The influence of academic discourses on medical students' identification with the discipline of family medicine.

PURPOSE: To understand the influence of academic discourses about family medicine on medical students' professional identity construction during undergraduate training. METHOD: The authors used a multiple case study research design involving international medical schools, one each from Canada, France, Spain, and the United Kingdom (UK). The authors completed the fieldwork between 2007 and 2009 by conducting 18 focus groups (with 132 students) and 67 semistructured interviews with educators and by gathering pertinent institutional documents. They carried out discursive thematic analyses of the verbatim transcripts and then performed within- and cross-case analyses. RESULTS: The most striking finding was the diverging responses between those at the UK school and those at the other schools. In the UK case, family medicine was recognized as a prestigious academic discipline; students and faculty praised the knowledge and skills of family physicians, and students more often indicated their intent to pursue family medicine. In the other cases, family medicine was not well regarded by students or faculty. This was expressed overtly or through a paradoxical academic discourse that stressed the importance of family medicine to the health care system while decrying its lack of innovative technology and the large workload-to-income ratio. Students at these schools were less likely to consider family medicine. CONCLUSIONS: These results stress the influence of academic discourses on medical students' ability to identify with the practice of family medicine. Educators must consider processes of professional identity formation during undergraduate medical training as they develop and reform medical education.

[Patients members to a network's representations: prospects for the improvement of care]. / Les représentations de patients adhérents à un réseau de santé: perspectives d'amélioration de leur prise en charge.

OBJECTIVE: Identify the representations of patients regarding their disease, their accession and the positive and resistance factors of their participation in the network to understand how the network could improve their care. METHOD: Qualitative survey. We conducted twenty interviews, using open-ended questionnaires, with diabetic type 2 patients, registered for over a year in the healthcare Codiab network in the department of Morbihan. RESULTS: The relationship with their diabetes was built in connection with their stories, their family history, their socio-economic conditions. These dimensions strongly affect the perception they may have of their care. Their accession to the network, whether they are "participants" or "non" is mostly passive, perceived as a "prescription" which responds primarily to a need identified by a professional of care. The network may appear as an alternative to attending physician instead of an asset in connection with him. CONCLUSION: It would be necessary to establish a consulting educational diagnosis before the patients enter in the network in order to better identify their needs and expectations to improve the response of the network. It would then be a matter of ensuring a personalized therapeutic educational journey adapted over time to the patient's lifestyle. Finally, it would seem necessary to reposition in the network, physicians, local actors, which are essential to a relationship of care guided by care structured by networks.

Obstacles to adherence in living with type-2 diabetes: an international qualitative study using meta-ethnography (EUROBSTACLE).

Quantitative studies failed to determine variables which consistently explain adherence or non-adherence to treatment recommendations. Qualitative studies identified issues such as the quality of the health provider-health receiver relationship and the patient's health beliefs. According to these findings, 39 focus groups of 246 people living with type-2 diabetes were conducted in seven European countries, assessing health beliefs, communication with caregivers and problems encountered in adhering to treatment regimens. Meta-ethnography was later applied to make a qualitative meta-analysis. Obstacles to adherence are common across countries, and seem to be related less to issues of the health-care system and more to patient's knowledge about diabetes, beliefs and attitudes and the relationship with health-care professionals. The resulting key themes are course of diabetes, information, person and context, body awareness and relationship with the health care provider. Meta-ethnography is a feasible tool for the meta-analysis of multilingual qualitative data and leads to a richer account.

Confidentiality for adolescents seeking reproductive health care in Lithuania: the perceptions of general practitioners.

Confidentiality is a major determinant of the accessibility and acceptability of sexual and reproductive health care for adolescents. Previous research has revealed that Lithuanian adolescents lack confidence in guarantees of confidentiality in primary health care settings. This study aimed to assess the factors that affect general practitioners' decisions whether to respect confidentiality for Lithuanian adolescents under the age of 18. Twenty in-depth interviews were carried out with a purposive sample of general practitioners. The decision whether to respect confidentiality was found to be influenced by external forces, including the legislative framework and societal attitudes towards adolescent sexuality; institutional features in clinical facilities, such as the presence of a nurse during consultations and the openness of the medical record filing system; and individual factors, including GPs' relationships with adolescents' families and their personal attitudes towards sexual and reproductive health issues. The findings reflect the urgent need for a comprehensive policy to ensure adolescents' right to confidentiality in Lithuanian primary care settings, including legislative reforms, institutional changes in health care settings, professional guidelines and (self-)regulation, and changes in medical training and continuing medical education. Other ways to safeguard confidentiality in adolescent health services, such as establishing youth clinics, should also be explored.

The appropriateness of gatekeeping in the provision of reproductive health care for adolescents in Lithuania:the general practice perspective.

BACKGROUND: Adolescents' consultation of primary health care services remains problematic despite their accessibility. The reproductive health service seeking behavior of adolescents is the object of much research but little is known about how this behavior is influenced by the gatekeeping system. This study aimed to explore general practitioners' perceptions of the appropriateness of gatekeeping in adolescent reproductive health care. METHODS: Twenty in-depth interviews regarding factors affecting adolescent reproductive health care were carried out on a diverse sample of general practitioners and analyzed using grounded theory. RESULTS: The analysis identified several factors that shaped GPs' negative attitude to gatekeeping in adolescent reproductive health care. Its appropriateness in this field was questionable due to a lack of willingness on the part of GPs to provide reproductive health services for teenagers, their insufficient training, inadequately equipped surgeries and low perceived support for reproductive health service provision. CONCLUSION: Since factors for improving adolescent reproductive health concern not only physicians but also the health system and policy levels, complex measures should be designed to overcome these barriers. Discussion of a flexible model of gatekeeping, encompassing both co-ordination of care provided by GPs and the possibility of patients' self-referral, should be included in the political agenda. Adolescents tend to under-use rather than over-use reproductive health services and every effort should be made to facilitate the accessibility of such services.