François Goulet

Practice Features Associated With Patient-Reported Accessibility, Continuity, and Coordination of Primary Health Care

PURPOSE On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict accessibility, continuity, and coordination of care as experienced by patients. METHODS Primary health care clinics were selected by stratified random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on first-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic. RESULTS One hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). First-contact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their office. CONCLUSIONS The way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.

Influence of remedial professional development programs for poorly performing physicians

Introduction: The Collège des médecins du Québec (CMQ) offers an individualized remedial professional development program to help physicians overcome selected clinical shortcomings. To measure the influence of the remedial professional development program, physicians who completed the program between 1993 and 2004 and who were assessed by peer review during a 2‐year period preceding or following the remedial activities were tracked. Methods: For each physician, 30 to 50 patient records were selected randomly for review. Ratings were assigned for the quality of record keeping and for 3 elements pertaining to the quality of care: the clinical investigation plan, diagnostic accuracy, and patient treatment and follow‐up. The impact of the program was measured by comparing the proportion of physicians with satisfactory ratings assigned by peer review before and after the remedial professional development program. Results: Statistically significant improvements (p < .05) were observed for a proportion of physicians (n = 51) with satisfactory ratings with regard to record keeping (20% before and 54% after remediation), the clinical investigation plan (13% before and 59% after remediation), diagnostic accuracy (32% before and 61% after remediation), and patient treatment and follow‐up (31% before and 67% after remediation). Discussion: Participation in a CMQ remedial professional development program can result in improved clinical performance, as assessed through peer review.

Poorly performing physicians: does the Script Concordance Test detect bad clinical reasoning?

Introduction Evaluation of poorly performing physicians is a worldwide concern for licensing bodies. The Collège des Médecins du Québec currently assesses the clinical competence of physicians previously identified with potential clinical competence difficulties through a day‐long procedure called the Structured Oral Interview (SOI). Two peer physicians produce a qualitative report. In view of remediation activities and the potential for legal consequences, more information on the clinical reasoning process (CRP) and quantitative data on the quality of that process is needed. This study examines the Script Concordance Test (SCT), a tool that provides a standardized and objective measure of a specific dimension of CRP, clinical data interpretation (CDI), to determine whether it could be useful in that endeavor. Methods Over a 2‐year period, 20 family physicians took, in addition to the SOI, a 1‐hour paper‐and‐pencil SCT. Three evaluators, blind as to the purpose of the experiment, retrospectively reviewed SOI reports and were asked to estimate clinical reasoning quality. Subjects were classified into 2 groups (below and above median of the score distribution) for the 2 assessment methods. Agreement between classifications is estimated with the use of the Kappa coefficient. Results Intraclass correlation for SOI was 0.89. Cronbach alpha coefficient for the SCT was 0.90. Agreement between methods was found for 13 participants (Kappa: 0.30, P = 0.18), but 7 out of 20 participants were classified differently in both methods. All participants but 1 had SCT scores below 2 SD of panel mean, thus indicating serious deficiencies in CDI. Discussion The finding that the majority of the referred group did so poorly on CDI tasks has great interest for assessment as well as for remediation. In remediation of prescribing skills, adding SCT to SOI is useful for assessment of cognitive reasoning in poorly performing physicians. The structured oral interview should be improved with more precise reporting by those who assess the clinical reasoning process of examinees, and caution is recommended in interpreting SCT scores; they reflect only a part of the reasoning process.

An innovative approach to remedial continuing medical education, 1992-2002.

The authors describe the process of remedial retraining programs organized and planned for Quebec physicians by the Collège des médecins du Québec (CMQ) and report the outcomes of these efforts from April 1992 to March 2002. The CMQ (the Quebec medical licensing authority) developed a process to identify physicians who had shortcomings in their clinical performance, determine their educational needs, propose, in collaboration with the four medical schools in the province, personalized retraining programs (clinical training programs, tutorials, focused readings, workshops, and refresher courses), and subsequently evaluate the impact of these retraining programs. During the ten-year period reported, 305 physicians (216 family physicians and 89 specialists) were referred to the Practice Enhancement Division of the CMQ for personalized remedial retraining. The vast majority of these physicians were men (81%). The following difficulties were identified: therapeutic knowledge (37%), diagnostic knowledge (32%), record-keeping (14%), technical skills (10%), clinical judgment (5%), and communication skills (2%). A total of 329 personalized retraining programs were completed: 273 clinical training programs, 41 tutorials, and 15 focused readings. A reevaluation of all these physicians showed that 70% of the retraining programs had succeeded, 15% were partially successful and only 13% had failed. The remaining 2% involved missing data or withdrawal of physicians. The authors conclude that the collaborative CME process described has important and effective original features.

Determining the Number of Patient Charts Necessary for a Reliable Assessment of Practicing Family Physicians’ Performance

In many countries, peer assessment programs based on the examination of patient charts are becoming a standard to assess physician’s clinical performance. Although data on validity of the process are acceptable, reliability issues need some improvement. This article addresses the rarely studied aspect of optimal number of patient charts for an acceptable reliable assessment. Fifteen patient charts for each of a group of 20 practicing physicians were independently reviewed by 4 professional peer assessors. Generalizability (G) and decision (D) studies were applied to the data. It appears that as few as 10 patient charts are sufficient for any assessor to obtain a G coefficient of 0.80. Results of the current study suggest the possibility of getting generalizable assessments by peer reviewer with minimal information. These results are not in accordance with the concept of case specificity in which it is claimed that performance on a case is a poor predictor of performance on a different case.