European General Practice Research Network (EGPRN)

KEY NOTE LECTURES

Use of Simulated or Standardized Patients to motivate learning

Jan-Joost Rethans, MD, PhD, The Netherlands

Director of Simulated Patient - and Communication Skills programme at the Maastricht Medical School, Skillslab, Maastricht University, the Netherlands E-mail: [email protected]

More than 45 years ago Barrows and Abrahamson introduced the use of simulated patients. A simulated patient (SP) is defined as a ‘normal person who has been carefully coached to accurately portray the characteristics of a specific patient’. Originally SPs were exclusively used in medicine but nowadays they are used in many other areas as for example in nursing, physiotherapy, dentistry, pharmacy, dietetics and veterinary medicine.

Despite SPs long history and its widespread use, there are still many issues to be clarified or resolved in the use of SPs. Ignorance about the use of SPs leads to myths and fantasies about SPs, sometimes resulting in scepticism about the use of SP, whereas in modern teaching one should focus on facts.

Amongst the issues to be clarified or resolved in the use of SPs are: -what is the difference between simulated and standardized patients? -Are SPs only useful in the teaching of communication? -Is feedback by SPs really useful? -How does the use of SPs compare to the use of real patients? -Can all medical diseases be simulated?

In this presentation I will try to get rid of the myths, while beholding some fantasies, but foremost I will focus on the facts and experiences about the use of SPs.

I hope I can inspire those of you who are in doubt about introducing SPs to start with them and to show others who are at a dead end with SPs there always is a way out to other uses of SPs. Finally, I hope to show you all that working with SPs and students in an inspiring educational atmosphere is great fun for all.

And we know for sure: there is no better motivator for learning than having fun!

Motivation or Manipulation?

Norbert Donner-Banzhoff, MD, PhD – Germany

Abt. Allgemeinmedizin - Philipps University of Marburg, Marburg/Lahn, Germany E-mail: [email protected]

Motivating patients to adopt healthy behaviours is seen by many as a core contribution of general practitioners to prevent future disease.

More than 20 years ago psychologists and therapists in addiction developed sophisticated techniques to achieve this aim. ‘Motivational interviewing’ (MI), ‘Stages of Change’ and the ‘Transtheoretical Model’ stand for a conceptual model of behavioural change that postulates distinct stages. Behavioural support interventions have to be tailored to the stage the patient is currently in. This approach has been particularly useful for primary care clinicians since their patients are not selected regarding their motivation to behavioural change.

Since then, Shared Decision-Making (SDM) has entered the field. SDM takes us one step further away from the old paternalist model. Patients and doctors negotiate decisions regarding diagnosis, prevention and treatment. Decision support technologies are expected to enable the patient to take part in a dialogue of two partners at, wherever possible, equal level. Against this background, behavioural interventions seem to undermine the encounter of patients and doctors as equal partners.

SDM requires us to redefine the role of motivational techniques. The distinction between decision-making and problem solving can provide a key for a new understanding of the two approaches. Decision-making implies the definition of goals. Here behavioural techniques have only a very limited role. However, goals that patient and clinician have agreed upon will be achieved easier if motivational and/or behavioural techniques are used in a skilful manner.

Research in primary care - the Swiss cheese challenge

Klaus Bally, MD / Andreas Zeller, MD, Switzerland

Allgemeine Medizin FMH, Institut für Hausarztmedizin IHAMB, Universität Basel, Basel, Switzerland E-mail: [email protected], [email protected]

Knowledge of the Swiss federal system of primary care is necessary to appreciate the challenge of primary care research in Switzerland. On the one hand high standards of continuing education should facilitate high-quality research, on the other hand institutional conditions for primary care research are still unsatisfactory. Government and its health agencies are very reluctant to sponsor primary care research. Despite these adverse conditions, primary care research is thriving.

The Swiss Academy of Medical Sciences is an exception and supports primary care research in our country with an annual amount of 200000 Swiss Franks. With these funds about six small research projects per year are funded. We would like to give you some insight into current primary care research in Switzerland by presenting some research projects, which applied for grants.

Following are some of the topics, which are of interest to Swiss general practitioners:

– Epidemiological research: incidence and prevalence of acute und chronic diseases in primary care (epidemiology in the out-patient versus in-patient setting, e.g. community acquired pneumonias, hypertension cohort study)

– Diagnostic research: value benefit analysis and validity assessment of screening measures, especially in low-prevalence situations

– Quality control research: maintenance of standards for diagnostic and therapeutic measures, control of guidelines in private practices, development of therapeutic measures and control of efficacy

– Doctor-patient relationship: patients’ risk perception and doctors’ risk communication. Development of instruments to assess primary care quality, including soft factors. Documenting the importance of the narrative in primary care consultations

– Health services research: development of procedures to improve health care of patients with chronic diseases by teaching nurses/attendants, research concerning treatment quality of marginal groups

– Education research: evaluation of teaching, e.g. one-on-one tutorials, patients’ burden by being part of teaching students.

