John Yaphe

Early clinical exposure in medical curricula across Europe: An overview

Background: Many faculties of medicine now include programmes using early clinical exposure (ECE) to introduce medical students to important topics in medicine. Objective: To sketch the landscape of ECE in Europe, describing existing courses. Methods: A survey questionnaire was developed by the Basic Medical Education Committee of the European Academy of Teachers in General Practice (EURACT). This survey used the key informant interviews method, with EURACT Council members serving as key informants by filling in the questionnaire and gathering descriptive data on ECE programmes in their own countries. Results: We asked representatives of 32 EURACT member countries to complete the questionnaire in 2006. We received responses from 21 countries, and the programmes of 40 medical schools from 16 countries were included in the study. Thirty-two medical schools implemented ECE starting in the first year. The duration of ECE programmes ranged from 2 weeks to 2 years. The length of each session varied from 2 hours to a full day. Primary care played an important role in ECE. ECE programmes were implemented with a wide range of objectives. Conclusion: ECE is a new and rewarding trend in European medical schools, and general practice/family medicine (GP/FM) departments are widely involved in these teaching activities. This could help establish GP/FM departments in some countries that still do not have them in their medical schools.

Asthma control, quality of life, and the role of patient enablement : a cross-sectional observational study

Background: Self-assessment of asthma and a stronger doctor-patient relationship can improve asthma outcomes. Evidence for the influence of patient enablement on quality of life and the control of asthma is lacking. Aims: To assess asthma severity, medication use, asthma control, and patient enablement in patients with asthma treated in primary care and to study the relationship between these variables and quality of life. Methods: A cross-sectional study was conducted in an urban clinic in northern Portugal. Data were collected from both clinical records and questionnaires from a random sample of asthma patients. The modified Patient Enablement Instrument, the Asthma Quality of Life Questionnaire, and the Asthma Control Questionnaire were used. Peak expiratory flow and forced expiratory volume in one second (FEV1) were measured. Receiver operating characteristic curve analysis was performed to establish cut-off values for the quality of life measurements. The associations between enablement, asthma control, and quality of life were tested using logistic regression models. Results: The study sample included 180 patients. There was a strong correlation between asthma control and quality of life (r=0.81, p<0.001). A weak association between patient enablement and asthma control and quality of life was found in the logistic regression models. Poor control of asthma was associated with female gender, concomitant co-morbidities, reduced FEV1, and increased severity of asthma. Conclusions: The weak correlation between enablement and asthma control requires further study to determine if improved enablement can improve asthma outcomes independent of gender, severity, and concomitant co-morbidities. This study confirms the strong correlation between asthma control and quality of life.

Faculty development for teachers of family medicine in Europe: Reflections on 16 years’ experience with the international Bled course

Background: Instruction in principles and methods of medical education is a core component of the training of medical teachers. Curricula for new medical teachers have developed across Europe, but few European courses have had the success of the EURACT Bled course for teachers of family medicine. The course focuses on practical issues in medicine and the professional development of physicians. This article describes 16 years’ experience with the Bled course for teachers in general practice/family medicine (GP/FM). Course structure: The course is centred on the preparation of a teaching module, exploring a specific theme in family medicine. The main teaching methods used are: keynote lectures, small group sessions, field work and preparation of a teaching module by the participants. Outcomes: This course has attracted 555 participants from 20 countries since 1992. The course and its outputs have been applied in undergraduate and postgraduate teaching, and in continuous professional development (CPD) in several countries. It is a respected forum for faculty development. The experience of the Bled course suggests that academic medicine may be better able to fulfil its responsibilities by paying attention to relevant topics and using appropriate methods in undergraduate and postgraduate medical curricula.

