Showing papers in "Canadian Family Physician in 2002"

What patients want to know about their medications. Focus group study of patient and clinician perspectives.

Abstract: OBJECTIVE: To describe what patients want to know about their medications and how they currently access information. To describe how physicians and pharmacists respond to patients' information needs. To use patients', physicians', and pharmacists' feedback to develop evidence-based treatment information sheets. DESIGN: Qualitative study using focus groups and a grounded-theory approach. SETTING: Three regions of Canada (British Columbia, Nova Scotia, and Ontario). PARTICIPANTS: Eighty-eight patients, 27 physicians, and 35 pharmacists each took part in one of 19 focus groups. METHOD: Purposeful and convenience sampling was used. A trained facilitator used a semistructured interview guide to conduct the focus groups. Analysis was completed by at least two research-team members. MAIN FINDINGS: Patients wanted both general and specific information when considering medication treatments. They wanted basic information about the medical condition being treated and specific information about side effects, duration of treatment, and range of available treatment options. Physicians and pharmacists questioned the amount of side-effect and safety information patients wanted and thought that too much information might deter patients from taking their medications. Patients, physicians, and pharmacists supported the use of evidence-based treatment information sheets. CONCLUSION: Patients and clinicians each appear to have a different understanding of what and how much information patients should receive about medications. Feedback from patients can be used to develop patient-oriented treatment information.

Does counseling help patients get active? Systematic review of the literature.

Abstract: OBJECTIVE To determine the effect of counseling patients to become more physically active. DATA SOURCES PubMed was searched for articles during the past 30 years on physicians promoting physical activity. Identified studies were cross-referenced, and experts were consulted for additional articles. STUDY SELECTION Thirteen articles described primary care counseling on exercise. Six studies were randomized controlled trials (RCTs); seven were quasi-experimental designs. Three of the four RCTs and three of the five quasi-experimental studies were short term (4 weeks to 2 months); the remaining three trials lasted longer than 6 months. Most studies used strategies to address stage of change. SYNTHESIS Outcome measures included adoption of physical activity, stage of change, and change in physical activity level. Most studies found positive relationships between counseling and these outcomes. No reliable evaluation instruments were found, nor was the long-term effect of interventions established. CONCLUSION Interventions that included written materials for patients, considered behaviour change strategies, and provided training and materials for physicians were effective at increasing levels of physical activity. New strategies that involve measuring and prescribing specific amounts of exercise might also improve fitness levels and hence improve outcomes of chronic disease. Shortcomings of these studies include lack of long-term data, lack of sustaining activities for family physicians, and scant cost-efficacy analysis.

Psychosocial effect of common skin diseases.

Abstract: OBJECTIVE To increase awareness of the psychosocial effect of acne, atopic dermatitis, and psoriasis. QUALITY OF EVIDENCE A literature review was based on a MEDLINE search (1966 to 2000). Selected articles from the dermatologic and psychiatric literature, as well as other relevant medical journals, were reviewed and used as the basis for discussion of how skin disease affects patients’ lives and of appropriate management. Studies in the medical literature provide mainly level III evidence predominantly based on descriptive studies and expert opinion. MAIN MESSAGE Dermatologic problems can result in psychosocial effects that seriously affect patients’ lives. More than a cosmetic nuisance, skin disease can produce anxiety, depression, and other psychological problems that affect patients’ lives in ways comparable to arthritis or other disabling illnesses. An appreciation for the effects of sex, age, and location of lesions is important, as well as the bidirectional relationship between skin disease and psychological distress. This review focuses on the effects of three common skin diseases seen by family physicians: acne, atopic dermatitis, and psoriasis. CONCLUSION How skin disease af fects psychosocial well-being is underappreciated. Increased understanding of the psychiatric comorbidity associated with skin disease and a biopsychosocial approach to management will ultimately improve patients’ lives. RESUME

Frequent users of emergency departments. Do they also use family physicians' services?

