Marija Petek Šter

Factors related to consultation time: Experience in Slovenia

Objective. Consultation time has a serious impact on physicians’ work and patient satisfaction. No systematic study of consultation time in general practice in Slovenia has yet been carried out. The aim of the present study was to measure consultation time, to identify the factors influencing it, and to study the influence of the workload of general practitioners on consultation time. Design. A total of 42 general practitioners participated in this cross-sectional study. Each physician collected data from 300 consecutive consultations and measured the length of the visit. Setting. Forty-two randomly selected general practices in Slovenia. Subjects. Patients of 42 general practices. Main outcome measures. Average consultation time in general practice in Slovenia; factors influencing consultation time in Slovenia. Results. Data from 12 501 visits to the surgery were collected. A quarter of all visits (25.5%) were administrative. The mean consultation time was 6.9 minutes (median 6.0 minutes, 5%–95% interval: 1.0–16.0 minutes). Longer consultation time was predicted by: patient-related factors (female gender, higher age, higher level of education, higher number of health problems, change of physician within the last year), physician-related factors (higher age), physicians’ workload (absence of high workload), and the type of visit (consultation and/or clinical examination). Conclusion. Consultation time in general practice is short, and depends on the characteristics of the patient and the physician, the physicians workload, and the type of visit. A reduction of high workload in general practice should be one of the priorities of the healthcare system.

Psychotropic medication use among elderly nursing home residents in Slovenia: cross-sectional study

Aim To determine the prevalence of psychotropic medication prescribing in elderly nursing home residents in Slovenia and to explore the residents’, physicians’, and nursing home characteristics associated with prescribing. Methods In a cross-sectional study, we collected the data for 2040 nursing home residents aged 65 years and older in 12 nursing homes in Slovenia between September 25 and November 30, 2006. Prescribed medications lists were retrieved from patients’ medical records. Psychotropic medications were coded according to Anatomical Therapeutic Chemical Classification 2005, which we adjusted for the purposes of the study. Multivariate logistic regression analysis was performed to determine the residents’, physicians’, and nursing home characteristics associated with prescribing. Results Residents were from 65 to 104 years old (median, 83 years) and 1606 (79%) of them were female. A total of 970 (48%) residents had dementia and 466 had depression (23%). In 1492 (73%) residents, at least one psychotropic medication was prescribed. Nine hundred sixty residents were prescribed hypnotics and sedatives (47%), 572 (28%) antipsychotics, 460 (23%) antidepressants, and 432 (21%) anxiolytics. Residents’ characteristics associated with psychotropic medication use were female sex (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.03-1.80), age (OR, 0.97; 95% CI, 0.95-0.98), permanent restlessness (OR, 2.54; 95% CI, 1.71-3.78), dementia (OR, 1.76; 95% CI, 1.33-2.34), depression (OR, 5.51; 95% CI, 3.50-7.58), and the number of prescribed medications (OR, 1.29; 95% CI, 1.23-1.35). Of physicians’ characteristics (sex, age, specialization in general practice, years of working experiences as a general practitioner, and years of experiences working in a nursing home), male sex was associated with psychotropic medication prescribing (OR, 1.80; 95% CI, 1.17-2.76). Conclusion Frequency of psychotropic medication prescribing in elderly nursing home residents in Slovenia is high and is comparable to Western European countries. Our next step should be optimizing the prescribing in patients with the highest prescription rate.

Knowledge and acceptance of hypertension guidelines in clinical practice : Experience from Slovenia

