Approach to caring for developmentally disabled adults in the community: medical, ethical, and legal considerations.

OBJECTIVE: To review the medical, ethical, and legal obligations in caring for adults with developmental disabilities (DDs) living in the community. SOURCES OF INFORMATION: Google and MEDLINE searches were conducted using the terms disabled, disability, vulnerable, and community. The pertinent legislation was reviewed. MAIN MESSAGE: The treatment of a patient with DDs varies with factors such as the pathogenesis of the patient's current problem, comorbid conditions, the severity of his or her disabilities, and his or her current social supports. While the shift from institutional to community care for patients with DDs is widely accepted as being beneficial, providing high-quality community care has proven to be challenging. However, there is little research on how to effectively provide community support to adults with DDs. As primary care providers, family physicians are often the first point of contact for patients, and are responsible for both the coordination and the continuity of care. With the movement toward preventive care and early disease detection, the patient's active participation is also vital. The patient's values and goals are an essential consideration, even when they are contrary to the patient's good health or the clinician's own values. The legislation for vulnerable persons varies among the provinces. Thus, the obligation to report suspected abuse might depend on whether the vulnerable person is living in a care facility or the community; whether the person with the suspicion is a service provider or health care professional; and whether the specific circumstances fall within the legislative definition of abuse or neglect. CONCLUSION: Primary care providers must give adults with DDs compassionate care that respects the patients' wishes.

Effect of family medicine residents on use of diagnostic investigations: in a rural community emergency department.

OBJECTIVE: To determine the effect of the presence of family medicine residents on the use of laboratory and imaging investigations in a rural emergency department (ED). DESIGN: A retrospective cross-sectional electronic chart audit was completed. Background characteristics, as well as type and number of ordered investigations, were compared between study groups. SETTING: Strathroy Middlesex General Hospital in Strathroy, Ont, a rural community hospital that sees approximately 20 000 ED visits per year. PARTICIPANTS: A total of 2000 sequential ED visits, including adult and pediatric patients. The test group consisted of patients seen while a resident was present in the ED. The control group consisted of patients seen while no residents were present in the ED. MAIN OUTCOME MEASURES: Twenty-two distinct categories of common ED investigations were studied. RESULTS: There was no statistically significant difference between study groups for 19 of the 22 categories of investigations. There were significant differences in 3 categories: an increased number of D-dimer assays for patients seen while there were no residents in the ED (1.7% of patients vs 0.5% of patients, P = .03) and increased computed tomography and ultrasound imaging for patients seen while a resident was in the ED (4.8% vs 1.8%, P = .0012, and 5.3% and 1.7%, P < .001, respectively). These differences are likely not owing to resident involvement but are explained by a difference in test availability between groups. CONCLUSION: The study was underpowered for most categories of studied investigations. However, the trends demonstrated in this study suggest that the presence of family medicine residents in a rural community ED does not substantially affect the overall use of diagnostic investigations.

Mammography screening: how far is too far?

INTRODUCTION: This study answers the question: 'How far must a Canadian woman travel before the risk of a motor vehicle accident (MVA) outweighs the benefits of mammography screening?'. METHODS: Numbers needed to screen and false positive rates were extracted from information in the breast screening guidelines from the Canadian Task Force on screening for breast cancer. Motor vehicle accidents per billion vehicle kilometres were extracted from Transport Canada. The charts of women undergoing screening mammograms were reviewed to determine the average number of extra trips generated from a false positive mammogram. A formula was devised to determine when the distance travelled and risk of MVA outweighed the benefits of mammogram screening. RESULTS: How far a woman would need travel before the risk of that travel outweighed the benefits of screening mammography is determined by the province in which she lives (location) and her age. The distance of a round trip before the risk of travel outweighed the benefit of screening mammography varied from 65 km to 1151 km, according the patient's age and location. CONCLUSION: Travel risk is rarely discussed in recommending screening examinations. Nevertheless the benefits of screening can be outweighed by the risk of travel. Knowledge of travel risk is essential before recommending screening procedures.

Randomized trial of distance-based treatment for young children with discipline problems seen in primary health care.