Abstract: OBJECTIVE To determine whether frequent users of emergency department (ED) services use more or fewer primary care services than other ED patients. DESIGN Population-based, observational, cross-sectional study. SETTING Province of Ontario in 1997-1998. PARTICIPANTS Frequent users of EDs, defined as people with at least 12 ED physician assessments yearly, were compared with those with one to 11 assessments yearly. MAIN OUTCOME MEASURES Number of general practitioner and family physician (GP/FP) office visits and number of GP/FPs visited; diagnoses made during office visits; referrals by GP/FPs to specialists. RESULTS Three quarters of frequent users of EDs visited GP/FPs at least six times yearly, and more than half visited at least 12 times yearly. Although frequent users of EDs saw many GP/FPs (4.2 vs 1.6 in the control group, P < .001), they received, on average, 73% of their primary care from the GP/FPs whom they saw most frequently. Frequent users of EDs also had more referrals to specialists (4.0 vs 1.0). Frequent users of EDs were more likely to live in low socioeconomic neighbourhoods and to be diagnosed with psychosocial conditions (24.1% vs 11.1%). CONCLUSION Most frequent users of EDs have periodic contact with primary care physicians. Communication and coordination of care between EDs and primary care settings could be easier than anticipated, because in most cases, frequent users of EDs seek most of their care from one main ED and one primary care physician.

Physical activity to prevent cardiovascular disease. How much is enough

Abstract: OBJECTIVE To review the role of physical activity in primary prevention of cardiovascular (CV) diseases with particular attention to the intensity and amount of physical activity needed to benefit health. QUALITY OF EVIDENCE MEDLINE was searched for articles published in the indexed English literature from January 1991 to December 2000 using key words related to physical activity (e.g., exercise, physical fitness), CV and coronary artery disease (CAD) risk factors (e.g., diabetes, hypertension, hyperlipidemia, obesity). Findings were supplemented by consensus documents and other published literature. Most articles described prospective observational studies. MAIN MESSAGE Clear evidence indicates an inverse linear dose response between amount of physical activity and all-cause mortality, total CV disease, and CAD incidence and mortality. The minimal effective dose is unclear, but physical activity that results in energy expenditure of approximately 4200 kJ.week-1 appears to be associated with substantial benefits. Physical activity need not be vigorous to benefit health. CONCLUSION Moderate activity, such as brisk walking for 30 to 60 minutes a day most days of the week, is associated with significant reductions in the incidence and mortality of CV disease.

Dissemination of discharge summaries. Not reaching follow-up physicians.

Abstract: OBJECTIVE: To discover how often hospital discharge summaries were available to physicians seeing patients for follow-up visits after hospitalization. DESIGN: Cohort study. SETTING: Teaching hospital in Ottawa, Ont. PARTICIPANTS: We studied 792 patients discharged from an internal medicine service after treatment for acute illness. We determined when and by which physician each patient was seen during the first 6 months after discharge. We also determined the date each patient's discharge summary was printed and the physicians to whom it was sent. We confirmed that summaries were received by means of a survey or by telephoning physicians' offices. Patients were observed for 6 months or until they were readmitted to hospital. MAIN OUTCOME MEASURES: Proportion of follow-up visits to physicians for which discharge summaries were available. RESULTS: During the observation period, patients made 6619 visits (median six per patient, interquartile range [IQR] 2 to 9) to 914 different physicians (median three per patient, IQR 2 to 4). Discharge summaries were available for only 996 (15%) visits. Summaries were available for only 65 initial visits (8.2%); no summaries were available for any visit for 542 (68.4%) patients. Summaries were most commonly unavailable because they were not generated in time for follow-up visits (20.0%) or were not sent to follow-up physicians (50.8%). CONCLUSION: At our institution, discharge summaries often did not get to physicians seeing patients after discharge from hospital.

Preventing diverticular disease. Review of recent evidence on high-fibre diets.

Abstract: OBJECTIVE To review recent evidence on dietary factors associated with diverticular disease (DD) with special emphasis on dietary fibre. QUALITY OF EVIDENCE MEDLINE was searched from January 1966 to December 2001 for articles on the relationship between dietary and other lifestyle factors and DD. Most articles either focused on dietary intervention in treating symptomatic DD or were case-control studies with inherent limitations for studying diet-disease associations. Only one large prospective study of male health professionals in the United States assessed diet at baseline and before initial diagnosis of DD. MAIN MESSAGE A diet high in fibre mainly from fruits and vegetables and low in total fat and red meat decreases risk of DD. Evidence indicates that the insoluble component of fibre is strongly associated with lower risk of DD; this association was particularly strong for cellulose. Caffeine and alcohol do not substantially increase risk of DD, nor does obesity, but higher levels of physical activity seem to reduce risk of DD. CONCLUSION A diet high in fibre and low in total fat and red meat and a lifestyle with more physical activity might help prevent DD.

Medical conditions, medications, and urinary incontinence. Analysis of a population-based survey.

