Collaboration between family physicians and nurse clinicians: opinions of graduates in family medicine.

OBJECTIVE: To determine whether graduating family physicians are exposed to collaboration between family physicians and nurse clinicians during their training, as well as their opinions about shared care between doctors and nurse clinicians in the delivery of patient care. DESIGN: Anonymous online survey. SETTING: Two French-Canadian university family medicine residency programs. PARTICIPANTS: The 2010 and 2011 graduating family physicians (N = 343) from the University of Montreal and Laval University in Quebec. MAIN OUTCOME MEASURES: The extent to which nurse clinicians in graduating family physicians' training milieu were involved in preventive and curative patient care activities, and graduates' opinions about nurse clinicians sharing care with physicians. RESULTS: Of 343 graduates, 186 (54.2%) participated in the survey. Although as residents in family medicine their exposure to shared care with nurse clinicians was somewhat limited, respondents indicated that they were generally quite open to the idea of sharing care with nurse clinicians. More than 70% of respondents agreed or strongly agreed that nurse clinicians could adjust, according to protocols of clinical guidelines, the treatment of patients with diabetes, hypertension, and asthma, as well as regulate medication for pain control in terminally ill patients. By contrast, respondents were less favourable to nurse clinicians adjusting the treatment of patients with depression. More than 80% of respondents agreed or strongly agreed that nurse clinicians could initiate treatment via a medical directive for routine hormonal contraception, acne, uncomplicated cystitis, and sexually transmitted infections. Respondents' opinions on nurse clinicians initiating treatment for pharyngitis and otitis were more divided. CONCLUSION: Graduating family physicians are quite open to collaborating with nurse clinicians. Although they have observed some collaboration between physicians and nurses, there are areas of shared clinical activities in which they would benefit from further exposure and training.

Collaboration between family physicians and community pharmacists: opinions of graduates in family medicine.

OBJECTIVE: To ascertain the opinions of graduating family physicians about collaboration between family physicians and community pharmacists. DESIGN: Anonymous online survey. SETTING: Two French-Canadian university family medicine residency programs. PARTICIPANTS: The 2010 and 2011 graduating family physicians (N = 343) from the University of Montreal and Laval University in Quebec. MAIN OUTCOME MEASURES: Content of written prescriptions; frequency of and reasons for consultations with community pharmacists; and graduates' perceptions of sharing professional responsibilities with community pharmacists. RESULTS: The response rate was 54.2%. Overall, graduates were open to collaborating actively with community pharmacists. For example, at least 60% of graduates reported that it was important to write on prescriptions about any changes to patients' medication and creatinine clearance. Most graduates responded positively to sharing responsibility for the adjustment of treatment of patients with certain chronic conditions (88.3% for anticoagulation, 64.7% for hypercholesterolemia, 61.2% for hypertension, and 60.6% for diabetes) and for the initiation of treatment of minor conditions according to a collective prescription (80.6% for traveler's diarrhea, 74.1% for juvenile acne, and 73.6% for allergic rhinitis). However, such interprofessional collaboration requires that each professional group continues to adapt to its roles and responsibilities. CONCLUSION: Family medicine graduates are open to actively collaborating with community pharmacists, but they have some reservations regarding sharing certain responsibilities. As collaborative practices are changing, graduates' opinions should be documented once they are actually practising.

The challenge of teaching occupational medicine to medical students: the Université de Montréal experience.

Nonrecognition and mismanagement of work-related diseases is often linked to inadequate medical training. However, undergraduate training in occupational medicine faces many challenges, including lack of student interest and limited curriculum time. The purpose of this article is to present an undergraduate training program developed in one medical school to ensure that all medical students acquire the basic knowledge to recognize work-related health conditions and understand the fundamental principles of workers' comprehensive care. The program involves various learning methods including case studies, small-group learning, interactive large-group teaching, field activities, and e-learning. It has resulted in improving students' attitudes and competencies in occupational medicine and requires little curriculum time.

Adolescent care. Part 1: are family physicians caring for adolescents' mental health?

OBJECTIVE: To investigate how often family physicians see adolescents with mental health problems and how they manage these problems. DESIGN: Mailed survey completed anonymously. SETTING: Province of Quebec. PARTICIPANTS: All 358 French-speaking family physicians who practise primarily in local community health centres (CLSCs), including physicians working in CLSC youth clinics, and 749 French-speaking practitioners randomly selected from private practice. MAIN OUTCOME MEASURES: Frequency with which physicians saw adolescents with mental health problems, such as depression, suicidal thoughts, behavioural disorders, substance abuse, attempted suicide, or suicide, during the last year or since they started practice. RESULTS: Response rate was 70%. Most physicians reported having seen adolescents with mental health problems during the last year. About 10% of practitioners not working in youth clinics reported seeing adolescents with these disorders at least weekly. Anxiety was the most frequently seen problem. A greater proportion of physicians working in youth clinics reported often seeing adolescents for all the mental health problems examined in this study. Between 8% and 33% of general practitioners not working in youth clinics said they had not seen any adolescents with depression, behavioural disorders, or substance abuse. More than 80% of physicians had seen adolescents who had attempted suicide, and close to 30% had had adolescent patients who committed suicide. CONCLUSION: Family physicians play a role in adolescent mental health care. The prevalence of mental health problems seems higher among adolescents who attend youth clinics. Given the high prevalence of these problems during adolescence, we suggest on the basis of our results that screening for these disorders in primary care could be improved.

