Making connections: exploring residents' perspectives on a virtual World Café as a novel approach for teaching Indigenous health issues.

World Café is a methodology where small groups of participants rotate around tables for spirited conversations. It creates an environment for sharing and exchange. Learning about Indigenous healthcare is ideally suited to an intimate discussion format. Adapting the World Café to a virtual platform allowed us to connect disparate learners, encourage peer-to-peer learning, and address inequities in curriculum exposure to different patient groups. Owing to the safe environment, there can be surprising findings too. In our case, participants identified unconscious biases and recognized the program as a new learning opportunity. Try it and see!

Le Café du monde est une méthode permettant aux participants, passant de table en table, de prendre part à des discussions animées en petits groupes. Elle crée un environnement propice au partage et à l'échange. Le format de discussion intime est intéressant pour aborder le sujet des soins de santé autochtones. L'adaptation du Café du monde à une plateforme virtuelle nous a permis de mettre en relation un groupe d'apprenants hétéroclite, d'encourager l'apprentissage entre pairs et de remédier aux inégalités entre les cursus de formation quant à l'exposition des apprenants à des groupes de patients diversifiés. L'environnement sûr donne lieu à des résultats qui peuvent surprendre. Dans notre cas, les participants ont identifié des préjugés inconscients et ont reconnu que le programme constitue une nouvelle possibilité d'apprentissage. Essayez-le pour voir!

The Effects of Hot Yoga on Kidney Function: An Observational Pilot and Feasibility Study.

Yoga has been shown to have health benefits, whereas exercising in a hot environment has deleterious effects on kidney function. There are no long-term studies on the physiological effects of hot yoga. The purpose of this study was to investigate changes in renal function acutely and over time between practitioners of hot and non-hot yoga. Urine and capillary samples were collected for urinalysis, albumin-creatinine ratio, and serum creatinine at yoga studios preand postexercise over 1 year. Thirty-two participants in non-hot yoga and 19 participants in hot yoga were recruited. Difference in blood capillary creatinine (post-yoga minus pre-yoga) showed a 7.52 µmol/L (SD 11.46) increase for practitioners of hot yoga and a 4.07 µmol/L (SD 9.94) increase for practitioners of non-hot yoga, with a between-group difference of 3.45 µmol/L (95% CI -0.42, 7.32; p = 0.08). Over 1 year, the mean difference in blood capillary creatinine for the hot group increased by 0.91 µmol/L (SD 11.00) and by 3.08 µmol/L (SD 9.96) for the non-hot group, with a between-group difference of -2.17 µmol/L (95% CI -10.20, 5.86; p = 0.58). Over 1 year, the mean difference in albumin-creatinine ratio for the hot group was -0.16 mg/mmol creatinine (SD = 0.74); for the non-hot group the difference was -0.20 mg/µmol (SD = 0.80). The difference in difference between the hot and non-hot groups was 0.04 mg/µmol (95% CI -0.60, 0.68; p = 0.90). Urine collected for urinalysis could not be analyzed due to too many 0 values. This pragmatic observational study did not find a statistically significant change in renal function between participants in non-hot and hot yoga either acutely or over 1 year. A larger and longer study focusing on blood creatinine over time would help to inform the long-term effects of hot yoga on the kidneys.

Increasing Organ Donor Registration in a Primary Care Clinic.

Only 30% of Ontarians are registered organ donors in spite of the vast unmet need for organ donations in Ontario, Canada. The purpose of this quality improvement (QI) initiative was to increase the number of registered organ donors in a primary care practice by providing an educational fact sheet and registration form to patients in the clinic's waiting room. Three Plan-Do-Study-Act (PDSA) cycles were conducted. In the first PDSA cycle, we created an information sheet to explain the need for organ donors and the registration process. Nine patients were surveyed regarding the clarity of the information sheet, which resulted in subsequent modification of the information sheet prior to the second PDSA cycle. For the second cycle, the revised information sheet was attached to a donor registration form and distributed to 30 patients in the primary care practice over a two-week period. 23 forms were returned, in which 4 patients were already registered organ donors and 5 patients completed registration forms. In the third PDSA cycle, a more compelling graphic was used on the pamphlet. Similarly, 30 forms were distributed; 23 forms were returned, with 6 newly completed registration forms. Overall, the project increased the donor registration rate from 10.0% to 28.3%. The process allowed patients to become more knowledgeable about organ donation need and aware of the Trillium Gift of Life website. We believe that providing patients with an information pamphlet and registration form in the clinic waiting room enhanced their awareness of organ donation and facilitated registration without delay. This QI initiative represents an effective and practical study to increase donor knowledge and provide opportunities for interested individuals to become registered organ donors.

Curriculum to enhance pharmacotherapeutic knowledge in family medicine: interprofessional coteaching and web-based learning.

