the course, and personal thoughts related to life experiences and becoming a doctor. A summary of evaluations of journal writing by teachers and students is presented. We have observed that journal writing facilitates a personal and reflective perspective to the first-year medical curriculum for both students and teachers. Journal writing appears to initiate and encourage self-awareness by providing a safe place for students to describe their experiences and relationships and to question their own values and beliefs. In the journal, through a mutual sharing of thoughts and feelings, barriers between students and teachers are diminished, leading to enhanced rapport and communication.

Family medicine resident research: how about an N of 1 trial?

Encouraging family-practice residents to undertake a research project should be a mandate of every Department of Family Medicine. In order to have an effective resident research program, time, expertise, funding and ideas are needed. An N of 1 randomized trial is one study design that may be attractive to family-medicine residents as a methodology from which to learn basic concepts of research. This paper provides a background description of single-patient trials and their use in resident research.

Transferring records when patients change family doctors.

While previous records of a new patient can be of great benefit, the process of record transfer often leads to frustration for both the receiving and sending physician. This report describes a survey of the current record-transfer practices of 475 randomly selected Ontario family physicians who responded to a questionnaire. This represented an overall response rate of 84%. Only 36.5% of respondents always or frequently found the transferred information useful. Only 51.5% of physicians regularly obtain past records for their patients. Respondents showed a preference for consultation letters and hospital-discharge summaries. Most of the respondents sent copies of consultation letters written by other physicians, even though the CMA policy on record transfer recommends against this practice. Data on office visits was seldom perceived as useful information. A written summary of the patient's history with photocopies of select information was the most popular format for transfer of patient information. Unfortunately, it is also the most time-consuming and expensive method. Approximately 62.1% of respondents thought that a fee should be charged for transfer of patient information; 42.1% thought the patient's medical care plan should pay; while 41.5% thought that the patient should be responsible. Guidelines for information transfer are suggested.

Morphologic evaluation of gastric mucosal protection by colloidal bismuth subcitrate (De-Nol).

The morphologic changes in the gastric mucosa of rats receiving colloidal bismuth subscitrate (CBS) at 120 mg/kg p.o. followed by intragastric instillation of 1 ml absolute ethanol have been assessed by macroscopic examination, quantitative histology and scanning electron microscopy. Macroscopically, virtually complete protection against ethanol injury was noted in CBS-pretreated animals, while control animals showed severe necrotic haemorrhagic lesions. Although light microscopy revealed disruption of the epithelium extending into the gastric pits, CBS protected deep pit cells and necrotic lesions were almost absent. By 6 h after ethanol instillation, surface epithelium was mostly restituted in the CBS group but not in the controls. Scanning electron microscopy (SEM) confirmed these findings. It is concluded that CBS protects the gastric mucosa against ethanol injury by preventing deep mucosal necrosis and that as a consequence the recovery of mucosal integrity is promoted.

Diagnostic testing in family practice.

Laboratory and radiological investigations are central to the diagnosis and management of our patients' health problems. Physicians often order a diagnostic test routinely without giving much thought to the benefits, risks, and costs of the test. The increase in the number and use of diagnostic tests has contributed to the rising cost of health care over the last two decades. By consciously following a process when ordering tests, physicians may improve the effectiveness and efficiency of the tests they request. This paper provides a background and approach to the rational use of diagnostic tests.

Antacid use in a family-practice population.

According to market surveys, antacid use is common in the general population. This study of antacid use in a university-based family-practice clinic supports this conclusion. In a sample of 731 adult patients, 51.3% reported taking antacids at least once in the previous six months and 10.9% took antacids daily. Highest antacid users were people 31-40 years of age. Heartburn was the most common symptom in patients taking antacids, but antacid use increased as the patients reported more symptoms. Antacid use by patients is often unknown to the physician. This has some clinical importance because antacids are known to interfere with the absorption of some commonly used drugs. Physicians should routinely ask their patients about antacid use, as well as about their use of other over-the-counter products.

Hypertension screening in a primary care clinic.

A chart audit of 250 randomly selected adult patients at a university-based family practice unit showed that 91.9% had attended the clinic during a five-year period (89.0% for males and 94.5% for females). Overall, 80.6% of the patients had their blood pressure recorded on the office chart in the five-year period (75.3% for males and 85.0% for females). For males 30-39 years old, however, the rate was only 54.5%. Flow sheets are suggested as a practical method for recording health maintenance items in an effort for the primary care physician to follow the recommended guidelines for hypertension screening.

Ultrasonography in the diagnosis of gallbladder disease.

Ultrasonography is the technique of choice in diagnosing gallbladder calculi. In the mid-1970s ultrasound was only accurate enough to use as an adjunct to oral cholecystography but refinements such as gray scale and real-time imaging mean that in experienced hands it has a sensitivity of 96% and a specificity of 93%. Sonography is also the test of choice in the initial evaluation of jaundiced patients. It is an excellent technique for distinguishing between obstructive and nonobstructive jaundice, although it is less accurate in demonstrating the cause of the obstruction. Ultrasound is painless and relatively inexpensive, and has several advantages over oral cholecystography; it doesn't depend on contrast material, causes no adverse reactions or side-effects, is safe during pregnancy, does not expose the patient to radiation, and is less time-consuming.

Haemorrhagic complications of heparin therapy.

In a prospective trial 76 patients with venous thromboembolism have received intermittent constant-dosage heparin or continuously infused heparin with laboratory control. Frequencies of bleeding were similar in both groups. 32% of all patients bled, 13% severely. Retroperitoneal haemorrhage occurred in 5 patients. Major spontaneous bleeding was commoner in older patients and minor spontaneous bleeding in women. Bleeding was uncommon during the first 2 days of treatment, and its daily frequency was relatively constant thereafter. 21% of surgical wounds and 7% of arterial and venous puncture sites bled. These preliminary results illustrate the hazards of heparin therapy and suggest that bleeding complications are more closely related to duration of therapy, age, sex, and surgical trauma than to method of administration.