Abstract: OBJECTIVE: To assess associations between various medical conditions and drug treatments and reports of urinary incontinence. DESIGN: Secondary analysis of responses to the second wave of the National Population Health Survey (NPHS). Odds ratios were calculated using survey-weighted multiple logistic regression; confidence intervals were calculated using bootstrap methods. SETTING: Canadian households in all 10 provinces, as assessed by Statistics Canada's NPHS. PARTICIPANTS: From among respondents to the NPHS, the 54,920 people aged 30 years or older. MAIN OUTCOME MEASURES: Responses to the question "Do you have urinary incontinence diagnosed by a health professional?" and analysis of variables related to medical conditions and medications. RESULTS: Urinary incontinence was associated with strokes, arthritis, and back problems in both sexes. Odds ratios for incontinence were elevated among men and women who reported having asthma. Narcotics and diuretics were strongly associated with incontinence in both sexes. Psychoactive medications were associated with incontinence in women; antidepressants were associated with incontinence in men. CONCLUSION: Physicians should consider the possibility that patients with common conditions, such as arthritis, back problems, or respiratory conditions associated with coughing, might also have urinary incontinence. Physicians should also be aware that urinary incontinence might be a side effect of therapies and make relevant inquiries. Medications associated with incontinence could be changed.

Influenza vaccination during pregnancy.

Abstract: QUESTION: A 27-year-old patient of mine recently learned she is pregnant. She took the influenza vaccine offered at work when she was 7 weeks pregnant. Is her fetus at risk of malformations? ANSWER: No evidence indicates that killed influenza vaccine is teratogenic, even if given during the first trimester. Since 1996, Health Canada's Centre for Disease Control and Prevention has recommended that pregnant women in their second and third trimesters be vaccinated. This should not be interpreted as evidence that the vaccine is teratogenic in the first trimester because such evidence does not exist.

Preventive screening. What factors influence testing

Abstract: OBJECTIVE To determine factors associated with having preventive screening tests in a population-based sample of Ontario women. DESIGN Secondary analysis of data from Statistics Canada9s National Population Health Survey linked to data from the Ontario Health Insurance Plan to ascertain whether women aged 20 or older had Pap smears, mammography, bone densitometry, or cholesterol testing. Factors associated with having testing were subjected to logistic regression analysis. SETTING Ontario. PARTICIPANTS Women aged 20 or older; from 19,600 Canadian households, 2232 Ontario women gave consent to linkage of administrative databases. MAIN OUTCOME MEASURES Age-specific population screening rates. Odds ratios and probabilities of having screening in relation to socioeconomic, geographic, and physician-associated factors. RESULTS Having screening was associated with age, income, education, and place of residence. Women with regular physicians were more likely to have Pap smears (odds ratio [OR] 4.4, range 1.7 to 12), densitometry (OR 22, range 3.6 to 140), and cholesterol testing (OR 8.0, range 2.3 to 29). Women who had periodic health examinations were more likely to have Pap smears (OR 6.7, range 4.6 to 9.8), mammograms (OR 3.7, range 2.3 to 5.9), densitometry (OR 3.7, range 1.3 to 10.5), and cholesterol testing (OR 3.0, range 2.0 to 4.5). The probability of having testing increased with number of visits a year to a doctor, but ceased to increase after three visits. CONCLUSION Having screening tests was associated with socioeconomic factors including income, education, and place of residence. Patients who went to doctors for episodic care only were less likely to have preventive screening than patients who went for periodic health examinations.

St John's wort or sertraline? Randomized controlled trial in primary care

Abstract: OBJECTIVE To compare the change in severity of depressive symptoms and occurrence of side effects in primary care patients treated with St John9s wort (SJW) and sertraline. DESIGN Double-blind, randomized 12-week trial. SETTING Community-based offices of 12 family physicians practising in greater Montreal, Que. PARTICIPANTS Eighty-seven men and women with major depression and an initial score of > or = 16 on the Hamilton Rating Scale for Depression (Ham-D). INTERVENTIONS Patients were randomized to treatment with either sertraline (50 to 100 mg/d) or SJW (900 to 1800 mg/d) in a double-blind fashion. Assessment of depression was done at entry and at 2, 4, 8, and 12 weeks using the Ham-D, the Beck Depression Inventory (BDI), and a questionnaire asking about compliance and side effects. MAIN OUTCOME MEASURES Changes from baseline in Ham-D and BDI scores and self-reported side effects. RESULTS There were no important differences in changes in mean Ham-D and BDI scores (using intention-to-treat analysis), with and without adjustment for baseline demographic characteristics, between the two groups at 12 weeks. Significantly more side effects were reported in the sertraline group than in the SJW group at 2 and 4 weeks9 follow up. CONCLUSION The more benign side effects of SJW make it a good first choice for this patient population.

