Acceptability and feasibility of an evaluation table to assess the competency of general medicine interns during ambulatory rotations in Brest.

BACKGROUND: General practitioner interns need to acquire the expected clinical, communication, personal and professional competencies. Internship evaluations use qualitative evaluation tables to assess competency acquisition. However, there is no standardised evaluation table used in France. Some faculties use the exhaustive, precise, and manageable Exceler evaluation tool. We aim to evaluate opinions of General practice interns in Brest about the acceptability and feasibility of using the Exceler evaluation tool to monitor competency acquisition during internships. METHODS: This qualitative study used intern focus groups. Six-open ended questions with optional follow-up questions were asked. Cards from the Dixit® game were used to guide and facilitate discussion. Open, axial, then integrative analysis of the verbatim was performed. RESULTS: This is the first study to evaluate intern opinions about GP internship evaluations using focus groups. Participants felt that the quality of existing evaluations was insufficient, and it was difficult to monitor their progress. Adapting evaluations to individual profiles and backgrounds seemed necessary. Exceler appeared to be a possible solution due to its content validity, flexibility of use and accessibility. However, there were comments about possible modifications. CONCLUSIONS: Analysing opinions of tutors, supervisors and other practice centers could help identify potential barriers and reveal solutions to facilitate its implementation and use. TRIAL REGISTRATION: Not applicable.

Practical dietary interventions to prevent cardiovascular disease suitable for implementation in primary care: an ADAPTE-guided systematic review of international clinical guidelines.

PURPOSE: Cardiovascular diseases (CVD) are the leading cause of death globally. The current model of care for high-income countries involves preventive medication and highly trained healthcare professionals, which is expensive and not transposable to low-income countries. An innovative, effective approach adapted to limited human, technical, and financial resources is required. Measures to reduce CVD risk factors, including diet, are proven to be effective. The survey "Scaling-up Packages of Interventions for Cardiovascular disease prevention in selected sites in Europe and Sub-Saharan Africa" aims to develop non-pharmacological cardiovascular prevention and control programs in primary care and community settings in high, middle, and low-income countries. This review aims to identify the existing, validated dietary interventions for primary CVD prevention from national and international clinical guidelines that can be implemented in primary care and communities. METHODS: A systematic review of CVD prevention guidelines was conducted between September 2017 and March 2023 using the Turning Research Into Practice medical database, the Guidelines International Network, and a purposive search. The ADAPTE procedure was followed. Two researchers independently conducted the searches and appraisals. Guidelines published after 01/01/2012 addressing non-pharmacological, dietary interventions for primary CVD prevention or CVD risk factor management, in the adult general population in primary care or in community settings were included and appraised using the Appraisal of Guidelines Research and Evaluation II score. Individual dietary recommendations and the studies supporting them were extracted. Then supporting data about each specific dietary intervention were extracted into a matrix. RESULTS: In total, 1375 guidelines were identified, of which 39 were included. From these, 383 recommendations, covering 10 CVD prevention themes were identified. From these recommendations, 165 studies for effective dietary interventions for CVD prevention were found. Among these, the DASH diet was the most effective on multiple CVD risk factors. Combining diet with other interventions such as exercise and smoking cessation increased efficacy. No guidelines provided detailed implementation strategies. CONCLUSION: The DASH diet combined with other interventions was the most effective on an individual basis. However, expansion in the wider population seems difficult, without government support to implement regulations such as reducing salt content in processed food. TRIAL REGISTRATION: Clinical Trials NCT03886064.

