Physicians' preventive practices: more frequently performed for male patients and by female physicians.

BACKGROUND: We sought to analyze gender differences in General Practitioners' (GP) preventive practices: variations according to the GP's and the patient's genders, separately and combined, and the homogeneity of GPs' practices according to gender. METHODS: Fifty-two general practitioners volunteered to participate in a cross-sectional study. A sample of 70 patients (stratified by gender) aged 40-70 years was randomly chosen from each GP's patient panel. Information extracted from the medical files was used to describe the GPs' preventive practices for each patient: measurements of weight, waist circumference, glucose, and cholesterol; inquiry and counseling about smoking, alcohol consumption, diet, and physical activity, and dates of cervical smears and mammographies. An aggregate preventive score was calculated to assess the percentage of these practices performed by each GP for patients overall and by gender. Mixed models were used to test for gender differences. RESULTS: Questionnaires were collected in 2008-2009 for 71% of the 3640 patients and analyzed in June 2017. Male patients and female GPs were associated with the most frequent performance of many types of preventive care. The aggregate preventive score was higher for male patients (OR = 1.60, 95% CI 1.47-1.75) and female GPs (OR = 1.35, 95% CI 1.05-1.73). There was no combined effect of the genders of the two protagonists. Female patients of male GPs appeared to receive preventive care least frequently and female GPs to deliver preventive care more consistently than their male colleagues. CONCLUSION: Physicians need to be aware of these differences, for both patient gender and their own.

[Social inequalities and preventive care: The case of physical activity counselling in general practice]. / Inégalités sociales et soins préventifs : le cas du conseil en activité physique délivré par les généralistes.

INTRODUCTION: Healthy behaviours become less common when descending the social ladder, which contributes to social inequalities in health. General practitioners (GPs) could have an impact on this general trend by providing preventive care counselling. We wanted to describe the social inequalities related to physical activity (PA) and the counselling given to patients, in order to improve our understanding of how inequalities can be produced at the doctor-patient relationship level. METHODS: Prev Quanti simultaneously examined social differences in the patients' level of PA and in the PA counselling provided by their GPs. 3,640 registered patients were randomly selected from the patient list of 52 GPs involved in GP training in two Parisian Universities. Based on interviews with 99 GPs from the same area on preventive care, Prev Quali explored the construction of the GP's PA counselling practice style. RESULTS: A social gradient was observed, with less counselling at the bottom of the social ladder, where lower levels of PA were also reported by patients. Interviews revealed a common difficulty for GPs to consider PA as a valuable form of medical care and the lack of a systematic approach. An implicit triage process leads to an indirect social selection of the patients ?worth trying? to deliver PA counselling, by GPs barely aware of the social gradient among their patients in terms of PA. CONCLUSION: Improving the PA level without widening social inequalities is challenging for GPs.

Accumulation of unhealthy behaviors: Marked social inequalities in men and women.

The objective of this study was to compare the accumulation of unhealthy behaviors at the bottom of the social scale in men and women and, secondarily, to compare social and gender-based inequalities. Fifty-two general practitioners from the Paris area volunteered to participate. A sample of 70 patients (stratified by gender) aged 40-74 years was randomly chosen from each physician's patient panel and asked to complete a questionnaire about their social position and health behaviors: tobacco and alcohol use, unhealthy diet, and physical inactivity. Mixed Poisson models were used to describe, with relative risks (RRs) and relative inequality indexes (RIIs), the social inequalities in the accumulation of these four unhealthy behaviors. In 2008-2009, 71% of the 3640 patients returned their questionnaires. Men had an average of 1.59 of the 4 unhealthy behaviors we studied, and women 1.35 (RR = 1.18; 95% CI [1.11-1.25]). The mean number of unhealthy behaviors increased significantly for both genders from the top to the bottom of the social scale. The order of magnitude of RIIs was similar among men and women, ranging from 1.33 (occupational RII among women, 95% CI [1.11-1.60]) through 1.69 (financial RII among women, 95% CI [1.43-1.99]). None of the interaction tests between gender and social position was significant. The social inequalities had significantly wider amplitudes than those between genders for two of the three indicators of social position. The amplitude of social gradients related to unhealthy behaviors was similar between men and women and exceeded the gender inequality between them.

