Why do some women bypass their family physician in seeking preventive care?: a qualitative study [abstract]

The Health Watch clinic at Women's College Hospital, Toronto, provides screening and preventive services primarily to women in Ontario. These services can be seen as a duplication of those that can be provided by family physicians. Nevertheless, some Ontario women continue to bypass their family physicians and attend this clinic. This study was done to understand the decision-making processes women go through in deciding to bypass their family physician when seeking preventive health services and to understand which features of this model of preventive care are so attractive. Seventeen women attending the Health Watch Clinic agreed to participate. In-depth interviews were carried out until saturation was achieved. The interviews were taped and later transcribed. The data were analyzed using qualitative methods, specifically, grounded in theory. Emergent themes were extracted while listening to tapes and reading transcripts. Themes were discussed between researchers and an agreement was arrived at. These themes were relayed back to participants to confirm interpretation. The emerging themes suggest that women bypass the family physician for several reasons, including: "Women negative" experiences, the inherent qualities of the woman, such as her locus of control, normative influences, and perceived positive aspects of the Health Watch Clinic and the Women's College Hospital. The findings suggest that women who bypass their family doctor have generally had a negative experience with the traditional healthcare system. The women in this study were highly educated with high internal motivation and tended to have extensive family and friend support and advice regarding health matters. (AU)

Taking the first steps. Research career program in family medicine.

PROBLEM BEING ADDRESSED: Research is not new to family medicine, yet it is pursued less than in other clinical disciplines. We need to establish a critical mass of family medicine researchers. OBJECTIVE OF PROGRAM: To establish a departmental research organization using a strategy implemented in 1995 by the Department of Family and Community Medicine at the University of Toronto. MAIN COMPONENTS OF PROGRAM: We set out to establish a critical mass of researchers. Applicants were required to complete credible and feasible 3- to 5-year research plans and to have formal support from their clinical chiefs. Once selected, researchers were supported for 40% of their time. Support was provided for 3 years and was renewable according to progress on their research plans. Researchers were expected to publish on average two papers yearly and be involved as principal investigator or co-principal investigator on at least one successful grant after the first 3 years. Since implementation in 1996, funded researchers have become principal investigators in 80% of the grants in which they are involved compared with 20% before the support program. Nine of 15 Medical Research Council grants held by family physicians in Canada have department members as principal investigators. Faculty-supported researchers contributed more than 200 peer-reviewed publications to the literature between 1996 and 2000. CONCLUSION: Four years of experience allows for early assessment of the first step taken to build a thriving family medicine research organization using limited departmental resources.

Canadians without regular medical doctors. Who are they?

OBJECTIVE: Because having a regular medical doctor is associated with positive outcomes, this study attempted to determine the characteristics of Canadians without regular doctors so that alternative methods of delivering care to people with those characteristics can be studied. DESIGN: Secondary data analysis of the National Population Health Survey using bivariate analyses and logistic regression. PARTICIPANTS: A total of 15,777 respondents older than 20 years. MAIN OUTCOME MEASURES: Responses to the question "Do you have a regular medical doctor?" and analysis of 11 variables covering demographics, health status, and lifestyle factors. RESULTS: One in seven respondents did not have a regular doctor. Younger respondents, men, single people, poorer respondents, respondents who perceived themselves in better health, recent immigrants, those without confidants, and smokers were more likely not to have regular doctors. Comparing provinces, participants from Quebec were least likely to have regular doctors. CONCLUSION: Primary care reform might need to consider alternative ways of providing care to certain people. Future primary care programs could be targeted to improve coverage of relatively underserviced people, particularly men, people on low incomes, those without confidants, and recent immigrants.

Does having regular care by a family physician improve preventive care?

OBJECTIVE: To assess whether regular care from a family physician is associated with receiving preventive services. DESIGN: Secondary analysis of the 1994 National Population Health Survey. SETTING: Cross-sectional sample of the Canadian population. PARTICIPANTS: A total of 15,731 non-institutionalized adults. MAIN OUTCOME MEASURES: Reported visits to general practitioners and specialists in the previous year and reports of having had blood pressure measurements, mammography, and Pap smears. RESULTS: A graded relationship was observed between level of regular care by a family physician in the previous year (none, some, regular) and receiving preventive services. Those without regular doctors and those reporting only some care by a family physician were less likely to have ever had their blood pressure checked than adults receiving ongoing care from a regular family physician. Women reporting some or no care were less likely to have had mammography within 2 years or to have ever had Pap smears. CONCLUSION: Adults who receive regular care from a family physician are more likely to receive recommended preventive services.

