[Bird watching among physicians]. / Quand le médecin rencontre l'oiseau : quelques similitudes entre la pratique clinique et l'ornithologie.

Bird watching can be an ideal activity for a physician. By their training, doctors may be more inclined than other professionals to take the time to observe birds. Medical studies provide basic knowledge, especially in biology and physics. Clinical training then teaches to watch, to listen. This article proposes a look at the similarities between medicine and ornithology : the importance of the meaning of observation, the identical « diagnostic ¼ approach, the use of an identical scientific methodology (participatory science), the impact of migration. It also recalls the balance that the practice of observation brings to physicians.

L'observation des oiseaux peut constituer une activité idéale pour le médecin. Par leur formation, les disciples d'Hippocrate sont peut-être plus enclins que d'autres professionnels à prendre le temps de les observer. Les études médicales apportent des connaissances de base, en biologie et physique notamment. La formation clinique nous apprend ensuite à regarder, à écouter. Cet article propose un regard sur les similitudes entre la médecine et l'ornithologie : importance du sens de l'observation, démarche « diagnostique ¼ identique, recours à une méthodologie scientifique identique (science participative), impact de la migration. Il rappelle également l'équilibre qu'apporte la pratique de l'observation aux médecins.

Adherence to recommended standards of diabetes care by Swiss primary care physicians.

OBJECTIVES: To assess adherence to recommended standards of diabetes care by Swiss primary care physicians. METHODS: Medical files of community-based primary care physician were reviewed to assess adherence to recommended standards of diabetes care. These standards of care were based on a uniform set of definitions addressing medical care processes involved in the detection and follow-up of pre-diabetic and diabetic patients. RESULTS: 186 physicians agreed to participate and 3,682 medical files were assessed. The prevalence of diabetes was 11% and 5% had impaired glucose tolerance (pre-diabetic). Screening of diabetes based on family or personal history was reported for 83% of the patients and on cardiovascular risk factors for 69%. Counselling for dietary changes was reported for 91% of diabetic patients and for 79% for physical activity, but only for 66% and respectively 60% of pre-diabetic patients. Among diabetic patients, regular HbA1c control was reported for 65%, yearly fundoscopy for 62%, yearly feet examination for 65%, yearly microalbuminuria control for 49%, regular blood pressure control for 96%, and yearly lipid profile for 89%. Regular screening of microangiopathic complications was reported for only 33% of diabetic patients. CONCLUSION: Adherence to recommended standards of diabetes care displayed important variations among this convenience sample of Swiss primary care patients. Screening and counselling of diabetic patients were frequent, whereas counselling for lifestyle changes of pre-diabetic patients and regular follow-up of microangiopathic complications among diabetic patients were suboptimal. These results could help to target areas of diabetes care that need to be addressed to improve adherence to recommended standards.

Importance of lifestyle counselling by primary care physicians for diabetic patients.

OBJECTIVE: To identify diabetic patients' characteristics and medical care factors associated with recommended glycaemic control (HbA(1c) < or =7%). METHODS: As part of a cross-sectional assessment of diabetes care involving 204 Swiss primary care physicians, we identified 366 diabetic patients with a recent HbA(1c) value. Cross-tabulations and X(2) tests were used to explore the association of patients' sociodemographic and disease characteristics and medical care characteristics with HbA(1c) < or =7%. Significant factors were included in a regression logistic model to identify multivariate predictors of HbA(1c) < or =7%. RESULTS: HbA(1c) values were in the recommended range for 57% of the patients. A less than five years' history of diabetes, absence of followup by a diabetes specialist, absence of microalbuminuria or retinopathy, adherence to dietary and physical activity counselling, no participation in a diabetic education programme, no glycaemic self-monitoring, oral or no antidiabetic therapy and influenza vaccine in the last 12 months were associated with HbA(1c) < or =7%. In the multivariate analysis, HbA(1c) < or =7% remained associated with a less than five years diabetes history (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.5-4.3), as well as patients' adherence to dietary (OR 1.9, 95% CI 1.2-3.0) and physical activity counselling (OR 1.8, 95% CI 1.1-2.9). CONCLUSION: In this sample of diabetic patients, adherence to dietary and physical activity counselling were associated with better glycaemic control. Further research should focus on the importance of appropriate lifestyle counselling by Swiss primary care physicians, ideally in prospective trials using objective and reproducible measures of patients' observance.

Osteoporosis case finding in the general practice: phalangeal radiographic absorptiometry with and without risk factors for osteoporosis to select postmenopausal women eligible for lumbar spine and hip densitometry.

