What is so difficult about managing clinical reasoning difficulties?

CONTEXT: Clinical reasoning is the cornerstone of medical competence. Difficulties in this area are often identified late in clinical training. Studies point to challenges faced by clinical educators in their dual roles as clinicians and educators. Little is known about the common, yet complex, issue of how they manage clinical reasoning difficulties. We therefore sought to: (i) describe the current state of affairs in various clinical teaching settings, and (ii) explore the factors that determine the behaviour of clinical educators in this respect. METHODS: Four focus groups were conducted with 26 clinical educators in general practice, internal medicine and emergency medicine in Belgium and Switzerland. Two researchers analysed the transcripts of the focus group discussions using Fishbein's integrative model of behaviour prediction in a theory-driven, immersion-crystallisation process. Experienced faculty members validated the findings. RESULTS: Across diverse settings, the process of identifying and remediating clinical reasoning difficulties was unstructured. Consistent with Fishbein's model, clinical educators' underlying beliefs determined their behaviour. They believed in the apprenticeship model of learning in the clinical environment, in which their educational role was limited to role-modelling and in which residents were responsible for assimilating skills. They were sceptical about the potential impact of remediation. A few more knowledgeable supervisors had a stronger sense of their educational role, but did not implement systematic procedures to manage clinical reasoning difficulties. Environmental constraints were symptomatic of a collective paradigm of residency as an apprenticeship, in which the focus is on clinical duties, rather than as an educational programme. CONCLUSIONS: In order to improve the current state of affairs in the management of clinical reasoning difficulties, a collective paradigm shift is required to alter the perception of residency as an apprenticeship to one of residency as a structured educational programme. Faculty development programmes should be designed in an integrated way so that they not only develop clinical educators' skills, but also modify their beliefs.

Can we import quality tools? a feasibility study of European practice assessment in a country with less organised general practice.

BACKGROUND: Quality is on the agenda of European general practice (GP). European researchers have, in collaboration, developed tools to assess quality of GPs. In this feasibility study, we tested the European Practice Assessment (EPA) in a one-off project in Belgium, where general practice has a low level of GP organisation. METHODS: A framework for feasibility analysis included describing the recruiting of participants, a brief telephone study survey among non-responders, organisational and logistic problems. Using field notes and focus groups, we studied the participants' opinions. RESULTS: In this study, only 36 of 1000 invited practices agreed to participate. Co-ordination, administrative work, practice visits and organisational problems required several days per practice. The researchers further encountered technical problems, for instance when entering the data and uploading to the web-based server. In subsequent qualitative analysis using two focus groups, most participant GPs expressed a positive feeling after the EPA procedure. In the short period of follow-up, only a few GPs reported improvements after the visit. The participant GPs suggested that follow-up and coaching would probably facilitate the implementation of changes. CONCLUSION: This feasibility study shows that prior interest in EPA is low in the GP community. We encountered a number of logistic and organisational problems. It proved attractive to participants, but it can be augmented by coaching of participants in more than a one-off project to identify and achieve targets for quality improvement. In the absence of commitment of the government, a network of universities and one scientific organisation will offer EPA as a service to training practices.

What does it mean to be a family physician?: Exploratory study with family medicine residents from 3 countries.

OBJECTIVE: To explore the conceptions that family medicine residents from 3 countries have of the roles and responsibilities of family physicians in order to gain a better understanding of challenges that might transcend the specific contexts of different health care systems. DESIGN: Qualitative study using focus groups. SETTING: Resident training programs in France, Belgium, and Canada. PARTICIPANTS: A total of 57 residents in the last year of training. METHOD: Ten focus groups were conducted in 3 countries: 2 in France, 3 in Belgium, and 5 in Canada. All focus groups were held in different cities, with residents registered in different universities in France and Canada and with residents from the same university in Belgium. The study was informed by Abbott's conceptual framework on the system of professions. Each 90-minute focus group was moderated by the same researchers. The transcripts were analyzed according to the immersion-crystallization method. MAIN FINDINGS: Respondents shared common conceptions of the family physician's role: continuity of care and patient advocacy were seen as the foundations of the discipline. Respondents also shared a sense of discomfort about how accessible they were expected to be for patients and about the scope of family practice. They saw family medicine as flexible and reported that they strove for balance between their professional and personal life goals. All respondents strongly believed that their profession was undervalued by the medical schools where they trained. CONCLUSION: This exploratory study suggests that there are more similarities than differences in the understanding that future family physicians from different countries have of their discipline and of their careers. We observed a tension between a desire to develop a "new general practice" and the more traditional vision of the discipline. The culture in academic settings appears to contribute to the persistent low appeal of being a primary care physician.

The development of self-efficacy beliefs during general practice vocational training: an exploratory study.

INTRODUCTION: Retention of general practitioners (GPs) is crucial to ensure appropriate primary care. However, some recently qualified GPs feel unprepared for practice, which may lead them to leave the profession or restrict their scope of practice. The development of self-efficacy beliefs during vocational training may be an important factor in this phenomenon. METHODS: Five focus groups with a total of 28 GP trainees and recent graduates were conducted in Belgium and France. Initial analysis using the immersion-crystallisation method was followed by analysis using Bandura's self-efficacy framework. RESULTS: Participants described beginning their training with low self-efficacy beliefs. Most participants described how they overcame stressful situations. Some, however, seemed to be developing avoidance strategies. Successfully resolving patient problems, sharing experiences with peers and receiving positive feedback from supervisors, colleagues and patients were conducive to the development of positive self-efficacy beliefs. DISCUSSION: Although low self-efficacy beliefs are natural at the beginning of training, participants seemed to develop in two ways, either overcoming their fears or avoiding them. Identifying the pattern of trainees' responses to allow tailoring of interventions should be investigated by those who run training programs. Interventions could include reassurance, peer interaction and an appropriate degree of autonomy.