Asthma in an Urban Population in Portugal: A prevalence study

BackgroundThe prevalence and incidence of asthma are believed to be increasing but research on the true incidence, prevalence and mortality from asthma has met methodological obstacles since it has been difficult to define and diagnose asthma in epidemiological terms. New and widely accepted diagnostic criteria for asthma present opportunities for progress in this field. Studies conducted in Portugal have estimated the disease prevalence between 3% and 15%. Available epidemiological data present a significant variability due to methodological obstacles.AimTo estimate the true prevalence of asthma by gender and age groups in the population of the area covered by one urban Health Centre in Portugal.MethodAn observational study was conducted between February and July 2009 at the Horizonte Family Health Unit in Matosinhos, Portugal. A random sample of 590 patients, stratified by age and gender was obtained from the practice database of registered patients. Data was collected using a patient questionnaire based on respiratory symptoms and the physicians best knowledge of the patients asthma status. The prevalence of asthma was calculated by age and gender.ResultsData were obtained from 576 patients (97.6% response rate). The mean age for patients with asthma was 27.0 years (95% CI: 20.95 to 33.16). This was lower than the mean age for non-asthmatics but the difference was not statistically significant. Asthma was diagnosed in 59 persons giving a prevalence of 10.24% (95% CI: 8.16 to 12.32). There was no statistically significant difference in the prevalence of asthma by gender.ConclusionThe prevalence of asthma found in the present study was higher than that found in some studies, though lower than that found in other studies. Further studies in other regions of Portugal are required to confirm these findings.

Assessing the Impact of a School Intervention to Promote Students’ Knowledge and Practices on Correct Antibiotic Use

The clinical efficacy of antibiotics depends on their correct use. Widespread ignorance and inappropriate attitudes to antibiotic use have been identified among consumers. In order to improve the knowledge of middle-school students on antibiotics and their correct use, 82 ninth-grade students were enrolled in a teaching activity. The teaching activity consisted of a slide show presentation followed by discussion in a regular class. To evaluate the impact of the teaching activity the students were asked to answer a questionnaire before and after the activity. This study aimed: (1) to evaluate knowledge on the use of antibiotics in students of two schools in the north of Portugal and (2) to evaluate the efficacy of the school intervention in improving students’ knowledge on correct antibiotic use. We found lack of knowledge among students regarding antibiotic spectra and indications and incorrect attitudes in the pre-test. Significant increases in knowledge were observed after implementation of the teaching activity. Knowledge of the correct use of antibiotics for bacterial diseases rather than viral diseases rose from 43% to 76% in the post-test (p < 0.01). Knowledge of the risk of bacterial resistance to antibiotics from their incorrect use rose from 48% to 74% in the post-test (p < 0.05). We believe that it is important to reinforce the teaching activities on microbiology and antibiotic use at the middle school level.

Asthma incidence and accuracy of diagnosis in the Portuguese sentinel practice network.

AIMS Asthma is frequently under-diagnosed with a wide variation in incidence rates. We aimed to assess how physicians in a Portuguese sentinel practice network perform using standardised diagnostic criteria. METHOD Patients consulting one of the 43 network physicians with complaints suggestive of asthma were enrolled in the study over a four-year period. Symptom frequency and diagnoses of asthma were tabulated. Diagnostic accuracy was computed by dividing the rate of asthma diagnosis by the true rate using established diagnostic criteria. RESULTS Over four years, 43 physicians followed 32,103 patients (128,412 patient-years) and diagnosed asthma in 310. The diagnosis was confirmed in 260 cases, giving a true incidence rate of 2.02/1000/year (95% confidence interval 1.8 to 2.2) and an accuracy of diagnosis of 84%. CONCLUSIONS Asthma incidence approaches published rates if accepted criteria are used. Educational efforts to ensure more accurate diagnosis may improve outcomes for asthma patients.

Non-specific symptoms as clues to changes in emotional well-being

Background -Somatic symptoms are a common reason for visits to the family physician. The aim of this study was to examine the relation between non-specific symptoms and changes in emotional well-being and the degree to which the physician considers the possibility of mental distress when faced with such patients.Methods -Patients who complained of two or more symptoms including headache, dizziness, fatigue or weakness, palpitations and sleep disorders over one year were identified from the medical records of a random sample of 45 primary care physicians. A control group matched for gender and age was selected from the same population. Emotional well-being was assessed using the MOS-SF 36 in both groups.Results -The study group and the control group each contained 110 patients. Completed MOS questionnaires were obtained from 92 patients, 48 patients with somatic symptoms and 44 controls. Sixty percent of the patients with somatic symptoms experienced decreased emotional well being compared to 25% in the control group (p = 0.00005). Symptoms of dizziness, fatigue and sleep disturbances were significantly linked with mental health impairments. Primary care physicians identified only 6 of 29 patients (21%) whose responses revealed functional limitations due to emotional problems as suffering from an emotional disorder and only 6 of 23 patients (26%) with a lack of emotional well being were diagnosed with an emotional disorder.Conclusions -Non-specific somatic symptoms may be clues to changes in emotional well-being. Improved recognition and recording of mental distress among patients who complain of these symptoms may enable better follow up and treatment.

