Workplace-based assessment of family medicine competencies using "field note tool" - A pilot study.

BACKGROUND: Department of Family Medicine in a medical college in South India introduced "field note" (FN) as a tool for Work-Place Based Assessment in postgraduate training. FN collects "open-ended" feedback from both resident and faculty and helps them to arrive at an action plan. This study describes our experience of implementing FN and perceptions of learners and faculty. METHODS: While precepting the residents in Family Medicine service areas, faculty documented their observations of the resident's clinical work using FN and provided an action plan. Faculty and residents described their experience and provided feedback. Focus group discussions were conducted for faculty and residents. Data were coded and grouped into themes. RESULTS: Four residents and seven faculties participated in the study during 12 weeks period using 17 consultations. Clinical expert (13/17) and communicator (6/17) are the most commonly assessed competencies followed by professionalism (2/17) and collaborator (2/17). Faculty and residents agreed that "FN" was a useful tool and it helped the faculty to give feedback and guide the learner. Residents and faculty arrived at an action plan in 70% of the consultations. Three of four residents perceived the change in their behaviour positively after the use of FN. Both resident and faculty found the rating of the learner using Dreyfus scale as a barrier. CONCLUSION: FN could be one of the important tools in our "Toolbox of Assessment Methods" for family medicine specialty. There is a need for sensitizing the learners to feedback process and training the faculty in assessment and feedback.

Injected corticosteroids for treating plantar heel pain in adults.

BACKGROUND: Plantar heel pain, commonly resulting from plantar fasciitis, often results in significant morbidity. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), orthoses, physical therapy, physical agents (e.g. extracorporeal shock wave therapy (ESWT), laser) and invasive procedures including steroid injections. OBJECTIVES: To assess the effects (benefits and harms) of injected corticosteroids for treating plantar heel pain in adults. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, CINAHL, clinical trials registries and conference proceedings. Latest search: 27 March 2017. SELECTION CRITERIA: Randomised and quasi-randomised trials of corticosteroid injections in the treatment of plantar heel pain in adults were eligible for inclusion. DATA COLLECTION AND ANALYSIS: At least two review authors independently selected studies, assessed risk of bias and extracted data. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures. We used a fixed-effect model unless heterogeneity was significant, when a random-effects model was considered. We assessed the overall quality of evidence for individual outcomes using the GRADE approach. MAIN RESULTS: We included a total of 39 studies (36 randomised controlled trials (RCTs) and 3 quasi-RCTs) that involved a total of 2492 adults. Most studies were small (median = 59 participants). Participants' mean ages ranged from 34 years to 59 years. When reported, most participants had heel pain for several months. The trials were usually conducted in outpatient specialty clinics of tertiary care hospitals in 17 countries. Steroid injection was given with a local anaesthetic agent in 34 trials. Follow-up was from one month to over two years. With one exception, trials were assessed at high risk of bias in one or more domains, mostly relating to lack of blinding, including lack of confirmation of allocation concealment. With two exceptions, we rated the available evidence as very low quality, implying in each case that we are 'very uncertain about the estimate'.The 39 trials covered 18 comparisons, with six of the seven trials with three or four groups providing evidence towards two comparisons.Eight trials (724 participants) compared steroid injection versus placebo or no treatment. Steroid injection may lead to lower heel pain visual analogue scores (VAS) (0 to 100; higher scores = worse pain) in the short-term (< 1 month) (MD -6.38, 95% CI -11.13 to -1.64; 350 participants; 5 studies; I² = 65%; low quality evidence). Based on a minimal clinically significant difference (MCID) of 8 for average heel pain, the 95% CI includes a marginal clinical benefit. This potential benefit was diminished when data were restricted to three placebo-controlled trials. Steroid injection made no difference to average heel pain in the medium-term (1 to 6 months follow-up) (MD -3.47, 95% CI -8.43 to 1.48; 382 participants; 6 studies; I² = 40%; low quality evidence). There was very low quality evidence for no effect on function in the medium-term and for an absence of serious adverse events (219 participants, 4 studies). No studies reported on other adverse events, such as post-injection pain, and on return to previous activity. There was very low quality evidence for fewer treatment failures (defined variously as persistent heel pain at 8 weeks, steroid injection at 12 weeks, and unrelieved pain at 6 months) after steroid injection.The available evidence for other comparisons was rated as very low quality. We are therefore very uncertain of the estimates for the relative effects on people with heel pain of steroids compared with other interventions in:1. Tibial nerve block with anaesthetic (2 trials); orthoses (4 trials); oral NSAIDs (2 trials); and intensive physiotherapy (1 trial).2. Physical modalities: ESWT (5 trials); laser (2 trials); and radiation therapy (1 trial).3. Other invasive procedures: locally injectable NSAID (1 trial); platelet-rich plasma injections (5 trials); autologous blood injections (2 trials); botulinum toxin injections (2 trials); cryopreserved human amniotic membrane injection (1 trial); localised peppering with a needle (1 trial); dry needling (1 trial); and mini scalpel needle release (1 trial).We are also uncertain about the estimates from trials testing different techniques of local steroid injection: ultrasonography-guided versus palpation-guided (5 trials); and scintigraphy-guided versus palpation-guided (1 trial).An exploratory analysis involving pooling data from 21 trials reporting on adverse events revealed two ruptures of plantar fascia (reported in 1 trial) and three injection site infections (reported in 2 trials) in 699 participants allocated to steroid injection study arms. Five trials reported a total of 27 participants with less serious short-term adverse events in the 699 participants allocated steroid injection study arms. Reported treatments were analgesia, ice or both. Given the high risk of selective reporting for these outcomes and imprecision, this evidence was rated at very low quality. AUTHORS' CONCLUSIONS: We found low quality evidence that local steroid injections compared with placebo or no treatment may slightly reduce heel pain up to one month but not subsequently. The available evidence for other outcomes of this comparison was very low quality. Where available, the evidence from comparisons of steroid injections with other interventions used to treat heel pain and of different methods of guiding the injection was also very low quality. Although serious adverse events relating to steroid injection were rare, these were under-reported and a higher risk cannot be ruled out.Further research should focus on establishing the effects (benefits and harms) of injected steroids compared with placebo in typical clinical settings, subsequent to a course of unsuccessful conservative therapy. Ideally, this should be preceded by research, including patient involvement, aimed to obtain consensus on the priority questions for treating plantar heel pain.