Adolescent care. Part 2: communication and referral practices of family physicians caring for adolescents with mental health problems.

OBJECTIVE: To document with whom family physicians communicate when evaluating adolescents with mental health problems, to whom they refer these adolescents, and their knowledge and perceptions of the accessibility of mental health services in their communities. DESIGN: Mailed survey completed anonymously. SETTING: Province of Quebec. PARTICIPANTS: All general practitioners who reported seeing at least 10 adolescents weekly (n = 255) among 707 physicians who participated in a larger survey on adolescent mental health care in general practice. MAIN OUTCOME MEASURES: Whether family physicians communicated with people (such as parents, teachers, or school nurses) when evaluating adolescents with mental health problems. Number of adolescents referred to mental health services during the last year. Knowledge of mental health services in the community and perception of their accessibility. RESULTS: When asked about the last 5 adolescents seen with symptoms of depression or suicidal thoughts, depending on type of practice, 9% to 19% of physicians reported routinely communicating with parents, and 22% to 32% reported not contacting parents. Between 16% and 43% of physicians referred 5 adolescents or fewer to mental health services during a 12-month period. Most practitioners reported being adequately informed about the mental health services available in their local community clinics. Few physicians knew about services offered by private-practice psychologists, child psychiatrists, or community groups. Respondents perceived mental health services in community clinics (CLSCs) as the most accessible and child psychiatrists as the least accessible services. CONCLUSION: Few physicians routinely contact parents when evaluating adolescents with serious mental health problems. Collaboration between family physicians and mental health professionals could be improved. The few referrals made to mental health professionals might indicate barriers to mental health services that could mean many adolescents do not receive the care they need. The lack of access to mental health services, notably to child psychiatrists, reported by most respondents could explain why some physicians choose not to refer adolescents.

Unsafe sex, substance abuse, and domestic violence: how do recently trained obstetricians-gynecologists fare at lifestyle risk assessment and counseling on STD prevention?

BACKGROUND: Unsafe sexual practices, substance abuse, and domestic violence impact women's health. This study examined whether lifestyle risk assessment during a general medical examination and counseling about sexually transmitted disease during consultations for adolescent contraception and treatment of a sexually transmitted disease were more frequently done by recently trained obstetricians-gynecologists compared to those of obstetrician-gynecologists licensed before 1990. It also documented obstetrician-gynecologists' evaluations of their medical training in that area. METHODS: A pretested anonymous mail survey was conducted in 1995 with all 241 obstetrician-gynecologists practicing in Quebec, Canada; 66% responded (N = 158). RESULTS: Compared to less recently trained obstetrician-gynecologists, recently trained obstetrician-gynecologists reported routinely assessing tobacco use (77 vs 51%, P = 0.01), alcohol use (50 vs 23%, P = 0.004), and illicit drug use (33 vs 17%, P = 0.05) more frequently during a patient's general medical evaluation. However, they did not assess condom use (50%), number of sexual partners, sexual partners' sexually transmitted disease risk (30%), or experiences of sexual abuse or domestic violence (3%) more frequently than less recently trained obstetrician-gynecologists. They were also not more likely to counsel teenagers about sexually transmitted disease prevention during a contraceptive consultation (30-60%) or to discuss human immunodeficiency virus infection (29%) and hepatitis B immunization (13%) during a sexually transmitted disease consultation. CONCLUSION: Although evaluation of substance use was better among recently trained OB-Gyn physicians, little or no improvement has been noted regarding STD prevention or the evaluation of sexual abuse or domestic violence, all important lifestyle risks that directly affect women's health and well-being.

[Theories emerging from daily clinical practice of community occupational therapists]. / Théories qui émergent du quotidien de la pratique communautaire de l'ergothérapie.

Occupational therapists working in the community have adapted their knowledge to the distinct characteristics and expectations of the various settings. To do so, they have had to reflect on the professional nature of their interventions, while intervening. This simultaneous process has yielded specific knowledge that is solidly anchored in current clinical reality. A survey on occupational therapy in the Centres locaux de services communautaires in Québec (CLSC) highlighted three theories developed by occupational therapists in their daily clinical practice. The first relates mostly to referral processing while the other two address the occupational therapist's role within the treatment team. This paper briefly presents the survey's results, then focuses mainly on the three emergent theories and underlines some elements congruent with the reference theories in occupational therapy. The author then proposes avenues for reflection to help foster balance between the constraints inherent to the community health care system and occupational therapy professional values.