Why don't men seek help? Family physicians' perspectives on help-seeking behavior in men.

BACKGROUND: Men tend to underuse primary care health services despite their susceptibility to particular types of illness. The purpose of this study was to report the family physician's perspective on why men do not access the health care system for medical problems. METHODS: We used focus group interviews to identify major themes. The participants were family physicians in active practice randomly selected from a list of 500 full- and part-time teachers. Four focus groups were formed from 18 participants (12 men, 6 women), in practice an average of 17 years. Eleven of the physicians were in community practice. RESULTS: Three key themes were identified: (1) Support: Men appear to get most of their support for health concerns from their female partners, little from their male friends. Their pattern of seeking support tends to be indirect rather than straightforward. (2) Help Seeking: Perceived vulnerability, fear, and denial are important influences on whether men seek help. They look for help for specific problems rather than for more general health concerns. (3) Barriers: Personal barriers involved factors related to a man's traditional social role characteristics: a sense of immunity and immortality; difficulty relinquishing control; a belief that seeking help is unacceptable; and believing men are not interested in prevention. Systematic barriers had to do with time and access; having to state the reason for a visit; and the lack of a male care provider. CONCLUSIONS: Many of these findings are supported by psychological theories. Future research should apply these theories in more transferable populations and settings. However, an in-depth understanding of the patterns of men's use of primary care services is needed before we can determine if a regular source of primary care would have a positive impact on their health.

Five Weekend National Family Medicine Fellowship. Program for faculty development.

PROBLEM ADDRESSEDMany faculty development programs are thought time-consuming and inaccessible to academic family physicians or physicians wanting to move into academic positions. This is largely due to difficulty in leaving their practices for extended periods. Canadian family medicine needs trained leaders who can work in teams and are well grounded in the principles of their discipline as they relate to education, management, research, and policy making.OBJECTIVE OF PROGRAMTo develop a team of leaders in family medicine.MAIN COMPONENTS OF PROGRAMThe Five Weekend National Family Medicine Fellowship Program focuses on the essentials of education, management, communication, critical appraisal skills, and the principles of family medicine to develop leadership and team-building skills for faculty and community-based family physicians entering academic careers. This unique 1-year program combines intensive weekend seminars with small-group projects between weekends. It emphasizes a broader set of skills than just teaching, has regional representation, and focuses on leadership and teamwork using a time-efficient format.CONCLUSIONThe program has graduated 34 Fellows over the last 3 years. More than 90% of the 35 projects developed through course work have been presented in national or provincial peer-reviewed settings. Quantitative ratings of program structure, course content, and course outcomes have been positive.

Transition to parenthood. What about fathers?

Family physicians are in a strategic position to help couples adjust to the many changes that occur during the transition to parenthood. We review some of the issues for fathers at this time and suggest strategies for family physicians for including fathers and assisting couples to adjust to the changes in the interest of promoting healthy families.

Applying the concept of the reflective practitioner to understanding and teaching family medicine.

This article contends that what makes family practice unique as a medical specialty is not so much its content (eg, continuity of care, broad range of patient population) as it is the process of clinical practice (ie, how the specialty is actually practiced in ongoing patient encounters). However, insufficient attention has been paid to critically analyzing and interpreting this process. We present a model derived from other "practice professions," such as architecture, known as reflection-in-action. This model is offered as a way of first apprehending and subsequently teaching the "professional artistry" which constitutes a critical component of family practice. Specific teaching approaches designed to enhance reflective medical practice are delineated.

Vive la Difference: Undergraduate teaching experience in the inner city.

Physicians meet clients with special challenges and lifestyles in their daily practice. "Vive la Difference," a selective program offered at the University of Toronto to first-year medical students, attempted to increase student awareness of their own attitudes toward their inner-city clients. The authors outline the content and process of this teaching experience.