Role of Family Medicine Education in India's Step Toward Universal Health Coverage.

India's commitment to universal health coverage has grown stronger with the submission of High Level Expert Group report by the Planning Commission in 2012. With this report comes the commitment to increase the primary health-care workforce to meet the population needs. However, the focus should not be just to increase the number of health workers, but to produce better health workers. Doctors, nurses and community health workers trained in primary and secondary health-care facilities can make a significant contribution in responding to the needs of the local community. The role of family medicine education is worth exploring in this context to equip the primary care health workers with the competencies of providing person-centered, comprehensive and continuous care.

Family medicine in undergraduate medical education in India.

The Medical Council of India has set appropriate and relevant objectives to train each medical student into a basic doctor for the country. Even though they envisage that these basic doctors would work as physicians of first contact, providing for the health needs of India at primary and secondary care level, the site of training and the context of clinical teaching do not seem to empower the students to become a basic doctor. 'Vision 2015', the document written by the board of governors of medical council of India suggests reforms in medical education such as early clinical exposure, integration of principles of family medicine, and clinical training in the secondary care level. Family medicine training with trained family medicine faculty might add this missing ingredient to our basic doctor training. This article discusses the role of family medicine in undergraduate medical training. We also propose the objectives of such training, the structure of the training process, and the road blocks with possible solutions to its implementation.

International classification of primary care: an Indian experience.