PROBLEM ADDRESSED: Prescribing is an essential skill for physicians. Despite the fact that prescribing habits are still developing in residency, formal pharmacotherapy curricula are not commonplace in postgraduate programs. OBJECTIVE OF PROGRAM: To teach first-year and second-year family medicine residents a systematic prescribing process using a medication prescribing framework, which could be replicated and distributed. PROGRAM DESCRIPTION: A hybrid model of Web-based (www.rationalprescribing.com) and in-class seminar learning was used. Web-based modules, consisting of foundational pharmacotherapeutic content, were each followed by an in-class session, which involved applying content to case studies. A physician and a pharmacist were coteachers and they used simulated cases to enhance application of pharmacotherapeutic content and modeled interprofessional collaboration. CONCLUSION: This systematic approach to prescribing was well received by family medicine residents. It might be important to introduce the process in the undergraduate curriculum-when learners are building their therapeutic foundational knowledge. Incorporating formal pharmacotherapeutic curriculum into residency teaching is challenging and requires further study to identify potential effects on prescribing habits.

Typology of after-hours care instructions for patients: telephone survey and multivariate analysis.

OBJECTIVE: To develop a typology of after-hours care (AHC) instructions and to examine physician and practice characteristics associated with each type of instruction. DESIGN: Cross-sectional telephone survey. Physicians' offices were called during evenings and weekends to listen to their messages regarding AHC. All messages were categorized. Thematic analysis of a subset of messages was conducted to develop a typology of AHC instructions. Logistic regression analysis was used to identify associations between physician and practice characteristics and the instructions left for patients. SETTING: Family practices in the greater Toronto area. PARTICIPANTS: Stratified random sample of family physicians providing office-based primary care. MAIN OUTCOME MEASURES: Form of response (eg, answering machine), content of message, and physician and practice characteristics. RESULTS: Of 514 after-hours messages from family physicians' offices, 421 were obtained from answering machines, 58 were obtained from answering services, 23 had no answer, 2 gave pager numbers, and 10 had other responses. Message content ranged from no AHC instructions to detailed advice; 54% of messages provided a single instruction, and the rest provided a combination of instructions. Content analysis identified 815 discrete instructions or types of response that were classified into 7 categories: 302 instructed patients to go to an emergency department; 122 provided direct contact with a physician; 115 told patients to go to a clinic; 94 left no directions; 76 suggested calling a housecall service; 45 suggested calling Telehealth; and 61 suggested other things. About 22% of messages only advised attending an emergency department, and 18% gave no advice at all. Physicians who were female, had Canadian certification in family medicine, held hospital privileges, or had attended a Canadian medical school were more likely to be directly available to their patients. CONCLUSION: Important issues identified included the recommendation to use an emergency department as the sole source of AHC, practices providing no specific AHC instructions to their patients, and physicians' lack of acceptance of Telehealth. To improve AHC, new initiatives should build upon the existing system, changes should be integrated, and there should be a range of AHC options for patients and physicians.

Continuous quality improvement and community-based faculty development through an innovative site visit program at one institution.

This article describes and evaluates a unique site-visit process for community-based teaching sites. A continuous quality-improvement program was developed by the undergraduate program in the Department of Family and Community Medicine at the University of Toronto Faculty of Medicine to facilitate and document both self- and peer-assessment. A pilot program was launched in 2000, and, after some adjustments based on initial feedback, the program in its current form was implemented in 2002. This program provides individualized support mechanisms to address the faculty development needs and infrastructure requirements of community-based, mostly volunteer, teachers. It also trains participating reviewers to provide individualized faculty development at the point of teaching. During their training, reviewers receive a toolkit consisting of suggestions for initial contact with teachers, guidelines for peer assessments, previously completed previsit teacher surveys, reviewer checklists, postvisit feedback forms, sample thank-you letters, and a faculty development reference resource list. A two-year evaluation of the program demonstrated that faculty and reviewer participants perceived it to be comprehensive, consistent, informative, and an acceptable method of reviewing existing and prospective community-based teaching sites. This program should be transferable to other institutions that engage in community-based teaching.

Below the belt: approach to chronic pelvic pain.

OBJECTIVE: To present a practical approach to the symptom complex called chronic pelvic pain (CPP). Chronic pelvic pain is defined as nonmenstrual pain lasting 6 months or more that is severe enough to cause functional disability or require medical or surgical treatment. SOURCES OF INFORMATION: MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched from January 1996 to December 2004. MAIN MESSAGE: While the source of pain in CPP can be gynecologic, urologic, gastrointestinal, musculoskeletal, or psychoneurologic, 4 conditions account for most CPP: endometriosis, adhesions, interstitial cystitis, and irritable bowel syndrome. More than one source of pain can be found in the same patient. Management involves treating the underlying condition, the pain itself, or both. Nonnarcotic analgesics are first-line therapy for pain relief; hormonal therapies are beneficial if the pain has a cyclical component. A multidisciplinary approach addressing environmental factors and incorporating medical management with physiotherapy, psychotherapy, and dietary modifications works best. CONCLUSION: Although caring for patients with CPP can be challenging and frustrating, family physicians are in an ideal position to manage and coordinate their care.