Heart disease is the leading cause of death around the world. Strategies to prevent heart disease in high-income countries rely on medications and the skills of highly trained healthcare professionals. However, this is expensive and unsuitable for low-income countries. Consequently, an innovative, effective approach, which can be adapted to countries with limited human, technical and financial resources is needed. A program called SPICES was developed to identify strategies other than medication to prevent and control heart disease. This program reviewed the evidence for smoking cessation, physical activity, and dietary strategies, which may be useful to prevent heart disease in communities with limited resources.In this review, the investigators searched online databases to find clinical guidelines that recommended dietary strategies to manage heart disease worldwide. The information found from this search revealed that the DASH diet, inspired by the Mediterranean diet, helps with weight loss, and improves blood pressure and cholesterol levels making it the most effective diet for preventing heart disease. It is even more effective if it is combined with other strategies such as exercise, stopping smoking or reducing the amount of alcohol consumed. However, this works well for individuals but is difficult to expand to the wider population. Therefore, government support is needed to implement regulations such as reducing salt content in processed food.

Changes in Alcohol Consumption after 1 Year of the COVID-19 Pandemic: A Cross-Sectional Study in a Region of France.

BACKGROUND: There is conflicting evidence on how the COVID-19 pandemic changed patterns of alcohol consumption. While some studies have suggested that alcohol consumption decreased at the beginning of the pandemic, there are limited data for a longer period. The objective of this study was to investigate changes in alcohol consumption 1 year after the onset of the COVID-19 pandemic in France, and to identify vulnerable subgroups in a French adult population. METHODS: This was a single-center, cross-sectional, descriptive study. Self-reported changes in alcohol consumption were collected from 2491 respondents in a survey carried out in western Brittany from 18 January to 9 March 2021. RESULTS: Of respondents, 27.64% reported that they had increased their alcohol consumption, 14.7% had decreased, 3.94% had ceased, and 53.72% reported no change in their alcohol consumption. Increased alcohol use was associated with male gender, age 26 to 44 years, living with a family, not being a health professional, having had a physical or psychological health problem during lockdowns, smoking tobacco, and using cannabis. Reduced alcohol use or cessation was associated with male gender, age 18 to 25 years, living in Brest, living alone, and using cannabis. CONCLUSIONS: Our study suggests that during the COVID-19 pandemic, a significant number of people increased their alcohol consumption in France, even outside lockdowns. These results should encourage health professionals and public authorities to implement more specific prevention measures to limit the risks associated with alcohol consumption.

A systematic literature review of patient self-assessment instruments concerning quality of primary care in multiprofessional clinics.

BACKGROUND: Quality of care remains a priority issue and is correlated with patient experience. Measuring multidimensional patient primary care experiences in multiprofessional clinics requires a robust instrument. Although many exist, little is known about their quality. OBJECTIVE: To identify patient perception instruments in multiprofessional primary care and evaluate their quality. METHODS: Systematic review using Medline, Pascal, PsycINFO, Google Scholar, Cochrane, Scopus, and CAIRN. Eligible articles developed, evaluated, or validated 1 or more self-assessment instruments. The instruments had to measure primary care delivery, patient primary care experiences and assess at least 3 quality-of-care dimensions. The COnsensus-based Standards for the selection of health status Measurement Instruments (COSMIN) checklist was used to assess methodological quality of included studies. Instrument measurement properties were appraised using 3 possible quality scores. Data were combined to provide best-evidence synthesis based on the number of studies, their methodological quality, measurement property appraisal, and result consistency. Subscales used to capture patient primary care experiences were extracted and grouped into the 9 Institute of Medicine dimensions. RESULTS: Twenty-nine articles were found. The included instruments captured many subscales illustrating the diverse conceptualization of patient primary care experiences. No included instrument demonstrated adequate validity and the lack of scientific methodology for assessing reliability made interpreting validity questionable. No study evaluated instrument responsiveness. CONCLUSION: Numerous patient self-assessment instruments were identified capturing a wide range of patient experiences, but their measurement properties were weak. Research is required to develop and validate a generic instrument for assessing quality of multiprofessional primary care. TRIAL REGISTRATION: Not applicable.