Mass screening for osteoporosis using DXA measurements at the spine and hip is presently not recommended by health authorities. Instead, risk factor questionnaires and peripheral bone measurements may facilitate the selection of women eligible for axial bone densitometry. The aim of this study was to validate a case finding strategy for postmenopausal women who would benefit most from subsequent DXA measurement by using phalangeal radiographic absorptiometry (RA) alone or in combination with risk factors in a general practice setting. The sensitivity and specificity of this strategy in detecting osteoporosis (T-score < or =2.5 SD at the spine and/or the hip) were compared with those of the current reimbursement criteria for DXA measurements in Switzerland. Four hundred and twenty-three postmenopausal women with one or more risk factors for osteoporosis were recruited by 90 primary care physicians who also performed the phalangeal RA measurements. All women underwent subsequent DXA measurement of the spine and the hip at the Osteoporosis Policlinic of the University Hospital of Berne. They were allocated to one of two groups depending on whether they matched with the Swiss reimbursement conditions for DXA measurement or not. Logistic regression models were used to predict the likelihood of osteoporosis versus "no osteoporosis" and to derive ROC curves for the various strategies. Differences in the areas under the ROC curves (AUC) were tested for significance. In women lacking reimbursement criteria, RA achieved a significantly larger AUC (0.81; 95% CI 0.72-0.89) than the risk factors associated with patients' age, height and weight (0.71; 95% C.I. 0.62-0.80). Furthermore, in this study, RA provided a better sensitivity and specificity in identifying women with underlying osteoporosis than the currently accepted criteria for reimbursement of DXA measurement. In the Swiss environment, RA is a valid case finding tool for patients with risk factors for osteoporosis, especially for those who do not qualify for DXA reimbursement.

Prevalence rate and reasons for refusals of influenza vaccine in elderly.

More knowledge on the reasons for refusal of the influenza vaccine in elderly patients is essential to target groups for additional information, and hence improve coverage rate. The objective of the present study was to describe precisely the true motives for refusal. All patients aged over 64 who attended the Medical Outpatient Clinic, University of Lausanne, or their private practitioner's office during the 1999 and 2000 vaccination periods were included. Each patient was informed on influenza and its complications, as well as on the need for vaccination, its efficacy and adverse events. The vaccination was then proposed. In case of refusal, the reasons were investigated with an open question. Out of 1398 patients, 148 (12%) refused the vaccination. The main reasons for refusal were the perception of being in good health (16%), of not being susceptible to influenza (15%), of not having had the influenza vaccine in the past (15%), of having had a bad experience either personally or a relative (15%), and the uselessness of the vaccine (10%). Seventeen percent gave miscellaneous reasons and 12% no reason at all for refusal. Little epidemiological knowledge and resistance to change appear to be the major obstacles for wide acceptance of the vaccine by the elderly.

Improving influenza vaccination rates in the elderly.

BACKGROUND: Vaccination coverage for influenza in the elderly remains low when the physician is the only person responsible for immunization. Integration of other health care workers may improve the coverage rate of at-risk groups. OBJECTIVES: To estimate vaccination coverage rate by using a strategy based on the systematic intervention of a health care professional proposing vaccination before the doctor's consultation, to evaluate the changes in coverage rates before and after introduction of this strategy, and to assess the feasibility of this intervention and the achieved coverage rate in family physician offices. STUDY DESIGN: Prospective study in a medical outpatient clinic and 5 family physician practices in Switzerland. POPULATION: Participants consisted of all patients 65 years or older attending a medical outpatient clinic during the vaccination period in 1999 (n = 401), patients 65 years or older regularly followed at a medical outpatient clinic in 1998 and 1999 (n = 195), and patients 65 years or older presenting to 5 family physician offices in 1999 (n = 598). OUTCOME MEASURED: Rates of vaccination coverage. RESULTS: Among all participants, vaccination coverage rates in 1999 were 85% at the medical outpatient clinic and 83% in family physician offices. Among participants regularly followed at the medical outpatient clinic, vaccination coverage increased from 48% in 1998 to 76% in 1999. Rates of refusal were 9% at the medical outpatient clinic and 14% in the family physician offices. CONCLUSIONS: The systematic intervention of a health care professional to suggest vaccination before the doctor's visit is an effective measure to achieve high coverage rate. Such a strategy also improves outpatient clinic or private practice efficiency by reducing pressures on physicians.