After-hours coverage: national survey of policies and guidelines for primary care physicians.

OBJECTIVE: To determine the prevalence and content of existing or developing policies and guidelines of medical associations and colleges regarding after-hours care by family physicians and general practitioners, especially legal requirements. DESIGN: Telephone survey in fall 2002, updated in fall 2004. SETTING: Canada. PARTICIPANTS: All national and provincial medical associations, Colleges of Family Physicians, Colleges of Physicians and Surgeons, local government offices for the north, and the Canadian Medical Protective Association (CMPA). MAIN OUTCOME MEASURE: RESPONSE TO THE QUESTION: "Does your agency have a policy in place regarding after-hours health care coverage by FPs/GPs, or are there active discussions regarding such a policy?" RESULTS: The College of Physicians and Surgeons of British Columbia was the first to institute a policy, in 1995, requiring physicians to make "specific arrangements" for after-hours care of their patients. The College of Physicians and Surgeons of Alberta adopted a similar policy in 1996 along with a guideline to aid implementation. In 2002, the College of Physicians and Surgeons of Nova Scotia approved a guideline on the Availability of Physicians After Hours. The Saskatchewan Medical Association and the College of Physicians and Surgeons of Saskatchewan formulated a joint policy on medical practice coverage that was released in 2003. Many agencies actively discussed the topic. Provincial and national Colleges of Family Physicians did not have any policies in place. The CMPA does not generate guidelines but released in an information letter in May 2000 a section entitled "Reducing your risk when you're not available." CONCLUSION: There is increasing interest Canada-wide in setting policy for after-hours care. While provincial Colleges of Physicians and Surgeons have traditionally led the way, a trend toward more collaboration between associations was identified. The effect of policy implementation on physicians' coverage of patients is unclear.

Medical errors in primary care: results of an international study of family practice.

OBJECTIVE: To describe errors Canadian family physicians found in their practices and reported to study investigators. To compare errors reported by Canadian family physicians with those reported by physicians in five other countries. DESIGN: Analytical study of reports of errors. The Linnaeus Collaboration was formed to study medical errors in primary care. General practitioners in six countries, including a new Canadian family practice research network (Nortren), anonymously reported errors in their practices between June and December 2001. An evolving taxonomy was used to describe the types of errors reported. SETTING: Practices in Canada, Australia, England, the Netherlands, New Zealand, and the United States. PARTICIPANTS: Family physicians in the six countries. MAIN OUTCOME MEASURES: Types of errors reported. Differences in errors reported in different countries. RESULTS: In Canada, 15 family doctors reported 95 errors. In the other five countries, 64 doctors reported 413 errors. Although the absence of a denominator made it impossible to calculate rates of errors, Canadian doctors and doctors from the other countries reported similar proportions of errors arising from health system dysfunction and gaps in knowledge or skills. All countries reported similar proportions of laboratory and prescribing errors. Canadian doctors reported harm to patients from 39.3% of errors; other countries reported harm from 29.3% of errors. Canadian physicians considered errors "very serious" in 5.8% of instances; other countries thought them very serious in 7.1% of instances. Hospital admissions and death were among the consequences of errors reported in other countries, but these consequences were not reported in Canada. CONCLUSION: Serious errors occur in family practice and affect patients in similar ways in Canada and other countries. Validated studies that analyze errors and record error rates are needed to better understand ways of improving patient safety in family practice.

After-hours care in Canada: analysis of the 2001 National Family Physician Workforce Survey.

OBJECTIVE: To determine family physicians' availability to their general practice patients after hours and to explore the characteristics and determinants of after-hours services. DESIGN: Secondary analysis of the 2001 National Family Physician Workforce Survey. SETTING: Canada. PARTICIPANTS: Canadian family physicians and general practitioners currently in practice (n = 10,553). MAIN OUTCOME MEASURES: Provision of after-hours care, defined as providing care to all practice patients outside of normal office hours. RESULTS: Sixty-two percent of Canadian family physicians reported providing after-hours service. The lowest rates were found in Quebec (34%) and the highest in Alberta and Saskatchewan (88%). Respondents practising in academic and community clinics, offering selective medical services (emergency care, palliative care, housecalls, after-hours care), or living outside of Ontario or Quebec were more likely to provide after-hours care. Women physicians, those practising in walk-in clinics, or physicians primarily paid by fee-for-service were less likely to do so. Urban versus rural location, organization of practice (solo or group), age of physician, country of graduation, and physician satisfaction were not found to significantly affect the likelihood of providing after-hours services. CONCLUSION: Knowledge of these factors can be used to inform policy development for after-hours service arrangements, which is particularly relevant today, given provincial governments' interests in exploring alternative payment plans and primary care reform options.