Melahat Akdeniz

Chronic noncancer pain management in primary care: family medicine physicians' risk assessment of opioid misuse.

Abstract Objective: The majority of patients with chronic noncancer pain (CNCP) are managed in the primary care settings. The primary care family physician (PCFP) generally has limited time, training, or access to resources to effectively evaluate and treat these patients, particularly when there is the added potential liability of prescribing opioids. The aim of this study is to make a favorable change in PCFPs’ knowledge, attitudes, and practices about opioid use in CNCP via education on assessment of the risk of opioid misuse. Materials and methods: The universe of this cross-sectional study comprised 36 family physicians working at Family Health Centers affiliated to Antalya Provincial Directorate of Health who volunteered to participate in the study. Initially, a survey on patients risk assessment was performed in both intervention and control groups; whereas the intervention group received education on assessment of the risk of opioid misuse, the control group did not. The survey was repeated after 6 months and the intervention group underwent a core examination. Data obtained were analyzed with Statistical Package for the Social Sciences 18.0 statistics program. Intervention and control groups were compared. Additionally, pre- and post-education results of the intervention group were also compared. Results: About 61.1% of family physicians reported concern and hesitation in prescribing opioids due to known risks, such as overdose, addiction, dependence, or diversion, and agreed that family physicians should apply risk assessment before opioid use in CNCP. Only 16.6% of PCFP reported that risk assessment is not so necessary, whereas 22.2% of PCFP were undecided. Although 47.2% of the family physicians expressed a willingness to apply risk assessment before starting opioids, the rate of eagerness increased markedly to 77.7% after the education, but the rate of increase in practicing was not statistically significant. Conclusion: Knowledge and competency of the family physicians in managing CNCP were improved as was expected. Although the rate of eagerness about risk assessment of opioid misuse was increased, expected increase in the rate of using risk assessment was not achieved. Further studies are needed to identify the reasons of the difficulties on changing the attitudes and practices of primary care physicians about this subject.

Family practice in Turkey: views of family practice residents.

Abstract Turkeys family practice training program is aimed at providing further training to clinically proficient family physicians who serve the community. A survey conducted in 2001 revealed that there was a need for providing additional training and more time in a specially dedicated family practice placement for family practitioners. Recent changes in the Turkish health care system have also impacted the training environment of family practice residents. Clearly, training needs to change with time. The aims of this study are to investigate the attitudes of resident family practice physicians regarding their training in the health care system in order to gather their views on the hospital learning environment, and to estimate their burnout levels. For this research, the design included a 1-phase cross-sectional study. This study was undertaken in 2008 in departments of family medicine at universities (n = 21) and training and research hospitals of the Ministry of Health (n = 11). Approximately 250 family practice residents in Turkey were approached. In total, 174 residents participated (70% response rate). The survey instruments included a questionnaire with 25 queries and 2 scales: The Postgraduate Hospital Educational Environment Measure and the Maslach Burnout Questionnaire–Human Services Survey. The average age of the participants was 32.2 years (standard deviation, 4.5 years; range, 24–57 years). The gender distribution was 57.6% women and 42.4% men. Marital status was 34.7% single, 62.9% married, and 2.4% divorced/widowed. In our results, residents affirmed that university hospitals were the best facilities for residency training. Their future plans confirmed that most would like to work in family health centers. This sample showed average levels of emotional exhaustion, depersonalization, and lack of personal accomplishment. Perceptions of professional autonomy, quality of training, and social support were below average. It may be concluded that certain milestones in the development of family practice in Turkey have been fulfilled. The new regulation for postgraduate training has increased the share of family practice training to 50% (18 months). Establishment of educational family health centers has been planned. Introduction of the formative and summative assessment processes in family practice training is anticipated. It is expected that an assessment such as the Membership of the Royal College of General Practitioners (International) (mRCGP[INT]) examination would be helpful for Turkish residents in reaching these goals.

Quaternary prevention: First, do not harm

Clinical prevention, under the influence of public health, has been organised in a chronological manner since the middle of the 20th century. A paradigm shift from a chronological to a constructivist relationship-based preventive pattern of care1 offers new insights into the practice of doctors. This paradigm shift brings to light the concept of quaternary prevention, a critical look at medical activities with an emphasis on the need not to harm. Quaternary prevention addresses the fundamental question of what constitutes too much or too little medicine. It is the fourth form of disease prevention, but also the fourth frame of action for family doctors (Figure 1). The shift from time-based prevention towards a relationship-based organisation offers new perspectives into physicians’ work. The physicians observe themselves and question the ethical limits of their activities. In this sense, quaternary prevention is aimed more at the doctor than the patient. Moreover, the four definitions of prevention, published in the Wonca Dictionary of Family Medicine,2 offer a structured way to discuss the activities of family doctors, including ethical considerations on the patient-doctor encounter. Quaternary prevention, also known as P4, is a new term for an old concept: first, do not harm. This concept enforces disciplines and attitudes such as evidence-based medicine, quality assurance, defensive medicine, avoiding abusive nosographic diagnoses and ethical issues including those linked to overinformation, and overmedicalisation.3