Level of agreement between physician and patient assessment of non-medical health factors.

Background: GPs need to consider assorted relevant non-medical factors, such as family or work situations or health insurance coverage, to determine appropriate patient care. If GPs' knowledge of these factors varies according to patients' social position, less advantaged patients might receive poorer care, resulting in the perpetuation of social inequalities in health. Objective: To assess social disparities in GPs' knowledge of non-medical factors relevant to patient care. Methods: Observational survey of GPs who supervise internships in the Paris metropolitan area. Each of the 52 enrolled GPs randomly selected 70 patients from their patient list. Their knowledge of five relevant factors (coverage by publicly funded free health insurance, or by supplementary health insurance, living with a partner, social support and employment status) was analysed as the agreement between the patients' and GPs' answers to matching questions. Occupational, educational and financial disparities were estimated with multilevel models adjusted for age, sex, chronic disease and GP-patient relationship. Results: Agreement varied according to the factor considered from 66% to 91%. The global agreement score (percentage of agreement for all five factors) was 72%. Social disparities and often gradients, disfavouring the less well-off patients, were observed for each factor considered. Social gradients were most marked according to perceived financial situation and for health insurance coverage. Conclusion: GPs must be particularly attentive toward their least advantaged patients, to be aware of the relevant non-medical factors that affect these patients' health and care, and thus provide management adapted to each individual's personal situation.

Are primary-care physician practices related to health behaviors likely to reduce social inequalities in health?

Our objective was to examine patients' health behaviors and the related practices of their primary-care physicians to determine whether physicians' actions might help to reduce the social inequalities in health behaviors among their patients. Fifty-two general practitioners, who were also medical school instructors in the Parisian area, volunteered to participate. A sample of 70 patients (stratified by sex) aged 40-70years was randomly chosen from each physician's patient panel and asked to complete a questionnaire about their social position and health behaviors: tobacco and alcohol use, diet, physical activity, and participation in breast and cervical cancer screening. Each physician reported their practices related to each such behavior of each patient. Mixed models were used to test for social differences. Questionnaires were collected in 2008-2009 from both patient and physician for 71% of the 3640 patients. Our results showed social inequalities disfavored those at the bottom of the social scale for all but one of the health behaviors studied among both men and women (exception: excessive alcohol consumption among women). Physicians' practices related to these health behaviors also appeared to be socially differentiated. Among men, this differentiation favored those with the lowest social position for all behaviors except physical activity. Among women, however, practices favored the most disadvantaged only for breast cancer screening. In all other cases, they were either socially neutral or unfavorable to the most disadvantaged. Physicians' practices related to their patients' health behaviors should focus more on those lowest in the social hierarchy, especially among women.

Time and feasibility of prevention in primary care.

BACKGROUND: Prevention is an essential task in primary care. According to primary care physicians (PCPs),lack of time is one of the principal obstacles to its performance. OBJECTIVE: To assess the feasibility of prevention in terms of time by estimating the time necessary to perform all of the preventive care recommended, separately from the PCPs and patient's perspectives, and to compare them to the amount of time available. METHODS: A review of the literature identified the prevention procedures recommended in France, the duration of each procedure and its recommended frequency, as well as PCPs' consultation time. A hypothetical patient panel size of 1000 patients, representative of the French population, served as the basis for our calculations of the annual time necessary for prevention for a PCP. The prevention time from the patient's perspective was estimated from data collected from a previous study of a panel of 3556 patients. RESULTS: For PCPs, the annual time necessary for all of the required preventive care was 250 hours, or 20% of their total patient time. For a patient, the annual time required for prevention during encounters with a PCP ranged from 9.7 to 26.4 minutes per year. The mean total encounter time was 75.9 minutes per year. Nearly 73% of patients had a prevention-to-care time ratio exceeding 15%. CONCLUSION: Feasibility thus differs substantially between patients. These differences correspond especially to disparities in the annual care time used by each patient. Specific solutions should be developed according to the patients' utilization of care.