BACKGROUND: India is in the process of transition to universal health coverage for Indian citizens. The focus is to strengthen the primary and secondary level services. Coupled with this national scenario, the development of Family medicine as a distinct discipline is in a crucial stage. There is a nation-wide urge to build family medicine training units and service centers across the country to fulfill the unmet health needs of the population. OBJECTIVES: This study aimed to bring out reasons for encounter (RFE) and morbidity pattern of patients seen in a family physician run urban health center in South India. METHODS: The study was conducted in an urban health center of a tertiary care hospital. Clinicians entered the data using International Classification of Primary Care (ICPC) codes. Data included were demographics, 3 RFE, 3 diagnoses, 3 outcomes of care that include prescriptions, investigations, procedures, and referrals made. RESULTS: During 47,590 patient encounters, 59,647 RFE, 62,283 diagnoses and 68269 outcomes of care were recorded. The majority of RFEs and diagnoses are in the following ICPC chapters: Endocrinology (38.6%), cardiovascular (35.91%), respiratory (20.26%), digestive (7.68% and musculo-skeletal (6.8%). The most frequent outcome of care was prescriptions, followed by counseling and nebulization. CONCLUSION: This study is the first to report on the RFE in India. This study demonstrated the breadth of clinical conditions seen by family physicians across all ages and in both genders. This study attempts to highlight the need for family physician based services as a training ground for trainees.

Quality of life of a patient with type 2 diabetes: a cross-sectional study in rural South India.

BACKGROUND: With a high prevalence of diabetes in India, there is a need to study the impact of this disease on the quality of life (QoL) of the patients. MATERIALS AND METHODS: This facility-based cross-sectional study assessed the QoL of patients attending the diabetic clinic using the World Health Organization (WHO) QoL BREF instrument in Tamil Nadu. The QoL was analyzed domain-wise and various socio-demographic factors affecting the QoL were studied. RESULTS: The mean total score of the QoL scale was 58.05 (95% CI, 22.18-93.88). Domain-wise, 63% had good physical, 69% had good psychological, 27% had good social and 85% had good environmental QoL scores. Males, currently married and those with BMI more than 25 had a statistically significantly better QoL compared to their counterparts. CONCLUSIONS: Diabetes does impair the QoL of patients but not to a great extent. There is a need to specifically target and improve the QoL of women, widowed and separated, and non-obese diabetics who are at risk of a poor QoL. QoL assessment should be routinely practiced in diabetic clinics.

Morbidity Profile of Inpatients in a Secondary Care Center Run by Family Physicians.

BACKGROUND: There is a scarcity of records of morbidity pattern in secondary care centers. Reliable morbidity data will help in proper allocation of human resources. MATERIALS AND METHODS: A retrospective study of inpatient admission records of an urban secondary health center run by family physicians was done between April 2010 and March 2011. RESULTS: Pneumonia and other respiratory illnesses (represented by ICD code J) was the most common diagnosis. This was followed by infectious and viral diseases, circulatory diseases like hypertension, ischemic heart disease and endocrine diseases like non-insulin dependent diabetes mellitus. CONCLUSION: Physicians working in secondary care centres need to be experts in managing respiratory diseases, viral diarrheal illnesses, hypertension, ischemic heart disease and diabetes mellitus and patients with co-morbidities. They also need to be able to manage common obstetrics and neonatal emergencies. As the discipline of family medicine specializes in management of common ailments and multiple co-morbidities with an attitude of patient centeredness, family physicians would be the best managers of such centers. Inclusion of family physicians as specialist in secondary care centers will help in covering the manpower shortage in such centers.

Antibiotic therapy for Shigella dysentery.

