Dale Dauphinee

Predictors of inappropriate antibiotic prescribing among primary care physicians

Background: Inappropriate use of antibiotics promotes antibiotic resistance. Little is known about physician characteristics that may be associated with inappropriate antibiotic prescribing. Our objective was to assess whether physician knowledge, time in practice, place of training and practice volume explain the differences in antibiotic prescribing among physicians. Methods: A historical cohort of 852 primary care physicians in Quebec who became certified between 1990 and 1993 was followed for their first 6–9 years of practice (1990–1998). We evaluated whether inappropriate antibiotic prescribing had occurred during the study period (1990–1998) for viral (prescription of antibiotics) and bacterial (prescription of second-or third-line antibiotics given orally) infections. We used logistic regression to estimate the independent contributions of time in practice, practice volume, place of medical training and scores on licensure examinations. Physician sex and visit setting were controlled for, as were patient age, sex, education, income and geographic area of residence. Results: A total of 104 230 patients who received a diagnosis of a viral infection and 65 304 who received a diagnosis of a bacterial infection were included in our study. International medical graduates were more likely than University of Montréal graduates to prescribe antibiotics for viral respiratory infections (risk ratio [RR] 1.78, 95% confidence interval [CI] 1.30–2.44). Inappropriate antibiotic prescribing increased with time in practice. Physicians with a high practice volume were more likely than those with low practice volume to prescribe antibiotics for viral respiratory infections (RR 1.27, 95% CI 1.09–1.48) and to prescribe second-and third-line antibiotics as first-line treatment (RR 1.20, 95% CI 1.06–1.37). Physician scores on licensure examinations were not predictive of inappropriate antibiotic prescribing. Interpretation: International medical graduates, physicians with high-volume practices and those who were in practice longer were more likely to prescribe antibiotics inappropriately. Developing effective interventions will require increased knowledge of the mechanisms that underlie these predictors of inappropriate antibiotic prescribing.

Guidelines for assessing clinical competence

Medical organizations responsible for assessing the clinical competence of large numbers of examinees have traditionally used written, oral, and observation‐based examination methods. The results from these examinations form the basis for major professional decisions regarding promotion or privileges of medical students or physicians. In this article, we present a set of guidelines that examining bodies should follow in developing and implementing assessment procedures that are a valid reflection of examinees’ current level of competence and of their ability to perform satisfactorily at the next stage of training or practice. The guidelines are based on our collective experiences as well as the growing literature on assessment of clinical competence. The discussion covers issues that have not been fully addressed in previously published reviews, including identifying the competencies to be tested, selecting appropriate and realistic test methods, dealing with test administration and scoring, and setting s...

Breaking down the walls: thoughts on the scholarship of integration.

The scholarship of integration is concerned with making connections across scientific disciplines, placing the work of individual investigators and their specialty fields into a larger context, and educating nonspecialists. The authors focus their comments on the biomedical sciences, but observe that closer integration of the biomedical and behavioral sciences will be particularly crucial to advance understanding of the human brain. They observe that as biomedical sciences become more technologically sophisticated, progress is increasingly dependent on sciences such as physics, chemistry, engineering, and related fields. However, the scholarship of integration has been slower than other forms of scholarship to gain acceptance as an integral activity of the professoriate. The isolation of disciplines from one another, particularly at large universities, and the perception of interdisciplinary work as risky and professionally unrewarding are among the forces that may discourage integrative scholarship. In addition, a troubling disconnect exists between the scientific community and the larger public in the understanding of science. Leaders in academic medicine and science must develop strategies to move interdisciplinary work from the margins into the mainstream of academia. Solutions that have been proposed include creating new research entities and funding mechanisms dedicated to interdisciplinary work; reinvigorating the integrative role of the physician-scientist; and training specialists in translational research. The scientific community must also work to develop more effective means of communicating the importance of its work to the public.

Doctor scores on national qualifying examinations predict quality of care in future practice

Objectives  This study aimed to determine if national licensing examinations that measure medical knowledge (QE1) and clinical skills (QE2) predict the quality of care delivered by doctors in future practice.

Effect of a community oriented problem based learning curriculum on quality of primary care delivered by graduates: historical cohort comparison study

Abstract Objective To assess whether the transition from a traditional curriculum to a community oriented problem based learning curriculum at Sherbrooke University is associated with the expected improvements in preventive care and continuity of care without a decline in diagnosis and management of disease. Design Historical cohort comparison study. Setting Sherbrooke University and three traditional medical schools in Quebec, Canada. Participants 751 doctors from four graduation cohorts (1988-91); three before the transition to community based problem based learning (n = 600) and one after the transition (n = 151). Outcome measures Annual performance in preventive care (mammography screening rate), continuity of care, diagnosis (difference in prescribing rates for specific diseases and relief of symptoms), and management (prescribing rate for contraindicated drugs) assessed using provincial health databases for the first 4-7 years of practice. Results After transition to a community oriented problem based learning curriculum, graduates of Sherbrooke University showed a statistically significant improvement in mammography screening rates (55 more women screened per 1000, 95% confidence interval 10.6 to 99.3) and continuity of care (3.3% more visits coordinated by the doctor, 0.9% to 5.8%) compared with graduates of a traditional medical curriculum. Indicators of diagnostic and management performance did not show the hypothesised decline. Sherbrooke graduates showed a significant fourfold increase in disease specific prescribing rates compared with prescribing for symptom relief after the transition. Conclusion Transition to a community oriented problem based learning curriculum was associated with significant improvements in preventive care and continuity of care and an improvement in indicators of diagnostic performance.