Good quality health care should be safe, effective, timely, efficient, equitable, and patient-centred. Patients describing their health care experience provides information about the quality of health care. Patient health care experiences can be recorded using questionnaires. These questionnaires measure specific aspects of the health care experience such as communication and timeliness, as well as their experience within a multiprofessional clinic, where different health professionals work together. These specific measurements evaluate how health care affects the patient's experience. However, more information is needed to understand which questionnaires are the most appropriate to evaluate patient experience. The objective of this systematic review study is to identify the number of patient experience questionnaires available and evaluate their effectiveness. Researchers examined different literature databases to identify questionnaires which measure primary care delivery, patient primary care experiences and assess at least 3 aspects of quality of care. Twenty-nine questionnaires were found which measured a wide range of patient experiences but none of them were found to be sufficient to understand all aspects of patient experience. An effective questionnaire needs to be developed and validated to assess quality of primary care in multiprofessional practices.

Talking about premature ejaculation in primary care: the GET UP cluster randomised controlled trial.

BACKGROUND: Premature ejaculation (PE) is the most common sexual dysfunction in males. A previous qualitative study identified six communication strategies described by GPs to tackle this topic during consultations. AIM: To determine whether these six strategies are more effective than usual care for promoting discussion about PE between patients and their GPs. DESIGN AND SETTING: Cluster randomised controlled trial, stratified in four French regions, with an intervention group (GPs who received a training session on the six communication strategies) and a control group (routine medical care). Participants were males aged 18-80 years consulting for a sexual, urogenital, or psychological reason. METHOD: The efficacy of the training session in communication skills, compared with usual care, was evaluated by determining the percentage of patients who discussed PE with their GP (primary outcome). The percentage of enrolled patients with PE was calculated using a cut-off score >9 of the premature ejaculation diagnostic tool (PEDT) completed by the enrolled patients at Week 4 after the consultation. The quality-of-life changes were evaluated as the SF-12 scale score difference between baseline and Week 4 post-consultation. RESULTS: In total, 130 patients were included by 32 GPs (n = 16 in the intervention and n = 16 in the control group). The percentage of patients who discussed PE was higher in the intervention group than in the control group (42.0% versus 4.9%, absolute difference = 37.1%; 95% confidence intervals [CI] = 24% to 50%, P<0.001). CONCLUSION: Training GPs in communication strategies about PE improves its detection.

Screening for cardiovascular risk in the general population: The SPICES implementation survey.

Background: In 2019, cardiovascular diseases (CVD) caused 32% of deaths worldwide. The SPICES survey involved five countries in an international primary CVD prevention implementation study in the general population. The French SPICES survey was implemented in the Centre Ouest Bretagne area (COB), which is a rural, economically deprived, medically underserved territory with high cardiovascular mortality. A CVD screening in the general population was needed to select the implementation population without overburdening family practitioner (FP) workforces. The efficacy and the replicability of such a screening were unknown. The aims of this study were to identify the characteristics of the individuals undergoing CVD risk assessment with the Non-Laboratory Interheart risk score (NL-IHRS), and to identify barriers and explore facilitators when screening the general population. Methods: An implementation study combining a cross-sectional descriptive study with qualitative interviews was undertaken. The NL-IHRS was completed by trained screeners selected from health students, pharmacists, nurses, and physiotherapists in the area with a dedicated e-tool in sport and cultural events and public places. After the screening, all screener groups were interviewed until theoretical saturation for each group. Thematic analysis was performed using double-blind coding. Results: In 5 months, 3,384 assessments were undertaken in 60 different places, mostly by health students. A total of 1,587, 1,309, and 488 individuals were at low, moderate, and high CVD risk. Stressed or depressed individuals were remarkably numerous (40.1 and 24.5% of the population, respectively). Forty-seven interviews were conducted. The main facilitators were willingness of the population, trust between screeners and the research team, and media publicity. The main barriers were lack of motivation of some screeners, some individuals at risk, some stakeholders and difficulties in handling the e-tool. Conclusion: The efficacy of CVD risk screening while using mostly health students was excellent and preserved the FP workforce. Replicability was highly feasible if research teams took great care to establish and maintain trust between screeners and researchers. The e-tools should be more user-friendly.

