Primary health care services provided by nurse practitioners and family physicians in shared practice.

BACKGROUND: Collaborative practice involving nurse practitioners (NPs) and family physicians (FPs) is undergoing a renaissance in Canada. However, it is not understood what services are delivered by FPs and NPs working collaboratively. One objective of this study was to determine what primary health care services are provided to patients by NPs and FPs working in the same rural practice setting. METHODS: Baseline data from 2 rural Ontario primary care practices that participated in a pilot study of an outreach intervention to improve structured collaborative practice between NPs and FPs were analyzed to compare service provision by NPs and FPs. A total of 2 NPs and 4 FPs participated in data collection for 400 unique patient encounters over a 2-month period; the data included reasons for the visit, services provided during the visit and recommendations for further care. Indices of service delivery and descriptive statistics were generated to compare service provision by NPs and FPs. RESULTS: We analzyed data from a total of 122 encounters involving NPs and 278 involving FPs. The most frequent reason for visiting an NP was to undergo a periodic health examination (27% of reasons for visit), whereas the most frequent reason for visiting an FP was cardiovascular disease other than hypertension (8%). Delivery of health promotion services was similar for NPs and FPs (11.3 v. 10.0 instances per full-time equivalent [FTE]). Delivery of curative services was lower for NPs than for FPs (18.8 v. 29.3 instances per FTE), as was provision of rehabilitative services (15.0 v. 63.7 instances per FTE). In contrast, NPs provided more services related to disease prevention (78.8 v. 55.7 instances per FTE) and more supportive services (43.8 v. 33.7 instances per FTE) than FPs. Of the 173 referrals made during encounters with FPs, follow-up with an FP was recommended in 132 (76%) cases and with an NP in 3 (2%). Of the 79 referrals made during encounters with NPs, follow-up with an NP was recommended in 47 (59%) cases and with an FP in 13 (16%) (p < 0.001). INTERPRETATION: For the practices in this study NPs were underutilized with regard to curative and rehabilitative care. Referral patterns indicate little evidence of bidirectional referral (a measure of shared care). Explanations for the findings include medicolegal issues related to shared responsibility, lack of interdisciplinary education and lack of familiarity with the scope of NP practice.

Does the site of postgraduate family medicine training predict performance on summative examinations? A comparison of urban and remote programs.

BACKGROUND: The location of postgraduate medical training is shifting from teaching hospitals in urban centres to community practice in rural and remote settings. We were interested in knowing whether learning, as measured by summative examinations, was comparable between graduates who trained in urban centres and those who trained in remote and rural settings. METHODS: Family medicine training programs in Ontario were selected as a model of postgraduate medical training. The results of the 2 summative examinations--the Medical Council of Canada Qualifying Examination (MCCQE) Part II and the College of Family Physicians of Canada (CFPC) certification examination--for graduates of the programs at Ontario's 5 medical schools were compared with the results for graduates of the programs in Sudbury and Thunder Bay from 1994 to 1997. The comparability of these 2 cohorts at entry into training was evaluated using the results of their MCCQE Part I, completed just before the family medicine training. RESULTS: Between 1994 and 1997, 1013 graduates of family medicine programs (922 at the medical schools and 91 at the remote sites) completed the CFPC certification examination; a subset of 663 completed both the MCCQE Part I and the MCCQE Part II. The MCCQE Part I results for graduates in the remote programs did not differ significantly from those for graduates entering the programs in the medical schools (mean score 531.3 [standard deviation (SD) 69.8] and 521.8 [SD 74.4] respectively, p = 0.33). The MCCQE Part II results did not differ significantly between the 2 groups either (mean score 555.1 [SD 71.7] and 545.0 [SD 76.4] respectively, p = 0.32). Similarly, there were no consistent, significant differences in the results of the CFPC certification examination between the 2 groups. INTERPRETATION: In this model of postgraduate medical training, learning was comparable between trainees in urban family medicine programs and those in rural, community-based programs. The reasons why this outcome might be unexpected and the limitations on the generalizability of these results are discussed.

Decreasing supply of family physicians and general practitioners. Serious implications for the future.

OBJECTIVE: To document a decrease in the supply of family physicians (FPs) and general practitioners among Canadian graduates of medical schools since rotating internships ceased to serve as a route to national licensure. DESIGN: Review of data from the Association of Canadian Medical Colleges, the Canadian Post-M.D. Education Registry, and the Canadian Institute for Health Information to track final training fields and eventual types of practice of graduates of Canadian faculties of medicine from 1987 to 1997. SETTING: Canadian faculties of medicine and residency training programs. MAIN OUTCOME MEASURES: Number of Canadian medical graduates entering family medicine training programs from 1991 to 1998, number of Canadian graduate physicians exiting from these training programs, and proportion of each graduating class (1987 to 1994) practising as FPs or GPs in Canada in 1997. RESULTS: In 1993, 890 physicians (51% of graduates) were trained as FPs or GPs. By 1994, although the proportion remained at 40%, the number of Canadian graduates entering family medicine had dropped to 646, and by 1998, to 619. CONCLUSIONS: A deficit of FPs is already noticeable in the practice environment. For the way in which medical care is delivered in Canada, with FPs serving as first contact for patients, the authors conclude that the number of graduating FPs in Canada will not be sufficient to provide the primary care services Canadians need.

Continuity of care in the family medicine residency. Results of a national survey of program directors.

Based on the results of a survey of family medicine residency program directors across the country, there is a need for a national consensus on the definition of continuity of care, and on structures for teaching it and methods of evaluating it.

Medicine in the Former Soviet Union: Developing an equivalent to family medicine.

At the time this article was written, the Soviet Union was in a state of transition and turmoil. Its health care system was one of the areas most affected. This article is based on the observations the authors made during visits to the Soviet Union in 1990 and 1991. Although the situation in the Soviet Union seemed quite bleak, some very exciting initiatives for change were and still are under way, the result of which could be a system that provides more efficient and effective health care.

Survey of Third-Year Postgraduate Training Positions in Family Medicine: Adding more positions for adequate training in primary care.

In a survey of 16 program directors of residency training in family medicine, respondents were asked about numbers and types of third-year positions they offer. As Canadian educational programs move toward implementing or expanding 2-year prelicensure requirements, many directors are exploring the need to add even more positions for adequate training in primary care. Respondents offered suggestions on tailoring strategies in view of the educational, political, and economic climate.

Jogger's Fatigue: A Case of Unsuspected Pathology.

While many organic diseases classically produce symptoms of fatigue, other problems such as iatrogenic drug effects, normal physiological alterations, and strees, present with this symptom. In order to rule out the presence of organic dissease, an adequate history and physical examination, and appropriate laboratory investigations are mandatory. The authors describe a case of fatigue in a highly stressed jogger.