Mothers, babies, and communities. Centralizing maternity care exposes mothers and babies to complications and endangers community sustainability.

Abstract: nder budgetary strains, regional health authorities across Canada are looking to cut costs by restructuring and consolidating services. Often undertaken in the guise of regionalization, centralization frequently appears to be applied without considering the consequences to patient and family care. Regionalization is distinct from centralization. Regionalization is the rational orga-nization of services among level I, level II, and level III facilities, recognizing the contribution of all levels to the care and support of patients, prac-titioners, and communities.

Premenstrual syndrome. Evidence-based treatment in family practice.

Abstract: OBJECTIVE To evaluate the strength of evidence for treatments for premenstrual syndrome (PMS) and to derive a set of practical guidelines for managing PMS in family practice. QUALITY OF EVIDENCE An advanced MEDLINE search was conducted from January 1990 to December 2001. The Cochrane Library and personal contacts were also used. Quality of evidence in studies ranged from level I to level III, depending on the intervention. MAIN MESSAGE Good scientific evidence shows that calcium carbonate (1200 mg/d) and selective serotonin reuptake inhibitors are effective treatments for PMS. The most commonly used therapies (including vitamin B6, evening primrose oil, and oral contraceptives) are based on inconclusive evidence. Other treatments for which there is inconclusive evidence include aerobic exercise, stress reduction, cognitive therapy, spironolactone, magnesium, nonsteroidal anti-inflammatory drugs, various hormonal regimens, and a complex carbohydrate-rich diet. Although evidence for them is inconclusive, it is reasonable to recommend healthy lifestyle changes given their overall health benefits. Progesterone and bromocriptine, which are still widely used, are ineffective. CONCLUSION Calcium carbonate should be recommended as first-line therapy for women with mild-to-moderate PMS. Selective serotonin reuptake inhibitors can be considered as first-line therapy for women with severe affective symptoms and for women with milder symptoms who have failed to respond to other therapies. Other therapies may be tried if these measures fail to provide adequate relief.

Urinary incontinence in Canada. National survey of family physicians' knowledge, attitudes, and practices.

Abstract: OBJECTIVE To determine current knowledge, attitudes, and management of urinary incontinence among family physicians in Canada. DESIGN Cross-sectional mailed survey. SETTING Family physicians in Canada. PARTICIPANTS A random sample of 1500 members of the College of Family Physicians of Canada. MAIN OUTCOME MEASURES Self-assessed knowledge, self-reported attitudes, and rating of various tests and treatments in the investigation and management of incontinence. RESULTS The overall unadjusted response rate was 43.3% (650/1500). Although most respondents reported that urinary incontinence was common in their practices, less than half (46.0%, 284/617) indicated that they clearly understood incontinence and just 37.9% (232/612) had an organized plan for incontinence problems. Only 35.0% (214/612) of respondents felt very comfortable dealing with incontinence. Physical examination, urodynamic studies, urinalysis, and testing blood sugar levels were all considered important investigations by more than 90% of respondents. CONCLUSION There are wide variations in knowledge, attitudes, practices, and comfort level among family physicians dealing with urinary incontinence.

Listening to native patients. Changes in physicians' understanding and behaviour.

Abstract: OBJECTIVE: To discover how physicians develop an understanding of Native patients and communities that enables them to communicate better with these patients. DESIGN: Qualitative method of in-depth interviews. SETTING: Native communities across Canada. PARTICIPANTS: Ten non-Native physicians providing primary care to Native patients and communities. METHOD: In-depth, semistructured interviews explored communication strategies developed by primary care physicians working with Native patients. The audiotaped and transcribed interviews were analyzed by the investigators using the phenomenologic approach of immersion and crystallization. MAIN FINDINGS: Three main themes emerged. First was elements of communication: during patient-physician communication, physicians speak less, take more time with patients, and become comfortable with silence. Second was community context: patients' illnesses are not distinct from their community context; patient care and community relations, culture, and values are often inseparable. Third was the process of change in physicians: over time, participants increased understanding of Native culture, ways of communicating, and behaviour. Change comes about through long service, listening well, and participating in community events. CONCLUSION: Developing cross-cultural communication was difficult and took years, if not forever. Understanding Native communities changed physicians. They described a journey of self-examination, development of personal relationships, and rewards and frustrations.

Return to work after occupational injury. Family physicians' perspectives on soft-tissue injuries.