Innovative cardiovascular primary prevention population-based strategies: a 2-year hybrid type 1 implementation randomised control trial (RCT) which evaluates behavioural change conducted by community champions compared with brief advice only from the SPICES project (scaling-up packages of interventions for cardiovascular disease prevention in selected sites in Europe and sub-Saharan Africa).

BACKGROUND: Cardiovascular diseases (CVD) caused 17.9 million deaths worldwide in 2016, being the world's leading cause of death. Prevention of CVD in high-income countries is expensive and fails to reach the population at risk. In low-income countries, it is under-developed. The SPICES project implements a community-based program to improve CVD prevention in 3 European countries and 2 Sub-Saharan countries, based on using community champions to effect behavioural changes. In France, the project operates in "Pays Centre Ouest Bretagne" (COB) which is the Central West Brittany area, and a vulnerable, rural setting. The aim of this study is to assess this innovative prevention strategy versus brief advice. METHODS: A two-step RCT hybrid type 1 implementation study will first of all screen a population using the Non-Laboratory INTERHEART Score (NL-IHRS) and will involve health-care students at public events in the COB area until 1000 participants have been recruited. Second, a RCT will be carried out. The research team will contact each participant with an intermediate NL-IHRS in order to include them. Participants will be over 18 years of age and work or live in the COB area. Participants will be equally randomised in two groups. The intervention group will receive brief advice plus behavioural change guidance carried out by community champions. The control group will receive brief advice only. The main objective for the RCT is to assess a difference of at least 15% in the NL-IHRS between the two groups after 24 months. The primary outcome will be analysed with intention to treat. Secondary outcomes for the RCT will be assessed using validated questionnaires: the WHOQOL-BREF, the DASH Q questionnaire, the IPAQ-short; smoking level will be assessed according to the NL-IHRS scoring system; a modified self-declared alcohol consumption questionnaire has been developed and gauges will be used to assess BMI. The implementation strategy will use mixed methods: qualitative research methods and quantitative epidemiological studies. DISCUSSION: A difference in the mean NL-IHRS of 15% will provide an argument in favour of reorganising prevention policies. A substantial change would favour relocating primary prevention from healthcare professionals to lay people and the community. TRIAL REGISTRATION: Clinical Trials NCT03886064 - the study was recorded on ClinicalTrials.gov , the 22nd of March 2019.

Accuracy of the general practitioner's sense of alarm when confronted with dyspnoea and/or chest pain: a prospective observational study.

OBJECTIVES: Dyspnoea and chest pain are symptoms shared with multiple pathologies ranging from the benign to life-threatening diseases. A Gut Feelings Questionnaire (GFQ) has been validated to measure the general practitioner's (GPs) sense of alarm or sense of reassurance. The aim of the study was to estimate the diagnostic test accuracy of GPs' sense of alarm when confronted with dyspnoea and chest pain. DESIGN AND SETTINGS: Prospective observational study in general practice. PARTICIPANTS: Patients aged between 18 and 80 years, consulting their GP for dyspnoea and/or chest pain, were considered for enrolment. These GPs had to complete the GFQ immediately after the consultation. PRIMARY OUTCOME MEASURES: Life-threatening and non-life-threatening diseases have previously been defined according to the pathologies or symptoms in the International Classification of Primary Care (ICPC)-2 classification. The index test was the sense of alarm and the reference standard was the final diagnosis at 4 weeks. RESULTS: 25 GPs filled in 235 GFQ questionnaires. The positive likelihood ratio for the sense of alarm was 2.12 (95% CI 1.49 to 2.82), the negative likelihood ratio was 0.55 (95% CI 0.37 to 0.77). CONCLUSIONS: Where the physician experienced a sense of alarm when a patient consulted him/her for dyspnoea and/or chest pain, the post-test odds that this patient had, in fact, a life-threatening disease was about twice as high as the pretest odds. TRIAL REGISTRATION NUMBER: NCT02932982.

