Peter L. Twohig

Asthma in primary care: making guidelines work.

OBJECTIVE To determine the views of family physicians regarding selected asthma recommendations from a Canadian practice guideline and the supporting evidence, and to identify issues needing further development if family physicians are to find guideline recommendations to be truly useful clinical tools. SETTING Four urban communities in Nova Scotia, Prince Edward Island and New Brunswick. PARTICIPANTS Twenty community family physicians representing different practice settings, and varying according to age and sex, were recruited to participate. DATA COLLECTION Four focus groups were held, each lasting 2 h, at which recommendations from a published asthma guideline were presented for discussion on the applicability to their practices. The data were analyzed using a grounded theory method. RESULTS Physicians rely on clinical judgment in lieu of objective measures in diagnosing asthma and resist treating every exacerbation with steroids. They thought that the recommendations on smoking and patient education should have been stronger or more prominent. Patient noncompliance limits the usefulness of home peak flow measures. Topics such as allergy assessment and most pharmacological therapies triggered little discussion. DISCUSSION Asthma guideline developers and those interested in enhancing compliance with recommendations will need to attend to factors such as physician attitudes and beliefs on a variety of issues, including the use of objective measures and the availability of adequate resources to conduct the tests. Similarly, negative patient attitudes toward an increased use of corticosteroids suggest that a public education program would be most helpful regarding that group of recommendations.

Innovating Expertise: X-ray and Laboratory Workers in the Canadian Hospital, 1920–1950

The modern healthcare system is a complex organization, comprising many occupational groups. There are those widely recognized as ‘professionals’ (physicians and nurses), those considered ‘allied health professionals’ (occupational therapy, physical therapy, speech pathology), and the ‘support staff’ (cleaners, porters, kitchen workers). Until recently, the historiography of healthcare in Canada has largely focused on professional groups and often uncritically. More recent studies, including the important work of Ruby Heap, Nadia Fahmy-Eid and others, have turned their attention to the allied healthcare groups.1 While such studies have enriched our understanding of health services in Canada, the occupational group largely remains the focus of the analysis. This is entirely understandable. Many groups have membership records or publish journals that make them natural areas of inquiry. Nevertheless, one effect of this professional gaze is that occupational groups in healthcare have acquired what Gerald Larkin has described as an ‘aura of inevitable permanence.’

Qualitative Perspectives on a Facilitated Change in Provincial Pharmacare Coverage

Background: During 2000, Nova Scotias Department of Health implemented policy changes and educational interventions to encourage a switch from wet nebulization therapy to dry-dose delivery systems. The policy changes applied to beneficiaries of the Nova Scotia Pharmacare Programs, while the educational interventions had a broader provincial perspective. Methods: Researchers from Dalhousie Universitys Department of Family Medicine subsequently interviewed family physicians, pharmacists, and other health professionals to gather their views on the initiative. A single researcher (PLT) conducted interviews in the summer of 2001 in two settings. Interviews were audiotaped and transcribed. Analysis was guided by a grounded theory approach and facilitated by the use of QSR N5, a software program designed for computer-assisted qualitative data analysis. Results: The results are discussed in several categories, including the role of evidence, change strategies, user devotion to older delivery systems, and health care provider perspectives on policy change. Conclusion: Health care professionals interviewed agreed that this was a well-designed initiative in many respects. Participants identified several key elements that offer insights for future policy-implementation design, execution, and evaluation.

Professionalism and the social role of medicine

There is much to commend in Wear and Kuczewski’s “The Professionalism Movement: Can We Pause?” (2004). The reforms they suggest are generally progressive. However, we identify three signiacant failings in the article. The arst is the adoption of a relationship-centered approach to professionalism, which fails to acknowledge that the profession is more than a collection of individual relationships. Second, Wear and Kuczewski focus on only the academic medical environment, to the exclusion of nonacademic clinical care. Finally, Wear and Kuczewski’s failure to recognize the complexity of the question of the social role of medicine leads them to endorse, too uncritically perhaps, a social-justice perspective for individual physicians. Indeed, all three failures arise from Wear and Kuczewski’s failure to recognize the complexity of the question of the social role of medicine.