In the last 10 years, a multitude of such projects have managed to wake up primary care research from its slumber. Just like all other fields of medicine, primary care needs a scientific base. Its significance needs to be marked with research projects. The results are promising. They enhance scientific knowledge of general practitioners in Switzerland and abroad. The results can be put into practice. Swiss cheese is still riddled with holes. Emergency situations, acute diseases, rehabilitation medicine and palliative care are some fields, which have been underrepresented in research. Limited personal and financial resources are responsible. In addition, it is not easy to introduce research projects into the relationship of trust that has grown during many years between doctor and patient. A national research project in primary care needs to be called for. This project will help establish the initiated activities. In the medium term, efficient high-quality primary care work will only be possible if it is based on research.

PRIZE WINNING POSTER

Arriba-lib-electronic library of decision aids: results of a feasibility study

Oliver Hirsch, Heidemarie Keller, Tanja Krones, Norbert Donner-Banzhoff

Dept. General Practice/Family Medicine, Philipps University Marburg, Marburg, Germany E-mail: [email protected]

Background: Evidence based medical decision aids have the goal to enable the patient to make an informed decision together with the physician. Individual values and preferences of the patient should be considered in this process. Most decision aids are designed to inform the patient outside the consultation.

Research question: The aim of our project was to create an electronic library of evidence based, interactive, and transactional decision aids based on the shared decision making (sdm) concept, which covers the spectrum of coronary heart disease.

Method: We created an electronic library of evidence based decision aids including cardiovascular prevention, atrial fibrillation, coronary heart disease, diabetes type 2 and depression. We conducted a feasibility study with 34 general practitioners recruiting 200 patients. Patients were included when there was a decision to be made in the treatment of the above-mentioned diseases. Counselling was based on the concept of sdm (definition of the problem, individual risk calculation, change of individual risk due to treatment options, discussing pros and cons of treatment options, plan for further action). Questionnaires, personal and telephone interviews, and focus groups were used to measure satisfaction of patients and physicians with the counselling and the decision aids.

Results: Will be presented at the conference because the study is in the data collection phase.

Conclusion: Will be presented at the conference.

THEME PRESENTATIONS ON Motivation in Medical Education and Patient Communication

Using videotaped consultations in primary care to unravel issues within the osteoarthritis consultation

Zoe Paskins, P.R. Croft, A.B. Hassell

Dept. Primary Care Sciences, Arthritis Research UK Primary Care Centre, Primary Care Sciences Keele University Staffordshire, Keele, UK E-mail: [email protected]

Background: Osteoarthritis (OA) is a common cause of pain and disability. In the UK, comprehensive guidelines exist regarding its optimal treatment, and these are based on principles of self-management. Current research suggests patients with osteoarthritis have significant unmet needs; however, little is known about what currently happens in the consultation between GP and patient when joint pain is discussed. In particular, little is known about the extent to which GPs engender self-management with patients. The Arthritis Research UK Primary Care Centre is currently undertaking research concerned with implementing OA guidance, including a training package for GPs; however, GPs’ current educational needs regarding OA are also not clearly established.

Research question: The aims of the study are to explore in depth the content of the patient-GP consultation when a patient presents with OA; to determine to what extent self-management is fostered and to determine the areas within the consultation for educational intervention.

Method: Consecutive consultations of consenting patients in primary care will be videotaped, and consultations including discussion of joint pain will be selected. The patients and GPs involved will then be invited for an interview where they will be shown the video clips of their own consultation. The interviews will provide contextual information for the consultations as well as gathering further information about GPs attitudes regarding OA consultations in general and patients’ views of the consultation and their interpretation of language used by the doctor. It will also allow for exploration of any differences between GP rhetoric and practice.

The video and interview data will be subject to qualitative and quantitative analysis and an analytical framework will be presented.

Results: No results as yet.

Conclusion: By videotaping consultations, we hope to gain a rich data set that will be of interest to practising clinicians and educationalists alike.