SummaryBACKGROUND: Arterial hypertension, which is an important risk factor for cardiovascular disease, is mainly treated by general practitioners. The initial step in an optimal therapeutic strategy for patients with arterial hypertension is the recognition and acceptance of hypertension guidelines by the physicians themselves. AIMS: To find out how well Slovene general practitioners know the current hypertension guidelines and to what extent they accept them. PARTICIPANTS AND METHODS: Knowledge of current recommendations in hypertension diagnosis, treatment, follow-up and special indications was assessed for 813 general practitioners in Slovenia using a questionnaire. The Slovene National Guidelines were taken as the reference standard. Adequate knowledge of the guidelines’ recommendations was defined as correct answers to at least seven out of eleven items; the correct answers had to include the appropriate target blood pressure, the elements of the “minimal diagnostic program” in hypertension and the correct estimation of cardiovascular risk. Acceptance of the guidelines was estimated on a five-grade scale: 5 meaning very useful, 1 meaning useless. RESULTS: A total of 321 questionnaires were suitable for analysis from 327 that were returned (a response rate of 40.2%). The mean number of correct answers was 7.8 (SD, 1.8, range, 4–11), but only 124 (38.8%) of the participating physicians answered the three key questions correctly. The physicians who answered the key questions correctly also answered more of the other questions correctly (6.1 vs. 5.4, p < 0.001). Adequate knowledge of the guidelines was found in 116 (36.8%) of the total study population; mean score for acceptance on the five-grade scale was 4.25. Knowledge of the guidelines was influenced by the physicians’ acceptance of the guidelines’ recommendations (p = 0.024). No other characteristics of physicians or organizational factors influencing knowledge of the guidelines were identified. Most of the participating physicians (72%) were willing to attend a workshop on managing hypertension and there was no connection between knowledge of the guidelines and willingness to attend the workshop. CONCLUSION: Knowledge of the hypertension guidelines among Slovene general practitioners is limited, and is comparable to the results of similar studies. The physicians’ acceptance of the guidelines is high and correlates with their knowledge of the guidelines. A workshop is an accepted form of continuing medical education among general practitioners.ZusammenfassungHINTERGRUND: Arterielle Hypertonie, ein wichtiger Risikofaktor für kardiovaskuläre Erkrankungen, wird hauptsächlich von Allgemeinmedizinern behandelt. Der erste Schritt in einer idealen therapeutischen Strategie für Patienten mit arterieller Hypertonie ist die Anerkennung und die Akzeptanz von Hypertonie-Leitlinien durch die Ärzte selbst. FRAGESTELLUNG: Wie gut kennen slowenische Ärzte für Allgemeinmedizin die ärztlichen Leitlinien für die Behandlung der Hypertonie und wie schätzen sie diese Leitlinien ein? METHODIK: Mittels eines Fragebogens wurden 813 slowenische Ärzte für Allgemeinmedizin über ihre Kenntnis der slowenischen Leitlinien zur Behandlung der Hypertonie befragt, wobei diese Leitlinien den internationalen Vorgaben folgen. Die Kenntnis galt als ausreichend, wenn mindestens 7 von 11 Fragen richtig beantwortet wurden. Unter den richtigen Antworten mussten der Ziel-Blutdruck, das minimale diagnostische Programm zur Abklärung und die Erfassung des kardiovaskulären Risikos sein. Die Akzeptanz der Leitlinien wurde in 5 Beurteilungsgraden erfasst: von 5, „sehr nützlich“, bis 1, „ohne Nutzen“. ERGEBNISSE: Von 327 retournierten Fragebögen (40,2 %) konnten 321 ausgewertet werden. Durchschnittlich waren 7,8 (SD, 1,8; 4 bis 11) Antworten richtig. Nur 124 oder 38,8 % der Ärzte beantworteten die drei wesentlichen Fragen richtig. Diese Ärzte beantworteten auch die restlichen der insgesamt 11 Fragen überwiegend korrekt (6,1 vs. 5,4, p < 0,001). Die Leitlinien waren damit bei 116 oder 36,8 % der Ärzte gut beziehungsweise hinreichend bekannt. Die durchschnittliche Einschätzung hinsichtlich der Nützlichkeit der Leitlinien betrug 4,25 auf der 5-teiligen Bewertungsskala. Die Kenntnis der Leitlinien und ihre Einschätzung zeigten eine signifikante Korrelation (p = 0,024). Die Kenntnis der Richtlinien bedeutete also auch bessere Akzeptanz. Keine anderen Charakteristika der Praxis oder des Arztes beeinflussten die Einschätzung der Leitlinien. Während 72 % der Ärzte bereit sind, an Fortbildungsveranstaltungen zum Management des erhöhten Blutdrucks teilzunehmen, besteht kein Zusammenhang zwischen der Kenntnis der Leitlinien und dieser Fortbildungsbereitschaft. SCHLUSSFOLGERUNGEN: Die Kenntnis der ärztlichen Leitlinien zur Behandlung der Hypertonie ist unter Ärzten für Allgemeinmedizin in Slowenien mäßig, jedoch mit den Ergebnissen von Studien aus anderen Ländern vergleichbar. Die Ärzte, die die Leitlinien kennen, beurteilen diese als sehr nützlich. Die Bereitschaft zur Teilnahme an Workshops als Methode der Fortbildung ist unter den Ärzten in Slowenien groß.