Abstract: OBJECTIVE: To document physicians' views about facilitating factors for and barriers to their helping workers recover after occupational soft-tissue injuries and to ascertain physicians' knowledge and attitudinal barriers to their involvement in return to work. DESIGN: Faxed survey. SETTING: Manitoba family practices and emergency departments. PARTICIPANTS: General practitioners, family physicians, and emergency physicians regularly caring for injured workers. MAIN OUTCOME MEASURES: Physicians' ranking of facilitating factors and barriers, changes to help their involvement in return to work, and their attitudes and knowledge about return to work. RESULTS: Respondents and nonrespondents were demographically similar, 232 physicians (51.3%) responded. Respondents believed the main facilitating factors were physicians' ability to explain the nature and prognosis of injuries to workers (69%) and the willingness of workplaces to accommodate injured workers (26%). The main barriers were workers' misunderstandings and fears about their injuries (70.7%) and non-supportive supervisors and co-workers (20.8%). The most frequently requested change was better workplace job accommodation (48%). Most physicians agreed they had a role in planning return to work and were aware of the effect of job satisfaction, psychosocial elements, and work-related factors. Despite supporting evidence, only one third of physicians stated they would say "try to continue usual activities" to patients with occupational low back pain. CONCLUSION: Most physicians seemed aware of their role in return to work and the effect of occupational factors, but their advice on activity after injury differed from that in practice guidelines.

Chronic cough. Three most common causes.

Abstract: OBJECTIVE: To describe an approach to diagnosis and treatment of patients with chronic cough. QUALIITY OF EVIDENCE: MEDLINE was search for reports of studies comducted between 1970 and 2000 on chronic cough and its epidemiology, natural history, diagnois, and theraphy. Articles were further selected based on clinical relevance and design. Most articles reviewed were epidemiology cohort and case studies and reviews. MAIN MESSAGE: Chronic cough, a commom ailment amoung adults, is often a diagnostic challenge. Most cases of chronic cough are associated with postnasal drip syndrome (PNDS), asthma, gastroesphageal reflux disease (GERD), or some combination of these. Initial investigation should include chest radiography to ruke out more ominous causes of chronic cough. Examinations and trials of treatment can diagnose PNDS, asthma, and GERD. Combination treatments are often necessary for managing chronic cough. CONCLUSION: The most common causes of chronic cough are PNDS, asthma, GERD, or some combination of these. A systematic approach to diagnosis and treatment is effective for most cases of chronic. cough.

Bipolar spectrum disorders. New perspectives

Abstract: OBJECTIVE To review new perspectives on diagnosis, clinical features, epidemiology, and treatment of bipolar II and related disorders. QUALITY OF EVIDENCE Articles were identified by searching MEDLINE and ClinPSYCH from January 1994 to August 2001 using the key words bipolar disorder, type II or 2; hypomania; spectrum; or variants. Reference lists from articles were reviewed. Overall, the quality of evidence was not high; we found no randomized controlled trials that specifically addressed bipolar II or bipolar spectrum disorders (BSDs). MAIN MESSAGE Characterized by elevated mood cycling with depression, BSDs appear to be much more common than previously thought, affecting up to 30% of primary care patients presenting with anxiety or depressive symptoms. Hypomania, the defining feature of bipolar II disorder, is often not detected. Collateral information, semistructured interviews, and brief screening instruments could improve diagnosis. Antidepressants should be used with caution. The newer mood stabilizers or combinations of mood stabilizers might be the treatments of choice in the future. CONCLUSION Family physicians, as primary providers of mental health care, should try to recognize and treat BSDs more frequently. These disorders are becoming increasingly common in primary care populations.

Patients with eating disorders. How well are family physicians managing them

Abstract: OBJECTIVE To assess the attitudes and behaviour of family physicians toward patients with eating disorders (EDs) and to assess these physicians' ongoing learning needs. DESIGN Confidential survey by mail. SETTING Family practices in London, Ont. PARTICIPANTS Two hundred thirty-six general FPs. MAIN OUTCOME MEASURES Proportion of FPs seeing patients with EDs, screening and management practices, learning needs. RESULTS Survey response rate was 87.7%; 64% of respondents were male, 36% were female, and 54% had completed a family medicine residency program. Overall, FPs were more comfortable with diagnosis, and less comfortable with management, of EDs. Most respondents shared care with other professionals, usually psychiatrists and nutritionists. Female physicians had identified a larger number of ED patients in their practices and were more likely to screen routinely for EDs. Three quarters of FPs rated their undergraduate training in EDs as poor, and 59% thought their postgraduate training was poor. Outpatient services, diagnostic issues, screening needs, and management planning were identified as important learning needs. Family physicians thought these needs could be best addressed in interactive workshops or peer-led case-discussion groups. CONCLUSION Family physicians are important in first-line treatment of EDs, but many barriers prevent effective diagnosis and management. Validated screening tools and management strategies could assist FPs in caring for patients with EDs.