High and variable use of primary care in prison. A qualitative study to understand help-seeking behaviour.

BACKGROUND: High and variable rates of attendance at GP consultations in prisons are observed. The aim of the study is to have a clearer understanding of social factors influencing inmates' help-seeking behaviour and demand for primary health care. METHODS: A qualitative study was carried out in five Belgian prisons (three Dutch-speaking and two French-speaking). Twenty-five male inmates were interviewed face-to-face and 18 caregivers (7 nurses and 11 GPs) in focus groups. RESULTS: Five main social factors explain inmates' help-seeking behaviour and demand for primary health care: (1) inmates' negative perception of imprisonment increases help-seeking behaviour; (2) inmates use their rights to health care as strategies to maintain some form of control over their lives; (3) the doctor's role distorts expression of need and demand; (4) health professionals' control over inmates' lives creates mistrust and a controlling therapeutic relationship; and (5) lack of alternatives to health care. These factors are mutually dependent and cause a confrontation in the inmates' and clinicians' agendas. CONCLUSION: The most important recommendation is to understand what the inmates are really seeking in their demands. This information can be used to develop appropriate alternatives in terms of human support and well-being facilities. The therapeutic and security roles of health care workers should be separated, in order to increase the trust that is central to the therapeutic relationship between them and inmates.

General practice as seen through the eyes of general practice trainees: a qualitative study.

OBJECTIVE: To explore the perceptions of general practice trainees regarding their discipline and to compare these spontaneously expressed views with recently proposed definitions of general practice. MATERIAL AND METHODS: A qualitative focus-group study was conducted in one Belgian and two French medical schools. Twenty-eight trainees took part (16 from Belgium and 12 from France). The transcripts were analysed by the immersion crystallization method. RESULTS: The participants in this study seemed prepared to take on the many responsibilities outlined in various definitions of general practice, but feared personal commitment to accessibility and continuous care. Being skilled clinicians and patients' advocates formed their "raison d'être" in the healthcare system. They were reluctant to act as gatekeepers within the system, a role that might jeopardize their advocacy function for their patients. They mentioned the lack of appeal of entrepreneurship aspect of practice. Participants reported that training settings typically offer traditional models of practice, which sometimes led them to feel estranged from a profession that they felt needs reorganization. CONCLUSIONS: Participants' descriptions generally coincided with official definitions of general practitioners' tasks, except for practice management and gate-keeping aspects. They were willing to accept the burden of general practice as long as responsibility could be shared and as long as there was freedom for flexible progress along a modern career track.

Teenagers and their family practitioner: matching between their reasons for encounter.

OBJECTIVES: The aim of this study was to analyse the reasons for encounter of teenagers in family practice and to compare them with the reasons recorded by their family practitioner (FP). METHODS: This cross-sectional study involved 91 FPs from the Paris area and from the French-speaking part of Belgium. The teenagers (12-17 years old) filled in an auto-administered questionnaire in the waiting room of their FP during a 1-week period. The doctor independently filled in a similar form after the consultation. Both questionnaires were matched afterwards to assess the concordance between the reasons for encounter recorded by the young patient and by his/her FP. RESULTS: More than 100 reasons for encounter were given by 457 teenagers. The majority of the complaints were respiratory (26%), general health (18.5%), osteoarticular (15%), digestive (11%) and neurological problems (9.5%). Gender did not influence the nature of the complaints, but age played a role. The older teenagers had more respiratory complaints, general and pregnancy/contraception problems. In 80% of the cases, the ailments listed by the teenagers were picked up by the practitioner. In 18% of the consultations, the FP recorded problems that had not been noted by the patient. CONCLUSION: Many common and a few serious although frequent youth problems were found among the reasons for encounter. Most of them were recorded by the practitioner. Time and communication skills are important to give the opportunity to the teenager to share sensitive topics with his/her FP.

GPs working in solo practice: obstacles and motivations for working in a group? A qualitative study.

OBJECTIVE: Our aim was to analyse the obstacles and eventual motivations of solo GPs for working in group practice. METHODS: A qualitative study using 12 focus groups was carried out in primary care in French-speaking Belgium. The subjects comprised four samples of GPs: 20 GP trainers, 18 GP trainees, 25 women GPs and 25 other GPs. The focus groups were taped and transcribed. Two independent researchers carried out the analysis using the QSR NUD.IST software. RESULTS: The participants (88 GPs) did not share a common definition of group practice-in particular multidisciplinary working-the need for a common pool of patients and shared premises. Their main sources of motivation for eventually setting up a group practice were better quality of life, continuity of care and sharing professional knowledge. The main obstacles were a required agreement between colleagues, the loss of a personal patient-GP relationship, budgetary constraints, and divergent views on group practice and GPs' profession (especially true for the association of GPs from different age groups). CONCLUSION: The current study shows that GPs working solo have divergent views of group practice. However, they clearly perceive advantages to this type of association (e.g. better quality of life and continuity of care). This study also confirms the high level of stress and tiredness felt by GPs and especially senior practitioners.