Training experts in family medicine teaching

ABSTRACT Family medicine teachers require specific educational skills. A framework for their professional development is essential for future development of the discipline in Europe. EURACT developed a framework on educational expertise, and subsequently applied it in a curriculum of teaching-skills courses of various levels. The aim of this article is to describe the development of the teaching framework, and of an international three-level course programme for ‘teaching-the-teachers’. Furthermore, we describe our experiences and lessons learned, in particular with regard to the level-three programme for proficient teachers, which was new. We conclude that it is possible to develop a theoretical framework of family medicine teaching expertise and to apply it in an international high-level educational programme for future experts in family medicine education. Research evidence of the usefulness of this approach is needed, and the threats for its further development into a sustainable activity are its high teacher/student ratio associated with relatively high costs and difficulties in recruiting suitable participants.

Prediction of intended career choice in family medicine using artificial neural networks

Abstract Background: Due to the importance of family medicine and a relative shortage of doctors in this discipline, it is important to know how the decision to choose a career in this field is made. Objective: Since this decision is closely linked to students’ attitudes towards family medicine, we were interested in identifying those attitudes that predict intended career choice in family medicine. Methods: A cross-sectional study was performed among 316 final-year medical students of the Ljubljana Medical Faculty in Slovenia. The students filled out a 164-item questionnaire, developed based on the European definition of family medicine and the EURACT Educational Agenda, using a seven-point Likert scale containing attitudes towards family medicine. The students also recorded their interest in family medicine on a five-point Likert scale. Attitudes were selected using a feature selection procedure with artificial neural networks that best differentiated between students who are likely and students who are unlikely to become family physicians. Results: Thirty-one out of 164 attitudes predict a career in family medicine, with a classification accuracy of at least 85%. Predictors of intended career choice in family medicine are related to three categories: understanding of the discipline, working in a coherent health care system and person-centredness. The most important predictor is an appreciation of a long-term doctor–patient relationship. Conclusion: Students whose intended career choice is family medicine differ from other students in having more positive attitudes towards family physicians’ competences and towards characteristics of family medicine and primary care.

How health system factors influence referral decisions in patients that may have cancer: European symposium report

Abstract Objective: To identify the system and other non-clinical factors that may influence a General Practitioners’ decision on whether to refer a patient who may have cancer. Study design: Expert group discussion and consensus formation. Methods: A group of eight General Practitioner (GP) researchers from Croatia, England, Slovenia, Spain, Sweden and Switzerland used brainstorming to identify the non-clinical factors that could affect GPs’ decision-making when faced with patients that might have cancer. The group refined and came to a consensus on these factors. Results: Many non-clinical factors are likely to have a significant impact on referral decisions. These include levels of gatekeeping responsibility, funding systems, access to special investigations, fear of litigation, and relationships with specialist colleagues. Conclusions: Many patients with cancer present without red-flag symptoms, but nevertheless still cause a feeling of concern in their GPs. How a health system is organised is likely to influence on how GPs act on those concerns.