In for the long haul. Which family physicians plan to continue delivering babies

Abstract: OBJECTIVE: To compare characteristics of family physicians planning to discontinue or stay in intrapartum care. DESIGN: Self-administered questionnaire. SETTING: Department of Family Practice at Children's and Women's Health Centre of British Columbia. PARTICIPANTS: Ninety-five family physicians who attended at least one birth at the Health Centre between April 1997 and August 1998. MAIN OUTCOME MEASURES: Intention to leave or stay in family practice maternity care, physician characteristics and beliefs. RESULTS: Forty-five percent (43/95) of family physicians planned to leave maternity care within the next 5 years. Physicians planning to leave had more negative attitudes about the alternative birthing centre, doulas, and practising in free-standing settings without on-site obstetricians; were more likely to report missing personal events because they had put their maternity patients first; were less likely to make housecalls during women's labour; and were more likely to be paid through fee-for-service. CONCLUSION: Being paid by fee-for-service, having negative attitudes toward non-traditional maternity care, and conflict between maternity care and personal life were associated with intention to leave intrapartum care.

Nausea and vomiting of pregnancy. Evidence-based treatment algorithm.

Abstract: QUESTION: One of my patients suffers from a moderate-to-severe form of morning sickness. She responded only partially to doxylamine and pyridoxine (Dicletin), and I wish to try adding another medication. What should my priority be? ANSWER: An algorithm used by Motherisk to manage thousands of patients takes a hierarchical approach to this condition. This approach is evidence based with regard to fetal safety as well as efficacy.

Performance assessment. Family physicians in Montreal meet the mark

Abstract: OBJECTIVE To assess the clinical performance of a representative non-volunteer sample of family physicians in metropolitan Montreal, Que. DESIGN Assessment of clinical performance was based on inspection visits to offices, peer review of medical records, and chart-stimulated recall interviews. The procedure was the one usually followed by the Professional Inspection Committee of the College des medecins du Quebec. SETTING Family physicians’ practices in metropolitan Montreal. PARTICIPANTS One hundred randomly selected family physicians. INTERVENTIONS For each physician, 30 randomly chosen patient charts with data on three to five previous visits were reviewed using explicit criteria and a standard scale using global scores from 1 to 5 (unacceptable to excellent). MAIN OUTCOME MEASURES Scores were assigned for office practices; record keeping; number of continuing medical education (CME) activities; and quality of clinical performance assessed in terms of investigation plan, diagnostic accuracy, treatment plan, and relevance of care. RESULTS Overall performance was judged to be good to excellent for 98% of physicians in their private practices; for 90% of physicians concerning CME activities; for 94% of physicians concerning their clinical performance in terms of quality of care; and for 75% of physicians as to record keeping. There was a link between record keeping and quality of care as well as between the number of CME activities and quality of care. CONCLUSION The overall clinical performance of family physicians in the greater Montreal region is excellent.

Family physicians and psychiatrists. Qualitative study of physicians' views on collaboration.

Abstract: OBJECTIVE To understand how to improve collaboration between psychiatrists and family physicians in primary care settings. DESIGN Qualitative study using 10 in-depth interviews and a focus group session. SETTING Catchment area in eastern Montreal, Que. PARTICIPANTS Five FPs and five psychiatrists. METHOD Ten interviews and a focus group were conducted to identify ways of improving collaboration between FPs and psychiatrists. All session were audiotaped and transcribed verbatim. Analysts used Atlas.ti to compare findings vertically and horizontally. MAIN FINDINGS Three strategies were identified: communication, continuing medical education (CME) for FPs, and access to consulting psychiatrists. The first two can be implemented by FPs and psychiatrists together, but psychiatrists thought the last one was not feasible due to lack of both time and remuneration for such activity. CONCLUSION Better communication and CME for FPs in psychiatry can help improve collaboration between FPs and psychiatrists. Increased access to consulting psychiatrists requires substantial alteration in established clinical roles and routines.

Taking ACE inhibitors during pregnancy. Is it safe

Abstract: QUESTION: A pregnant patient is taking enalapril for primary hypertension. How safe are angiotension-converting enzyme inhibitors (ACEI) during pregnancy? ANSWER: Evidence of whether ACEIs cause problems during the first trimester of pregnancy is reassuring. There is evidence that they cause severe renal and other problems during the second and third trimesters, however. These drugs should be avoided during pregnancy.