BACKGROUND: Shigella dysentery is a relatively common illness and occasionally causes death, worldwide. Mild symptoms are self-limiting but in more severe cases, antibiotics are recommended for cure and preventing relapse. The antibiotics recommended are diverse, have regional differences in sensitivity, and have side effects. OBJECTIVES: To evaluate the efficacy and safety of antibiotics for treating Shigella dysentery. SEARCH STRATEGY: In June 2009 we identified all relevant trials from the following databases: Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, issue 4), MEDLINE, EMBASE, LILACS and the metaRegister of Controlled Trials (mRCT). We also checked conference proceedings for relevant abstracts, and contacted researchers, organizations, and pharmaceutical companies. SELECTION CRITERIA: Randomized controlled trials of antibiotics for Shigella dysentery. DATA COLLECTION AND ANALYSIS: Four authors, working in pairs, independently assessed trial eligibility, methodological quality, and extracted data. We calculated risk ratios (RR) with 95% confidence intervals (CI) for dichotomous data, and used the random-effects model for significant heterogeneity. We explored possible sources of heterogeneity, when present, in subgroup analyses of participant age and percentage of participants with confirmed Shigella infection. MAIN RESULTS: Sixteen trials (1748 participants), spanning four decades and with differing sensitivity to Shigella isolates, met the inclusion criteria. Seven were judged to be at risk of bias due to inadequate allocation concealment or blinding, and 12 due to incomplete reporting of outcome data. Limited data from one three-armed trial of people with moderately severe illness suggest that antibiotics reduce the episodes of diarrhoea at follow-up (furazolidone versus no drug RR 0.21, 95% CI 0.09 to 0.48, 73 participants; cotrimoxazole versus no drug RR 0.30, 95% CI 0.15 to 0.59, 76 participants).There was insufficient evidence to consider any class of antibiotic superior in efficacy in treating Shigella dysentery, but heterogeneity for some comparisons limits confidence in the results. All the antibiotics studied were safe. There was inadequate evidence regarding the role of antibiotics in preventing relapses. AUTHORS' CONCLUSIONS: Antibiotics reduce the duration of Shigella dysentery.Regularly updated local or regional antibiotic sensitivity patterns to different species and strains of Shigella are required to guide empiric therapy. More trials adhering to standard guidelines are required to evaluate the role of antibiotics in the treatment of severe forms of Shigella dysentery and in groups who are at high risk of complications.

Antibiotic therapy for Shigella dysentery.

BACKGROUND: Shigella dysentery is a relatively common illness and occasionally causes death, worldwide. Mild symptoms are self-limiting but in more severe cases, antibiotics are recommended for cure and preventing relapse. The antibiotics recommended are diverse, have regional differences in sensitivity, and have side effects. OBJECTIVES: To evaluate the efficacy and safety of antibiotics for treating Shigella dysentery. SEARCH STRATEGY: In June 2009 we identified all relevant trials from the following databases: Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, issue 4), MEDLINE, EMBASE, LILACS and the metaRegister of Controlled Trials (mRCT). We also checked conference proceedings for relevant abstracts, and contacted researchers, organizations, and pharmaceutical companies. SELECTION CRITERIA: Randomized controlled trials of antibiotics for Shigella dysentery. DATA COLLECTION AND ANALYSIS: Four authors, working in pairs, independently assessed trial eligibility, methodological quality, and extracted data. We calculated risk ratios (RR) with 95% confidence intervals (CI) for dichotomous data, and used the random-effects model for significant heterogeneity. We explored possible sources of heterogeneity, when present, in subgroup analyses of participant age and percentage of participants with confirmed Shigella infection. MAIN RESULTS: Sixteen trials (1748 participants), spanning four decades and with differing sensitivity to Shigella isolates, met the inclusion criteria. Seven were judged to be at risk of bias due to inadequate allocation concealment or blinding, and 12 due to incomplete reporting of outcome data. Limited data from one three-armed trial of people with moderately severe illness suggest that antibiotics reduce the episodes of diarrhoea at follow-up (furazolidone versus no drug RR 0.21, 95% CI 0.09 to 0.48, 73 participants; cotrimoxazole versus no drug RR 0.30, 95% CI 0.15 to 0.59, 76 participants).There was insufficient evidence to consider any class of antibiotic superior in efficacy in treating Shigella dysentery, but heterogeneity for some comparisons limits confidence in the results. All the antibiotics studied were safe. There was inadequate evidence regarding the role of antibiotics in preventing relapses. AUTHORS' CONCLUSIONS: Antibiotics reduce the duration of Shigella dysentery.Regularly updated local or regional antibiotic sensitivity patterns to different species and strains of Shigella are required to guide empiric therapy. More trials adhering to standard guidelines are required to evaluate the role of antibiotics in the treatment of severe forms of Shigella dysentery and in groups who are at high risk of complications.