General practitioners' relationship with preventive knowledge: a qualitative study.

General practitioners (GPs) do not provide enough preventive care. Nonetheless, without a detailed understanding of the logical processes that underlie their practices, it remains difficult to develop effective means of improvement. Their relationship to knowledge is one of three elements that strongly structure GPs' preventive work (together with the doctor-patient relationship and the organisation of their professional space).The objective of this article was to explore the question of GPs' relationship to knowledge about prevention. In 2010-2011, semi-directive interviews with a diverse sample of 100 GPs practising in the Paris metropolitan area were conducted. These interviews were coded according a reading grid that was developed collectively and analysed in the framework of grounded theory. The cognitive universe of GPs is neither homogeneous nor stable. It is composed of biomedical knowledge (delivered via guidelines, the professional press, opinion leaders and pharmaceutical companies), clinical knowledge (fed by individual situations from their daily experience and often conflicting with epidemiologic reasoning and data) and lay knowledge (from folk culture). Plunged into this complex cognitive universe that is difficult for them to master, doctors construct their own idiosyncratic preventive style by themselves, mostly in isolation. Two types of actions emerged as likely to help GPs better appropriate preventive knowledge: clarification of scientific data (especially from epidemiology and the social sciences) but also development of a collective analysis of the cognitive work required to integrate the different types of knowledge mobilised daily in their preventive practices.

[General Practitioners and Physical Activity Counselling: from Evidence to Practice Contingencies]. / Les médecins généralistes et le conseil en activité physique : des évidences aux contingences de la consultation.

Introduction: One half of the French population has an insufficient level of physical activity. General Practitioners are consi-dered to be well-placed to promote physical activity. This article analyses how they address this issue. Methods: Semi-structured interviews were conducted on preventive care with 99 GPs from the Parisian area. Their approach to physical activity counselling was discussed in greater detail with 20 GPs. The analysis identified the diverse rationales and approaches of GPs in a grounded theory perspective. Results: Physical activity counselling is not systematically addressed and is never the subject of a specific consultation. Talking about physical activity may come up in a consultation, but not with all types of patients, and largely depends on contingencies and circumstances. A fear of sporting accidents and a negative anticipation of the patient's reactions make GPs reticent to address these issues, even in the presence of medical indications. Even when they talk about physical activity, their assessment and advice are succinct. GPs lack tools and resources to encourage physical activity. They rely on common sense and use their own sport experience, when present. General medical training is not very helpful, and incentive public policies are insufficient to make them feel both operational and legitimate. Conclusion: It is difficult to integrate physical activity preventive care in general practice. Perceived as a matter of personal taste, it is rarely part of routine medical practice, despite a favourable political context..

Factors associated with GPs' knowledge of their patients' socio-economic circumstances: a multilevel analysis.

BACKGROUND: To determine appropriate management for individual patients, GPs are supposed to use their knowledge of the patient's socio-economic circumstances. OBJECTIVE: To analyse factors associated with GPs' knowledge of these circumstances. METHODS: Observational survey of GPs who were internship supervisors in the Paris metropolitan area. Each of 52 volunteer GPs completed a self-administered questionnaire about their own characteristics and randomly selected 70 patients from their patient list. Their knowledge was analysed as the agreement between the patients' and GPs' responses to questions about the patients' socio-economic characteristics in questionnaires completed by both groups. The association between agreement and the GPs' characteristics was analysed with a multilevel model adjusted for age, sex and the duration of the GP-patient relationship. RESULTS: Agreement varied according to the socio-economic characteristics considered (from 51% to 90%) and between GPs. Globally, the GPs overestimated their patients' socio-economic level. GP characteristics associated with better agreement were sex (female), long consultations, the use of paper records or an automatic reminder system and participation in continuing medical education and in meetings to discuss difficult cases. CONCLUSION: Knowledge of some patient characteristics, such as their complementary health insurance coverage or perceived financial situation, should be improved because their overestimation may lead to care that is too expensive and thus result in the patients' abandonment of the treatment. Besides determining ways to help GPs to organize their work more effectively, it is important to study methods to help doctors identify their patients' social-economic circumstances more accurately in daily practice.