Shared mental health care. Update from the Collaborative Working Group of the College of Family Physicians of Canada and the Canadian Psychiatric Association.

Abstract: In December 1997, the Canadian Psychiatric Association (CPS) and the College of Family Physicians of Canada (CFPC) took the visionary step of establishing a Collaborative Working Group to facilitate better collaboration between psychiatrists and family physicians across Canada. The impetus to create this group came from development of a joint position paper on shared mental health care (SMHC) in Canada by the two organizations. This paper included recommendations for improving the working relationship between psychiatrists and family physicians. As the Collaborative Working Group enters its fifth year, it is an opportune time to review its activities and accomplishments and to reflect on the degree to which shared care has developed in Canadian communities. The Working Group has identified six major objectives: strengthen links between colleagues interested in shared mental health care; enhance residency and undergraduate training in SMHC; develop a national research strategy; develop models of shared care for rural communities and underserviced populations; advocate for shared care with government and major funders; and develop continuing education programs in shared care. The Collaborative Working Group has identified and refined specific goals for each of these areas. The achievements of its first 3 years are summarized in a report produced in December 2000 that is available from both organizations. It has been encouraging to watch the rapid expansion in shared care projects across Canada and the extent to which principles of shared care are now being accepted by planners and administrators of health systems as well as by clinicians. New initiatives in clinical service delivery, innovative training experiences for residents, creative continuing education programs, administrative links to facilitate shared care, and a small but expanding number of research projects have flourished. The range and diversity of these activities have been captured in a compendium of SMHC projects recently produced by the Working Group with the support of Health Canada. It details almost 100 projects under way across Canada. One goal of producing such a compendium is to provide support and direction for people interested in developing new projects, as well as to help them connect with colleagues who have similar goals. It has become apparent to the Working Group, however, that if shared care is to move forward, more is needed. First is an emphasis on training future practitioners who will incorporate shared care into daily practice. The Working Group has developed recommendations for curriculums for training family medicine and psychiatry residents. Second is to ensure new projects are based, as much as possible, on existing evidence about what has and has not worked. One author (M.C.) and Roger Bland have developed a comprehensive annotated bibliography on SMHC projects, which includes an extensive review of the research and evaluation literature relevant to SMHC and recommends a common framework for evaluating SMHC projects. Funded by Health Canada, the bibliography will be published shortly by the CPA and CFPC as a supplement to The Canadian Journal of Psychiatry. To maintain a national perspective on shared care, the Working Group and colleagues from St Joseph’s Health Centre in Toronto, McMaster University, and the University of Toronto (in 2000 and 2001) and the Alberta Mental Health Board (in 2002) have organized an annual national conference on SMHC in Canada. These meetings have been successful and have provided a forum for researchers to present their work. They also have provided informal opportunities for colleagues involved in SMHC to meet, exchange ideas, and discuss future collaboration. The last 5 years have been an exciting time for shared care, and the concepts are increasingly being integrated into provincial planning for both mental health and primary care reforms. Goals for the next 2 years include: completion of recommendations for implementing SMHC in underserviced areas; development of a national research strategy; broadening of the participation of other professional groups involved in the Collaborative Working Group; expansion of websites to support and link individuals interested in SMHC; completion of draft curriculums for sharing care between psychiatry and family medicine residents; and continued work with planners and funders to determine how principles and concepts of shared care can be incorporated into federal and provincial health reforms. For further information on any of the activities of the Working Group, to receive any of our reports, or to get on a mailing list, please contact either of the two Co-Chairs: Nick Kates, CPA Co-Chair at nkates@mcmaster.ca, or Marilyn Craven, CFPC Co-Chair at cravenm@mcmaster.ca.

Dealing with office emergencies. Stepwise approach for family physicians.

Abstract: OBJECTIVE: To develop a simple stepwise approach to initial management of emergencies in family physicians' offices; to review how to prepare health care teams and equipment; and to illustrate a general approach to three of the most common office emergencies. QUALITY OF EVIDENCE: MEDLINE was searched from January 1980 to December 2001. Articles were selected based on their clinical relevance, quality of evidence, and date of publication. We reviewed American family medicine, pediatric, dental, and dermatologic articles, but found that the area has not been well studied from a Canadian family medicine perspective. Consensus statements by specialty professional groups were used to identify accepted emergency medical treatments. MAIN MESSAGE: Family medicine offices are frequently poorly equipped and inadequately prepared to deal with emergencies. Straightforward emergency response plans can be designed and tailored to an office's risk profile. A systematic team approach and effective use of skills, support staff, and equipment is important. The general approach can be modified for specific patients or conditions. CONCLUSION: Family physicians can plan ahead and use a team approach to develop a simple stepwise response to emergency situations in the office.