Premature ejaculation in primary care: communication strategies versus usual care for male patients consulting for a sexual, urogenital or psychological reason - GET UP: study protocol for a cluster randomised controlled trial.

BACKGROUND: Premature ejaculation (PE) is the most common sexual dysfunction among men. According to patients, the general practitioner (GP) is the appropriate professional with whom to discuss this issue. However, few patients receive the medical help needed because GPs find it difficult to talk to their patients about sex. A previous qualitative study provided six strategies described by GPs who had tackled the topic during consultation. A pilot study showed that using one of these strategies after a training course led to an increase in the rate of consultations where the topic was raised: an increase from 6.6 to 30.8%. The aim of this study is to compare whether training in communication skills with these six strategies is more effective than usual care on the incidence of patients bringing up the topic of PE with their GP. METHODS: A cluster randomised controlled trial, stratified over four areas comparing an intervention group, which will receive the six strategies training session, and a control group, which ensures routine medical care. The primary outcome is to investigate the efficacy of a training in communication skills directed towards this pathology, compared with usual care procedures, on the incidence of patients bringing up the topic of PE with their GP. The secondary objective relates to the variation in the quality of life of patients after having recently addressed the topic of PE. Quality of life will be evaluated using the SF-12 health scale, with scoring filled in by the patient immediately after the consultation and 4 weeks later. The patients suffering from PE will be identified if their score is higher than 9 on the Premature Ejaculation Diagnostic Tool filled in 4 weeks after the consultation. The number of patients necessary to highlight a significant difference between the two groups from 5 to 20% is 101. Therefore, a total of 600 patients is expected, 300 in each arm (40 GPs, 15 patients per GP; risk α = 5%; power = 90%; intra-cluster correlation coefficient ρ = 0.2; Hawthorne effect = 15%; lost-to-follow-up rates for GPs = 10% and for patients = 20%). DISCUSSION: The implication for practice is the improvement in the quality of patient-centred care within a topic area which encompasses almost 30% of male sex-related complaints. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02378779 . Registered on 3 February 2015.

Gut Feelings Questionnaire in daily practice: a feasibility study using a mixed-methods approach in three European countries.

OBJECTIVES: The validated Gut Feelings Questionnaire (GFQ) is a 10-item questionnaire based on the definitions of the sense of alarm and the sense of reassurance. The purpose of the GFQ is to determine the presence or absence of gut feelings in the diagnostic reasoning of general practitioners (GPs).The aim was to test the GFQ on GPs, in real practice settings, to check whether any changes were needed to improve feasibility, and to calculate the prevalence of the GPs' sense of alarm and sense of reassurance in three different countries. SETTING: Primary care, six participating centres in Belgium, France and the Netherlands. PARTICIPANTS: We performed a think-aloud study with 24 experienced Dutch GPs, GP trainees and medical clerks who filled in the GFQ after diagnosing each of six case vignettes. We then performed a feasibility study in two phases, using a mixed-method approach, with 42 French and Dutch GPs in the first phase and then 10 Belgian, 10 Dutch and 10 French GPs in the second phase. All GPs filled in the GFQ after each of eight consultations with patients presenting new complaints and were subsequently interviewed about the use of the GFQ. OUTCOME MEASURES: GPs' experiences on using the GFQ in real practice, more specifically the average time needed for filling in the questionnaire.The prevalence of GPs' sense of alarm and sense of reassurance. RESULTS: The modified version of the GFQ, created without altering the sense of the validated items, was easy to use in daily practice. The prevalence of the GPs' sense of alarm occurred during 23%-31% of the included consultations. CONCLUSIONS: After a two-step study and several minor adaptations, the final version of the GFQ proved to be a feasible and practical tool to be used for prospective observational studies in daily practice.

Cross-sectional multicentre study on the cohort of all the French junior lecturers in general practice.