Final year medical students’ understanding of family medicine

OBJECTIVE The European Academy of Teachers in General Practice / Family Medicine (EURACT) has developed an educational agenda, the key document for teaching family medicine in Europe. The aim of our study was to find out how final year medical students at the beginning of their family medicine clerkship understand the discipline of family medicine. METHODS The attitudes toward family medicine were paraphrased and developed into a 164-item questionnaire, which was administered to 335 final-year medical students at the beginning of their clerkship. Using combinatorial optimization with genetic algorithms we selected 30 items which yielded the highest Cronbach alpha reliability coefficient. Finally, we performed a factor analysis to find which dimensions of family medicine were recognised by the students and compared them with the domains defined in the EURACT definition. RESULTS The 30-item questionnaire had a Cronbach alpha reliability coefficient of 0.919. The differences between male and female students were not very significant (p=0.061). With the factor analysis we recognised seven factors, belonging to three out of six domains of the EURACT educational agenda: primary care management, personcenteredness and comprehensive approach. CONCLUSION Final-year medical students at the beginning of their family medicine clerkship understand some of the dimensions of family medicine rather well, but they are not aware of some important competences of family doctors. There is a necessity to teach students about specific problem solving skills and the importance of balance between the health needs of an individual patient and the community.

How the probability of presentation to a primary care clinician correlates with cancer survival rates: a European survey using vignettes

Abstract Objective: European cancer survival rates vary widely. System factors, including whether or not primary care physicians (PCPs) are gatekeepers, may account for some of these differences. This study explores where patients who may have cancer are likely to present for medical care in different European countries, and how probability of presentation to a primary care clinician correlates with cancer survival rates. Design: Seventy-eight PCPs in a range of European countries assessed four vignettes representing patients who might have cancer, and consensus groups agreed how likely those patients were to present to different clinicians in their own countries. These data were compared with national cancer survival rates. Setting: A total of 14 countries. Subjects: Consensus groups of PCPs. Main outcome measures: Probability of initial presentation to a PCP for four clinical vignettes. Results: There was no significant correlation between overall national 1-year relative cancer survival rates and the probability of initial presentation to a PCP (r  = −0.16, 95% CI −0.39 to 0.08). Within that there was large variation depending on the type of cancer, with a significantly poorer lung cancer survival in countries where patients were more likely to initially consult a PCP (lung r = −0.57, 95% CI −0.83 to −0.12; ovary: r = −0.13, 95% CI −0.57 to 0.38; breast r = 0.14, 95% CI −0.36 to 0.58; bowel: r = 0.20, 95% CI −0.31 to 0.62). Conclusions: There were wide variations in the degree of gatekeeping between countries, with no simple binary model as to whether or not a country has a “PCP-as-gatekeeper” system. While there was case-by-case variation, there was no overall evidence of a link between a higher probability of initial consultation with a PCP and poorer cancer survival. KEY POINTS European cancer survival rates vary widely, and health system factors may account for some of these differences. The data from 14 European countries show a wide variation in the probability of initial presentation to a PCP. The degree to which PCPs act as gatekeepers varies considerably from country to country. There is no overall evidence of a link between a higher probability of initial presentation to a PCP and poorer cancer survival.

Intended Career Choice in Family Medicine in Slovenia: An Issue of Gender, Family Background or Empathic Attitudes in Final Year Medical Students? -

Background: Among a variety of complex factors affecting a decision to take family medicine as a future specialisation, this study focused on demographic characteristics and assessed empathic attitudes in final year medical students. Methods: A convenience sampling method was employed in two consecutive academic years of final year medical students at the Faculty of Medicine in Ljubljana, Slovenia, in May 2014 and May 2015. A modified version of the 16-item Jefferson Scale of Empathy – Student Version (JSE-S) was administered to examine self-reported empathic attitudes. An intended career in family medicine was reported using a five-point Likert scale. Results: Of the 175 medical school seniors in study year 2013/14, there were 64 (36.6%) men and 111 (63.4%) women, while in the second group (study year 2014/5), there were 68 (40.5%) men and 100 (59.5%) women; 168 students in total. They were 24.9±1.6 (generation 2013/4) and 24.9±1.7 (generation 2014/15) years old. Thirty-six percent of the students in the academic year 2013/14 intended to choose family medicine as a future career, and a similar proportion in academic year 2014/15 (31.7%). Gender (χ2=6.763, p=0.034) and empathic attitudes (c2=14.914; p=0.001) had a bivariate association with an intended career choice of family medicine in the 2014/15 generation. When logistic regression was applied to this group of students, an intended career choice in family medicine was associated with empathic attitudes (OR 1.102, 95% CI 1.040-1.167, p=0.001), being single (OR 3.659, 95% CI 1.150-11.628, p=0.028) and the father having only primary school education (OR 142.857 95% CI 1.868, p=0.025), but not with gender (OR 1.117, 95% CI 0.854-1.621, p=0.320). Conclusion: The level of students’ father’s education, and not living in an intimate partnership, increased the odds on senior medical students to choose family medicine, yet we expected higher JSE-S scores to be associated with interest in this speciality. To deepen our understanding, this study should be repeated to give us solid grounded insight into the determinants of career choice; associations with gender in particular need to be re-tested.