Influence of Physicians' Management and Communication Ability on Patients' Persistence With Antihypertensive Medication

BACKGROUND Less than 75% of people prescribed antihypertensive medication are still using treatment after 6 months. Physicians determine treatment, educate patients, manage side effects, and influence patient knowledge and motivation. Although physician communication ability likely influences persistence, little is known about the importance of medical management skills, even though these abilities can be enhanced through educational and practice interventions. The purpose of this study was to determine whether a physicians medical management and communication ability influence persistence with antihypertensive treatment. METHODS This was a population-based study of 13,205 hypertensive patients who started antihypertensive medication prescribed by a cohort of 645 physicians entering practice in Quebec, Canada, between 1993 and 2007. Medical Council of Canada licensing examination scores were used to assess medical management and communication ability. Population-based prescription and medical services databases were used to assess starting therapy, treatment changes, comorbidity, and persistence with antihypertensive treatment in the first 6 months. RESULTS Within 6 months after starting treatment, 2926 patients (22.2%) had discontinued all antihypertensive medication. The risk of nonpersistence was reduced for patients who were treated by physicians with better medical management (odds ratio per 2-SD increase in score, 0.74; 95% confidence interval, 0.63-0.87) and communication (0.88; 0.78-1.00) ability and with early therapy changes (odds ratio, 0.45; 95% confidence interval, 0.37-0.54), more follow-up visits, and nondiuretics as the initial choice of therapy. Medical management ability was responsible for preventing 15.8% (95% confidence interval, 7.5%-23.3%) of nonpersistence. CONCLUSION Better clinical decision-making and data collection skills and early modifications in therapy improve persistence with antihypertensive therapy.

Are physicians with better clinical skills on licensing examinations less likely to prescribe antibiotics for viral respiratory infections in ambulatory care settings

Background:Viral respiratory infections (VRIs) are a common reason for ambulatory visits, and 35% are treated with an antibiotic. Antibiotic use for VRIs is not recommended, and it promotes antibiotic resistance. Effective patient-physician communication is critical to address this problem. Recognizing the importance of physician communication skills, licensure examinations were reformed in the United States and Canada to evaluate these skills. Objective:To assess whether physician clinical and communication skills, as measured by the Canadian clinical skills examination (CSE), predict antibiotic prescribing for VRI in ambulatory care. Research Design and Subjects:A total of 442 Quebec general practitioners and pediatricians who wrote the CSE in 1993–1996 were followed from 1993 to 2007, and their 159,456 VRI visits were identified from physician claims. Measures:The outcome was an antibiotic prescription from a study physician dispensed within 7 days of the VRI visit. Multivariate logistic regression analyses were used to estimate the association between antibiotic prescribing for VRI and CSE score, adjusting for physician, patient, and encounter characteristics. Results:Better clinical and communication skills were associated with a reduction in the risk of antibiotic prescribing, but only for female physicians. Every 1-standard deviation increase in CSE score was associated with a 19% reduction in the risk of antibiotic prescribing (risk ratio, 0.81; 95% confidence interval, 0.68–0.97). Better clinical skills were associated with an even greater reduction in risk among female physicians with higher workloads (risk ratio, 0.48; 95% confidence interval, 0.29–0.79). Conclusion:Physician clinical and communication skills are important determinants of antibiotic prescribing for VRI and should be targeted by future interventions.

Do physician communication skills influence screening mammography utilization

BackgroundThe quality of physician communication skills influences health-related decisions, including use of cancer screening tests. We assessed whether patient-physician communication examination scores in a national, standardized clinical skills examination predicted future use of screening mammography (SM).MethodsCohort study of 413 physicians taking the Medical Council of Canada clinical skills examination between 1993 and 1996, with follow up until 2006. Administrative claims for SM performed within 12 months of a comprehensive health maintenance visit for women 50–69 years old were reviewed. Multivariable regression was used to estimate the relationship between physician communication skills exam score and patients’ SM use while controlling for other factors.ResultsOverall, 33.8 % of 96,708 eligible women who visited study physicians between 1993 and 2006 had an SM in the 12 months following an index visit. Patient-related factors associated with increased SM use included higher income, non-urban residence, low Charlson co-morbidity index, prior benign breast biopsy and an interval >12 months since the previous mammogram. Physician-related factors associated with increased use of SM included female sex, surgical specialty, and higher communication skills score. After adjusting for physician and patient-related factors, the odds of SM increased by 24 % for 2SD increase in communication score (OR: 1.24, 95 % CI: 1.11 - 1.38). This impact was even greater in urban areas (OR 1.30, 95 % CI: 1.16, 1.46) and did not vary with practice experience (interaction p-value 0.74).ConclusionPhysicians with better communication skills documented by a standardized licensing examination were more successful at obtaining SM for their patients.