BACKGROUND: General practice became an academic discipline quite recently in many western countries. In France, junior lecturer work is specified in a three-part mandate: medical work in general practice, teaching in the university, and research. Since 2007, 130 junior lecturers have been appointed in general practice. The aim of the creation of junior lecturer status was to align general practice with other specialties and to develop research and education in primary care. OBJECTIVES: To describe the healthcare, teaching and research undertaken by junior lecturers in general practice, practising in October 2014. METHODS: A cross-sectional multicentre study using an online self-administered questionnaire on the cohort composed of all the junior lecturers in general practice with open questions and the qualitative analysis of written verbatim accounts. RESULTS: Of the 95 junior lecturers practising at the date of the study, 75 (79%) responded; average age 32 years; gender ratio (F/M) 2.4:1. They spent five, two and three half-days per week respectively in healthcare, teaching and research. The healthcare activity was predominantly carried out in the community (73%). Thirty-nine per cent worked as part of a multi-professional team taking on 50 consultations per week. Most of the educational work involved lecturing and mentoring students specializing in general practice (median 86 hours per year). Research output increased during the fellowship. Research topics were varied and relevant to the disciplinary field. CONCLUSION: During the fellowship, the balancing, and even the reinforcement, of healthcare and research contributions were accompanied by a significant investment in educational provision.

Multimorbid outpatients: A high frequency of FP appointments and/or family difficulties, should alert FPs to the possibility of death or acute hospitalization occurring within six months; A primary care feasibility study.

BACKGROUND: The European General Practitioners Research Network (EGPRN) designed and validated a comprehensive definition of multimorbidity using a systematic literature review and qualitative research throughout Europe. This definition was tested as a model to assess death or acute hospitalization in multimorbid outpatients. OBJECTIVE: To assess which criteria in the EGPRN concept of multimorbidity could detect outpatients at risk of death or acute hospitalization in a primary care cohort at a 6-month follow-up and to assess whether a large scale cohort with FPs would be feasible. METHOD: Family Physicians included a random sample of multimorbid patients who attended appointments in their offices from July to December 2014. Inclusion criteria were those of the EGPRN definition of Multimorbidity. Exclusion criteria were patients under legal protection and those unable to complete the 2-year follow-up. Statistical analysis was undertaken with uni- and multivariate analysis at a 6-month follow-up using a combination of approaches including both automatic classification and expert decision making. A Multiple Correspondence Analysis (MCA) completed the process with a projection of illustrative variables. A logistic regression was finally performed in order to identify and quantify risk factors for decompensation. RESULTS: 19 FPs participated in the study. 96 patients were analyzed. 3 different clusters were identified. MCA showed the central function of psychosocial factors and peaceful versus conflictual relationships with relatives in all clusters. While taking into account the limit of a small cohort, age, frequency of family physician visits and extent of family difficulties were the factors which predicted death or acute hospitalization. CONCLUSION: A large scale cohort seems feasible in primary care. A sense of alarm should be triggered to prevent death or acute hospitalization in multimorbid older outpatients who have frequent family physician visits and who experience family difficulties.

The linguistic validation of the gut feelings questionnaire in three European languages.

BACKGROUND: Physicians' clinical decision-making may be influenced by non-analytical thinking, especially when perceiving uncertainty. Incidental gut feelings in general practice have been described, namely, as "a sense of alarm" and "a sense of reassurance". A Dutch Gut Feelings Questionnaire (GFQ) was developed, validated and afterwards translated into English following a linguistic validation procedure. The aims were to translate the GFQ from English into French, German and Polish; to describe uniform elements as well as differences and difficulties in the linguistic validation processes; to propose a procedural scheme for future GFQ translations into other languages. METHODS: We followed a structured, similar and equivalent procedure. Forward and backward-translations, repeated consensus procedures and cultural validations performed in six steps. Exchanges between the several research teams, the authors of the Dutch GFQ, and the translators involved continued throughout the procedure. RESULTS: 12 translators, 52 GPs and 8 researchers in the field participated to the study in France, Germany, Switzerland and Poland. The collaborating research teams created three versions of the 10-item GFQ. Each research team found and agreed on compromises between comparability and similarity on one hand, and linguistic and cultural specificities on the other. CONCLUSIONS: The gut feeling questionnaire is now available in five European languages: Dutch, English, French, German and Polish. The uniform procedural validation scheme presented, and agreed upon by the teams, can be used for the translation of the GFQ into other languages. Comparing results of research into the predictive value of gut feelings and into the significance of the main determinants in five European countries is now possible.