Validation of Slovenian version of Jefferson scale of empathy for students

Abstract Objective: Empathy is the most frequently mentioned humanistic dimension of patient care and is considered to be an important quality in physicians. The importance of fostering the development of empathy in undergraduate students is continuously emphasised in international recommendations for medical education. Our aim was to validate and adapt the Slovenian version of the Jefferson Scale of Empathy- Students version (JSE-S) on a sample of first-year medical students. Methods: First-year students of the Medical faculty in Ljubljana participated in the research. JSE-S version, a selfadministered 20-item questionnaire, was used for collecting the data. Descriptive statistics at the item level and at the scale level, factor analysis, internal consistency and test-retest reliability (two weeks after the first administration) of the JSE-S were performed. Results: 234 out of 298 (response rate 78.5%) students completed JSE-S. The mean score for the items on the 7-point Likert scale ranged from 3.27 (SD 1.72) to 6.50 (SD 0.82). The mean score for the scale (possible range from 20 to 140) was 107.6 (from 71 to 131, SD 12.6). Using factor analysis, we identified six factors, describing 57.2% of total variability. The Cronbach alpha as a measure of internal consistency was 0.79. The instrument has good temporal stability (test-retest reliability ICC = 0.703). Conclusion: Findings support the construct validity and reliability of JSE-S for measuring empathy in medical students in Slovenia. Future research is required to evaluate factors contributing to empathy. Izvleček Namen: Empatija je najpogosteje omenjena človeška lastnost v odnosu do bolnika in predstavlja pomembno vrednoto v zdravniškem poklicu. Krepitev empatičnega odnosa pri študentih medicine je pogosto poudarjena v mednarodnih smernicah za medicinsko izobraževanje. Namen raziskave je bil validacija in adaptacija slovenske variante študentske različice Jeffersonove lestvice za merjenje empatije na vzorcu študentov prvega letnika medicine. Metode: V raziskavo so bili vključeni študentje prvega letnika Medicinske fakultete v Ljubljani. Podatke smo zbrali s pomočjo študentske različice Jeffersonove lestvice - vprašalnika z 20 vprašanji, ki so ga izpolnili študentje. Naredili smo osnovno statistično analizo posameznih vprašanj, analizo celotne lestvice, faktorsko analizo ter analizo notranje konsistentnosti in časovne stabilnosti lestvice štirinajst dni po prvem izpolnjevanju. Rezultati: 234 od skupno 298 študentov je sodelovalo v raziskavi in izpolnilo vprašalnik. Povprečna vrednot za posamezno vprašanje na 7-stopenjski Likertovi lestvici se je gibala od 3,27 (SD 1,72) do 6,50 (SD 0,82). Povprečna vrednost celotne lestvice (mogoč razpon od 20 do 140) je bila 107,6 (od 71 do 131, SD 12,6). S faktorsko analizo smo prepoznali šest faktorjev, s katerim smo pojasnili 57,2 % celotne variabilnosti. Cronbach alfa kot merilo notranje konsistentnosti je znašal 0,79. Potrdili smo časovno stabilnost lestvice (ICC = 0,703). Zaključek: Potrdili smo veljavnost in zanesljivost slovenske variante študentske različice Jeffersonove lestvice za merjenje empatije. Potrebno bo nadaljnje raziskovanje, ki bo pojasnilo dejavnike, ki prispevajo k empatiji.