Understanding Dying Patients and Their Families: Using the family FIRO model.

Caring for dying patients and their families presents unique opportunities and challenges for the family physician. The family FIRO model provides a simple way of assessing families and providing appropriate, individualized care. This article outlines the model, discusses the care of dying patients and their families from the FIRO perspective, and provides a guideline for the family physician. A framework is suggested for teaching residents to support families.

Improving Feedback for Medical Students in a Family Medicine Clerkship: Evaluating medical student performance using frequent feedback.

To evaluate whether feedback to medical students could be improved by asking teachers to complete a student performance rating form during a family practice clerkship, the authors had students and teachers fill out a questionnaire. Teachers in the intervention group reported observing students more frequently. Students' perceptions of feedback frequency correlated strongly with their ratings of feedback quality.

Hypnosis training enhances communication skills.

We hypothesized that attending a brief, introductory hypnosis training workshop enhances communication skills. We speculated that attending such a programme would enable residents in a Family Medicine training programme to identify the psycho-social concerns of their patients more rapidly. To test the hypothesis five residents were videotaped interviewing a standardized patient before and after attending a hypnosis workshop. A blinded observer reviewed the tapes. The observer counted the number of comments made by the residents on their patient's non-verbal behaviour and the time required to confront the patient's primary concern. The residents made more comments on their patient's non-verbal communication after training than before, and more than the controls. They also shortened the time until they addressed the primary concern. This difference was not statistically significant. There was however a strong negative correlation (r = -0.92) between the number of these comments made and the time required to unveil the patient's hidden agenda. An increased awareness of non-verbal cues, achieved through hypnosis training, appears to help reveal a patient's hidden agenda. The implications of these findings are discussed.

Family Orientation in Family Medicine Training: A survey of Canadian programs.

Teaching about the family has become an important part of the family medicine curriculum. The family orientation index, a 39-item questionnaire, was designed to evaluate the family orientation of services and care provided as well as the teaching and research. The questionnaire was distributed to 55 program directors at 16 Canadian universities. The response rate was 84%. The results indicate that the family orientation of services is less than optimal.

Assessing postpartum family functioning.

The birth of a child requires adaptation and reorganization within the family system in order to accommodate the new family member and to allow the family to continue in its psychosocial development. Knowledge of the normative and transitional changes required at this stage of family life will enhance family practitioners' understanding of some of the common concerns and complaints related to them by various family members during the postpartum period. The Family FIRO model represents a helpful conceptual framework to increase the family physician's understanding of the issues of inclusion, control, and intimacy that are highlighted during the transition to parenthood. The authors briefly present this model and discuss its application to postpartum adjustment and its implications for health-care professionals.

Assessing the single-parent family.

The increase of single-parent families causes an increase in psychosocial problems and illness associated with stress. Divorce, separation, and lone parenting have now surpassed death as a cause of single-parent families. They are major life events, and the family physician who helps anticipate them and facilitates adaptation of the family can help prevent associated morbidity and mortality. A non-judgmental approach and understanding of system theory helps in assessing the single-parent family and its stresses. As in medical areas, diagnosis precedes treatment, appropriate assessment indicates management strategies. The acronym 'PRACTICE' describes an assessment tool for the areas likely to be problematic in single-parent families. The difference between the divorced, widowed and the never-married and their coping strategies are described.

Eating difficulties in the toddler and preschool child.

Parents frequently bring toddlers and preschool children with eating problems to the family physician. Eating problems are seldom caused by major, organic pathology. Eating is a cultural and social activity; children's nutritional history, their growth and development and the role of the family in defining, maintaining and/or resolving the problem are important components in the management of eating difficulties. The family doctor can help the family cope by giving information, specific suggestions, and support. Referral to a nutritionist may be necessary if the problem is complex or prolonged.

Anorexia nervosa: a lifestyle disorder.

Anorexia nervosa is a real lifestyle disorder. The apparent increase in frequency has been linked to the change of position of women in society. If families have an important role to play in the maintenance of the drama, they also hold the key to its resolution. The family physician in early contact with the anorectic patient is in an important position to involve the family in therapy and maximize the chances of recovery. The steps required are reframing, preparing the family involved for family therapy, exploring the benefits of change, and follow up.