COGITA network has constructed a glossary of diagnostic reasoning terms.

The role of gut feelings in diagnostic reasoning is recognized by most GPs throughout Europe, and probably throughout the world. Studies on this topic have emerged from different countries but there is the risk that authors will use different terms for similar concepts. The European Expert Group on Cognitive and Interactive Processes in Diagnosis and Management in General Practice, COGITA for short, was founded in 2008 to conduct cross-border research in the area of non-analytical diagnostic reasoning. Academic GPs, PhD students, psychologists, linguists and students meet once a year to share their experiences, exchange results and initiate new studies on the topic. A milestone in their research is this publication of a short glossary of diagnostic reasoning terms relating to the gut feelings research topic. It was constructed by the COGITA group members following a literature review, which aimed to define salient terms used in their publications. They described the terms, cross-reviewed the wording and reached consensus within the group. Two sections were created: (1) a diagnostic reasoning section that describes concepts such as analytical and non-analytical reasoning, clinical mind lines, and intuition, and (2) a research methods section describing concepts such as linguistic validity and saturation. The glossary, including relevant literature, has been published on the website http://www.gutfeelingsingeneralpractice.eu . In the future, the glossary will be modified if necessary and completed by members of the COGITA group. [Box: see text].

The accuracy of the general practitioner's sense of alarm when confronted with dyspnoea and/or thoracic pain: protocol for a prospective observational study.

INTRODUCTION: Dyspnoea and chest pain are signs shared with multiple pathologies ranging from the benign to life-threatening diseases. Gut feelings such as the sense of alarm and the sense of reassurance are known to play a substantial role in the diagnostic reasoning of general practitioners (GPs). A Gut Feelings Questionnaire (GFQ) has been validated to measure the GP's sense of alarm. A French version of the GFQ is available following a linguistic validation procedure. The aim of the study is to calculate the diagnostic test accuracy of a GP's sense of alarm when confronted with dyspnoea and chest pain. METHODS AND ANALYSIS: Prospective observational study. Patients aged between 18 and 80 years, consulting their GP for dyspnoea and/or thoracic pain will be considered for enrolment in the study. These GPs will have to complete the questionnaire immediately after the consultation for dyspnoea and/or thoracic pain. The follow-up and the final diagnosis will be collected 4 weeks later by phone contact with the GP or with the patient if their GP has no information. Life-threatening and non-life-threatening diseases have previously been defined according to the pathologies or symptoms in the (ICPC2) International Collegiate Programming Contest classification. Members of the research team, blinded to the actual outcomes shown on the index questionnaire, will judge each case in turn and will, by consensus, classify the expected outcomes as either life-threatening or non-life-threatening diseases. The sensitivity, the specificity, the positive and negative likelihood ratio of the sense of alarm will be calculated from the constructed contingency table. ETHICS AND DISSEMINATION: This study was approved by the ethical committee of the University de Bretagne Occidentale. A written informed consent form will be signed and dated by GPs and patients at the beginning of the study. The results will be published in due course.

"I can't find anything wrong: it must be a pulmonary embolism": Diagnosing suspected pulmonary embolism in primary care, a qualitative study.