Les troubles liés aux événements traumatiques: dépistage, évaluation et traitements

Abstract: OBJECTIF Informer les medecins de premiere ligne concernant le depistage, le diagnostic et le traitement des troubles psychologiques associes aux evenements traumatiques. QUALITE DES DONNEES Les recensions proviennent de recherches via les banques de donnees PsycLIT, PsyINFO, PILOTS et MEDLINE (de janvier 1985 a decembre 2000) utilisant les termes « acute stress disorder », « posttraumatic stress disorder », « traumatic stress », « psychotherapy », « psychosocial treatment », « treatment » et « pharmacotherapy ». Les recommandations concernant le traitement de l’etat de stress aigu (ESA) et du trouble de stress post-traumatique (TSPT) reposent sur des donnees probantes provenant d’essais therapeutiques d’excellente qualite. Les conclusions portant sur le diagnostic et l’evaluation reposent sur les plus recentes etudes epidemiologiques ainsi que sur des consensus et des opinions d’experts. PRINCIPAL MESSAGE Tres souvent, l’ESA et le TSPT sont sous-diagnostiques et sous-traites. Les medecins de famille sont susceptibles de recevoir des patients souffrant de ces troubles. Le depistage precoce en premiere ligne repose sur une ecoute attentive, sur une relation chaleureuse et securisante avec le patient et sur la recherche de difficultes d’adaptation en lien avec un evenement traumatique. Idealement, les individus souffrant d’un ESA ou d’un TSPT sont orientes vers une ressource specialisee. Si de telles ressources ne sont pas accessibles, le medecin peut offrir des conseils et prescrire une medication en fonction des symptomes. CONCLUSION Les medecins de famille peuvent contribuer a identifier et traiter les patients souffrant de l’un ou l’autre de ces troubles.

Managing diabetes in childhood and adolescence.

Abstract: OBJECTIVE: To describe management of children's and adolescents' diabetes outlining standards of care compatible with current clinical practice. QUALITY OF EVIDENCE: MEDLINE was searched using specified MeSH headings. Bibliographies of selected articles were used to find additional pertinent articles. Preference was given to randomized controlled trials, clinical practice guidelines, consensus statements, and task force recommendations. We also cite reviews of current practice regarding pediatric diabetes. MAIN MESSAGE: Managing children with diabetes presents a difficult challenge to parents and their advisors. Achieving good diabetic control is impossible unless parents are properly instructed in practical management of the disease. Children with diabetes should be managed quite differently from adults in several respects. Avoiding hypoglycemia is most important, particularly for preschool children. Higher target blood glucose levels than would be accepted for adults are both justifiable and necessary for preschool children. Controlling children's diabetes depends as much on personal factors and family adjustment as it does on insulin, food plans, and exercise. CONCLUSION: Diabetes mellitus is difficult to manage at any age. Managing children's diabetes successfully requires continuous education and encouragement of parents and children. Pediatric diabetes care teams and family physicians play a vital role in encouraging children to control their disease while participating fully in normal childhood activities.

Caring for seriously mentally ill patients: Qualitative study of family physicians' experiences

Abstract: OBJECTIVE: To examine family physicians' experiences in caring for patients with serious mental illness and their expectations of a shared mental health care (SMHC) model. DESIGN: Qualitative method of in-depth interviews. SETTING: London, Ont. PARTICIPANTS: Purposive sample of 11 full-time family physicians providing ongoing care for patients with serious mental illness. METHOD: Eleven interviews were conducted to explore family physicians' experiences. All interviews were audiotaped and transcribed verbatim. Analysis was done using a constant comparative approach and was carried out concurrently rather than sequentially. Researchers read all interview transcripts independently before comparing and combining their analyses. Final analysis involved examining all interviews together to discover relationships between and among emerging themes. MAIN FINDINGS: Findings reflected three main themes: what family physicians perceive they bring to care of seriously mentally ill patients (i.e., whole-person approach to care); challenges family physicians face in participating in shared care of these patients (i.e., communication and access issues); and family physicians' expectations of a SMHC model (i.e., guidance and feedback). CONCLUSION: As seriously mentally ill patients are moved out of institutions, the need for an effective and efficient SMHC model becomes imperative. Our findings suggest that family physicians could be an important part of SMHC models but only if systemic barriers are removed and collaborative practice is encouraged.