Advancing primary care: Establishing family medicine specialty in Tanzania.

Family medicine has existed as a training pathway through a private university in Tanzania since 2004. As global calls have increased to embrace primary health care as a pathway to ensuring universal health coverage, so has Tanzania recently turned to explore family medicine as a specialty to improve access to comprehensive, high-quality healthcare for her entire population. This article outlines ongoing efforts to define competencies and skills of a family medicine physician in Tanzania, engage government support and open the first public university training programme for family medicine postgraduate education.

A pilot study examining Toronto-area family physician perspectives on thyroid neoplasm evaluation.

OBJECTIVE: The incidence of thyroid cancer (TC) is known to be very high in the Greater Toronto Area of Ontario, Canada. We performed a pilot survey study examining Toronto-area family physician (FP) perspectives on thyroid neoplasm evaluation (i.e. thyroid nodules [TNs] or thyroid cancer [TC]) in this region, to explore for potential factors leading to overdiagnosis. METHODS: We performed a cross-sectional mail-out written survey of a random sample of 300 FPs in active practice in the Greater Toronto Area (Markham and Brampton). RESULTS: The overall response rate was 22.3, 95% confidence interval (CI) 18.0, 27.4% (67/300); the effective response rate was 19.9, 95% CI 15.7, 24.9% (58/291), after excluding 6 FPs that reported TN evaluation was outside their scope of practice and three FPs with an invalid mailing address. There were no missing responses to questions. The demographic characteristics were as follows: 58.6% (34/58) from Markham, 55.2% (32/58) were female, 58.6% (34/58) were in practice > 10 years, and 32.8% (19/58) affiliated with a University. All FPs reported easy access to thyroid ultrasound (TUS). About half of FPs were concerned about overdiagnosis of TC and most did not believe that there was any TC survival advantage with routine screening TUS. Although appropriate indications for TUS were endorsed by most respondents (e.g. palpable TN, incidental TN on other imaging), inappropriate recommendations were observed in a third of FPs (19/57) who recommended TUS for abnormal thyroid blood tests about half of FPs (30/56) who endorsed biopsy of sub-centimeter nodules. About half of FPs (31/58) reported that their patients sometimes request medically unnecessary TUS. CONCLUSION: There are likely multiple complex factors leading to potential overdiagnosis of TC in primary care, including some physicians' knowledge gaps about appropriate indications for TN investigations as well as patients' requests and expectations.

How applicable are clinical practice guidelines to elderly patients with comorbidities?

OBJECTIVE: To examine the applicability of 10 common clinical practice guidelines (CPGs) to elderly patients with multiple comorbidities. DESIGN: Content analysis of published Canadian CPGs for the following chronic diseases: diabetes, dyslipidemia, dementia, congestive heart failure, depression, osteoporosis, hypertension, gastroesophageal reflux disease, chronic obstructive pulmonary disease, and osteoarthritis. MAIN OUTCOME MEASURES: Presence or absence of 4 key indicators of applicability of CPGs to elderly patients with multiple comorbidities. These indicators include any mention of older adults or people with comorbidities, time needed to treat to benefit in the context of life expectancy, and barriers to implementation of the CPG. RESULTS: Out of the 10 CPGs reviewed, 7 mentioned treatment of the elderly, 8 mentioned people with comorbidities, 4 indicated the time needed to treat to benefit in the context of life expectancy, 5 discussed barriers to implementation, and 7 discussed the quality of evidence. CONCLUSION: This study shows that although most CPGs discuss the elderly population, only a handful of them adequately address issues related to elderly patients with comorbidities. In order to make CPGs more patient centred rather than disease driven, guideline developers should include information on elderly patients with comorbidities.

The scope of naturopathic medicine in Canada: an emerging profession.

In Canada, naturopathic medicine is an emerging profession that is gaining formal recognition, including provincial/territorial regulation. While naturopathic medicine has undergone significant growth and legitimization, it still faces substantial challenges to acceptance as a full-fledged health care profession within the Canadian health care system. For example, professionalization theories indicate the importance of clear professional boundaries as well as the need for 'new' groups to find a place in the system of professions. This has been problematic for naturopathic practitioners who continue to practice within a broad scope of practice that encompasses many different therapeutic modalities. Development of statutory regulation also requires delineation of a specific, well-defined scope of practice. The purpose of this study was to describe naturopathic practitioners' perception of their training and their current scope of practice. Two thirds (n = 315) of all licensed Canadian naturopathic practitioners responded to the survey. The results showed that naturopathic practitioners are trained in, and practice, a wide range of therapeutic modalities and diagnostic procedures. Practitioners disagreed about their scope of practice, as 57% thought it was too restrictive, 31% felt it was about right and 13% thought it was too broad. A large majority felt there was some or a great deal of overlap with other practitioners' scope of practice. We conclude that multiple challenges are facing naturopathic medicine, including scope of practice, overlap with other professions, social closure, scarcity of vacancies and lack of cohesion. The future of naturopathic medicine will depend on how effectively the profession will use available strategies to overcome barriers to statutory self-regulation.