The countrywide integrated non-communicable disease intervention programme (CINDI) and the effects of healthcare system reform in Slovenia

Objectives: The aim of this paper is to describe the organisation of the CINDI programme in Slovenia, to present the results of a survey of risk factors of chronic disease in the adult population and to describe the effects of political changes on the programme. Methods: Assessment of the health status of a random sample of 1692 adults from the Ljubljana population was performed in 1990. A series of medical and nonmedical interventions were introduced as a result of the survey and a follow-up assessment on a second representative sample of adults was performed in 1995. Results: Due to high prevalence of risk factors (hyperlipidaemia (64%), overweight (57%), hypertension (42%), smoking (39%), inactivity (15%)) found at the initial survey, almost all adults were entitled to some form of intervention. At the follow-up survey, reductions in the prevalence of overweight (48%) and smoking (28%) were noted along with increases in the prevalence of hyperlipidaemia (67%), hypertension (48%) and physical inactivity (26%). Initially, the main focus of the programme was on office-based interventions. With healthcare reform in Slovenia in 1993 and the introduction of a new financing scheme, the health-care system stopped payment for the majority of preventive medical activities. In 1998, prevention activities recommenced and negotiations began for reimbursement of general practitioners involved in prevention. In 2001, a new law obliged general practitioners to assess coronary risks in selected groups of patients. Conclusion: CINDI in Slovenia has faced unexpected political changes and managed to evolve towards more comprehensive health promotion activities at a national level.

Performance indicators for clinical practice management in primary care in Portugal: consensus from a Delphi study.

Abstract Background: Performance indicators assessing the quality of medical care and linked to pay for performance may cause disagreement. Portuguese indicators included in recent health care reform are controversial. Objectives: To obtain consensus from opinion leaders in family medicine regarding the performance indicators for practice management used in the evaluation of Family Health Units in Portugal. Methods: Eighty-nine specialists in primary care were invited to answer the following question in an online Delphi study: ‘Which performance indicators should be assessed regarding the organization and management of clinical practice in primary care in Portugal?’ A Likert scale was used to evaluate validity, reliability, feasibility and sensitivity to change. Twenty-seven experts participated in the second round and achieved a high degree of consensus. Eight categories were created for analysis. Results: The experts suggested the use of existing indicators as well as new indicators. Thirty-nine indicators suggested by the experts are currently in use in Portugal. The assessment of the number of clinical acts performed, the number of administrative acts, and evaluation of the clinical demographic profile achieved a high degree of consensus. The expert panel suggested fifty new indicators. Five categories of these new indicators had a high degree of consensus, and three categories had a low degree of consensus. Conclusion: The expert panel recommended that performance indicators of practice management should first assess the quantity of clinical and administrative activities undertaken. These indicators must take into account the human and financial resources available to the clinic and its demographic context.

The competence of primary care doctors in the investigation of patients with elevated blood pressure: results of a cross-sectional study using clinical vignettes.

BACKGROUND Specific laboratory tests are required to ensure adequate management of patients with hypertension, according to internationally accepted guidelines. There is wide variation in doctor test ordering behaviour. Many factors are known to affect this. Little is known about the interaction between doctor, patient and practice characteristics. The current study was designed to explore this. METHODS A series of eight case vignettes was designed to examine test ordering behaviour among primary care doctors in Poland. The cases differed with regard to the level of blood pressure and the presence or absence of other cardiovascular risk factors, including diabetes. Doctors stated their choices of laboratory investigations needed in these cases. Their responses were compared with recommendations in the 2003 European Society of Hypertension/European Society of Cardiology hypertension guidelines. Associations between the correct responses and patient, doctor and practice characteristics were tested. RESULTS One hundred and twenty-five out of 192 invited doctors (65%) participated in the study. They ordered a mean of 4.9 laboratory tests per case. This represents 47.9% of the tests recommended by current guidelines. Older doctors working in smaller practices and private settings ordered fewer laboratory tests. Specialization in family medicine was associated with greater compliance with guidelines. Grade 2 hypertension and the presence of other risk factors of cardiovascular disease were associated with ordering more tests but the presence of diabetes did not improve compliance with guidelines. CONCLUSIONS Further educational efforts are needed to promote rational test ordering for hypertensive patients by Polish primary health care doctors.