OBJECTIVE: Many parents of preschool-age children have concerns about how to discipline their child but few receive help. We examined the effects of a brief treatment along with usual care, compared with receiving usual care alone. Patients. Parents (N = 178) with concerns about their 2- to 5-year olds' discipline were recruited when they visited their family physician at 1 of 24 practices. METHODS: After completing mailed baseline measures, parents were randomly assigned to receive usual care or the Parenting Matters intervention along with usual care. Parenting Matters combined a self-help booklet with two calls from a telephone coach during a 6-week treatment period. Follow-up assessments were completed at 7 weeks post-randomization, and 3 and 6 months later. RESULTS: Behaviour problems (Eyberg Child Behaviour Inventory) decreased significantly more in the Parenting Matters condition compared with Usual Care alone, based on a significant time by treatment group effect in intent-to-treat, growth curve analyses (P = 0.033). The Parenting Matters group also demonstrated greater and more rapid improvement than in usual care alone in terms of overall psychopathology (Child Behaviour Checklist, P = 0.02), but there were no group differences in parenting. The overall magnitude of group differences was small (d = 0.15 or less). CONCLUSION: A brief early intervention combining a self-help booklet and telephone coaching is an effective way to treat mild behaviour problems among young children. This minimal-contact approach addresses the need for interventions in primary health care settings and may be a useful component in step-care models of mental health.

Characteristics of chronic pain patients in a rural teaching practice.

OBJECTIVE: To describe the characteristics of chronic noncancer pain (CNCP) patients taking oxycodone or its derivatives in a rural teaching practice. DESIGN: Characteristics of CNCP patients taking oxycodone over a 5-year period (September 2003 to September 2008) were compared with those of patients not taking opioid medications using a retrospective chart audit. SETTING: A rural teaching practice in southwestern Ontario. PARTICIPANTS: A total of 103 patients taking chronic oxycodone therapy for CNCP and a random sample of 104 patients not taking opioid medication. MAIN OUTCOME MEASURES: Number of visits, health problems, sex, and previous history of addiction and mental illness. RESULTS: Patients with CNCP taking oxycodone had significantly more health problems (P < .001), including drug and tobacco addictions. They had more than 3 times as many clinic visits during the same period of time as patients not taking opioid medication (mean of 39.0 vs 12.8 visits, P < .001). CONCLUSION: Patients with CNCP in this rural teaching practice had significantly more health issues (P < .001) and were more likely to have a history of addiction than other patients were. They created more work with significantly more visits over the same period compared with the comparison group.

Patients' attitudes to comforting touch in family practice.

OBJECTIVE: To examine patients' attitudes to comforting touch in family practice. DESIGN: A survey was designed with statements and responses to proposed scenarios. SETTING: Twenty family practices throughout Ontario. PARTICIPANTS: Family practice patients; of 400 surveys distributed, 376 were completed (94% response rate). MAIN OUTCOME MEASURES: Patients responded to scenarios on a five-point Likert scale, ranging from strongly disagree to strongly agree. Results were analyzed using SPSS for DOS. RESULTS: Most patients in this population believed that touch can be comforting (66.3%) and healing (57.9%). Women were more accepting of comforting touch than men in all scenarios. Acceptance of comforting touch declined for both sexes as touch became proximal and more intimate. Men and women were more accepting of comforting touch from female doctors. Acceptance of all comforting touch declined markedly if a physician was unfamiliar to a patient, regardless of the physician's sex. CONCLUSION: Most patients surveyed believed touch is comforting and healing and viewed distal touches (on the hand and shoulder) as comforting.

The impact of hissy fits in primary care.

BACKGROUND: Hissy fits are experienced by physicians and patients alike, yet their full impact has never been studied before. METHODS: Specially trained researchers observed hissy fits at a clinic over 12 months. They interviewed perpetrators, victims and witnesses and recorded their comments because they had to. RESULTS: Hissy fits were common at the clinic and sometimes escalated to riots. Seasonal variations were endured. INTERPRETATION: Nobody likes this behaviour. Efforts should be made to counsel hissy fitters in channeling their angst in other, more positive ways.

Dilemma of rural obstetrics. One community's solution.

PROBLEM BEING ADDRESSED: Increasing workload and concerns about physician exhaustion necessitated reorganizing the delivery of obstetric services on Manitoulin Island in Ontario. OBJECTIVE OF PROGRAM: To organize obstetrics in a remote rural community to provide safe, accessible care, improve working conditions for local physicians, and involve the local hospital and health care workers in the solution. MAIN COMPONENTS OF PROGRAM: A prenatal clinic for all obstetric care on the island was established. It was based at the local hospital and organized by a nurse-midwife. Local physicians rotated through the clinic and provided obstetric coverage on their on-call days. CONCLUSIONS: The clinic has helped improve working conditions for local physicians and maintain high-quality obstetric care in this remote area. Local women's initial resistance to the clinic seems to be disappearing with time. Ongoing chart audits reveal intervention rates similar to those found in other Canadian studies of rural obstetric care.