BACKGROUND: Before using any prediction rule oriented towards pulmonary embolism (PE), family physicians (FPs) should have some suspicion of this diagnosis. The diagnostic reasoning process leading to the suspicion of PE is not well described in primary care. OBJECTIVE: to explore the diagnostic reasoning of FPs when pulmonary embolism is suspected. METHOD: Semi-structured qualitative interviews with 28 FPs. The regional hospital supplied data of all their cases of pulmonary embolism from June to November 2011. The patient's FP was identified where he/she had been the physician who had sent the patient to the emergency unit. The first consecutive 14 FPs who agreed to participate made up the first group. A second group was chosen using a purposeful sampling method. The topic guide focused on the circumstances leading to the suspicion of PE. A thematic analysis was performed, by three researchers, using a grounded theory coding paradigm. RESULTS: In the FPs' experience, the suspicion of pulmonary embolism arose out of four considerations: the absence of indicative clinical signs for diagnoses other than PE, a sudden change in the condition of the patient, a gut feeling that something was seriously wrong and an earlier failure to diagnose PE. The FPs interviewed did not use rules in their diagnostic process. CONCLUSION: This study illustrated the diagnostic role of gut feelings in the specific context of suspected pulmonary embolism in primary care. The FPs used the sense of alarm as a tool to prevent the diagnostic error of missing a PE. The diagnostic accuracy of gut feelings has yet to be evaluated.

The transculturality of 'gut feelings'. Results from a French Delphi consensus survey.

BACKGROUND: General Practitioners (GPs) sometimes base their clinical decisions on 'gut feelings.' Research into the significance of this phenomenon with focus groups and a Delphi consensus procedure in the Netherlands provided a concept of 'gut feelings:' a sense of alarm, a sense of reassurance and several determinants. The transculturality of 'gut feelings' has been examined briefly until now as the issue is complex. OBJECTIVE: To determine whether a consensus on 'gut feelings' in general practice in France could be obtained. Using a similar Delphi consensus procedure and the same six initial statements as in the Netherlands, and compare the French results with the seven final Dutch consensual statements. METHOD: Qualitative research, including a Delphi consensus procedure after a forward-backward translation (FBT) of the initial Dutch statements of 'gut feelings.' A heterogeneous sample of 34 French expert GPs participated. FBT of the final French statements was undertaken for a content comparison with the Dutch. RESULTS: After three Delphi rounds, French GPs reached agreement on nine statements. Many similarities have been found between the Dutch and the French defining statements, with reservations concerning the 'sense of reassurance,' which French GPs seemed to feel more cautious about. CONCLUSION: 'Gut feelings' are a well-defined concept in France too. The Dutch and the French consensual statements seem very close. The transculturality of the concept is confirmed, which is a new indicator that 'gut feelings' are a self-contained concept.

The European General Practice Research Network presents a comprehensive definition of multimorbidity in family medicine and long term care, following a systematic review of relevant literature.

BACKGROUND: Multimorbidity is a new concept encompassing all the medical conditions of an individual patient. The concept links into the European definition of family medicine and its core competencies. However, the definition of multimorbidity and its subsequent operationalization are still unclear. The European General Practice Research Network wanted to produce a comprehensive definition of multimorbidity. METHOD: Systematic review of literature involving eight European General Practice Research Network national teams. The databases searched were PubMed, Embase, and Cochrane (1990-2010). Only articles containing descriptions of multimorbidity criteria were selected for inclusion. The multinational team undertook a methodic data extraction, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS: The team identified 416 documents, selected 68 abstracts, included 54 articles, and found 132 definitions with 1631 different criteria. These criteria were aggregated into 11 themes that led to the following definition: Multimorbidity is defined as any combination of chronic disease with at least one other disease (acute or chronic) or biopsychosocial factor (associated or not) or somatic risk factor. Any biopsychosocial factor, any risk factor, the social network, the burden of diseases, the health care consumption, and the patient's coping strategies may function as modifiers (of the effects of multimorbidity). Multimorbidity may modify the health outcomes and lead to an increased disability or a decreased quality of life or frailty. CONCLUSION: This study has produced a comprehensive definition of multimorbidity. The resulting improvements in the management of multimorbidity, and its usefulness in long term care and in family medicine, will have to be assessed in future studies.