Pharmaceutical advertisement: Medical students’ exposure and attitudes

Marcel S. Kremer, Michael M. Kochen, Jean-François Chenot

Dept. of General Practice, University Medicine Göttingen, Göttingen, Germany E-mail: [email protected]

Background: As future doctors medical students represent potentially valuable customers for the pharmaceutical industry. Only few studies have examined the subject of pharmaceutical industry–medical student relationship. Early exposure to drug sale representatives and gifts is the first step to gain influence and might foster the sense of entitlement.

Research question: What is the attitude of medical students towards pharmaceutical advertisement and how frequent is their exposure?

Method: We conducted a survey of all medical students in the 3rd, 4th and 5th year of the University of Göttingen Medical School in Germany. The questionnaire contained questions about exposure, gifts and attitudes toward pharmaceutical advertisements.

Results: At total of 641 questionnaires from 961 medical students (response rate 67%) were returned. One third (34%) reported having had contact with a drug sale representative and 76% have accepted gifts. The majority (93%) stated that accepting gifts is acceptable. Although 44% assumed that gifts influence prescribing, however most students (85%) stated that gifts would not influence themselves. Only 10% felt well prepared to deal with pharmaceutical advertisements, but only 60% of them expressed a wish for further training on the subject.

Conclusion: There is a lack of awareness of medical students about the effectiveness of pharmaceutical advertisement and associated ethical problems. Training and role models are needed to prepare medical students to develop an appropriate and critical attitude towards pharmaceutical advertisement.

Reliability and validity of the German version of the OPTION scale

Heidemarie Keller, M. Müller-Engelmann, O. Hirsch, N. Donner-Banzhoff, T. Krones

Dept. General Practice/ Family Medicine, Philipps University Marburg, Marburg, Germany E-mail: kellerhe@staff. uni-marburg.de

Background: Elwyn et al., have developed the OPTION scale (acronym for ‘observing patient involvement’), which assesses the extent to which clinicians involve patients in decisions across a range of situations in clinical practice. A German version of the OPTION scale was used in the study of Loh et al., in the context of depression. Apart from an inter-rater-concordance of 67%, a Kappa coefficient of .5 and an intra-class coefficient (ICC) of .7, no further psychometric characteristics were reported. Consequently, there is a lack of such data concerning the German version of the OPTION scale.

Research question: Our study is the first to examine the instrument in detail and is part of an extensive phase 4 study investigating patient participation in the shared decision-making (SDM) process in cardiovascular prevention.

Method: Fifteen GPs were asked to recruit three patients each in whom discussion of cardiovascular risk and of preventive measures seemed indicated. Four experienced raters, using a crossover design, carried out the OPTION ratings based on videotapes. The data were then compared with a reference standard for SDM (SDM took place [yes/no]) rated by two experts of the shared decision-making field.

Results: Cronbach-a of the whole scale based on the data of all four raters was .90 and therefore on a high level. The Kaiser-Meyer-Olkin criterion with .88 was high and a factor analysis was therefore feasible. The correlations between the total scores of the raters and the dichotomized SDM expert ratings were satisfactorily.

Conclusion: We conclude that the OPTION instrument is a useful tool to measure the concept of SDM in the consultation. The German version is reliable and valid at total score level. Some items need further revision in the direction of more concrete, observable behaviour.

Communication skills training: (de)motivation for patient-centredness? Experiences and attitude scores of medical students

Katrien Bombeke, L. Symons, E. Vermeire, B. De Winter, S. Schol, L. Debaene, P. Van Royen

Dept. of Primary and Interdisciplinary Care, University of Antwerp, Wilrijk, Belgium E-mail: [email protected]

Background: In Dubrovnik (EGPRN ’09), we presented the unexpected results of a cohort study investigating the impact of communication skills training on the evolution of patient-centred attitudes during clinical clerkships. Remarkably, students trained for five years declined in attitude scores, whereas untrained students remained stable. This study explores the intentions and experiences of the trained students.

Research question: What explanations do the participants themselves offer for these unexpected findings? How do participants experience the impact of communication skills training on the development of patient-centredness? Are participants’ personal reflections on their development of patient-centredness in line with their attitude scores on four different scales?

Method: Data-gathering: We conducted 20 in-depth interviews with students from the cohort with declining scores (n = 37). We purposively select participants based on attitude scores (extreme scores, specific changes during clerkships). Before the interview, participants completed the attitude scales again. Interview topics: personal evolution in patient-centredness, confrontation with own and group scores, and explanations for the cohort study findings. Analysis: Two researchers independently performed open and axial coding on the audio recordings (Nvivo8). All coding results were compared and discussed. Qualitative findings were compared with answers on specific scale items and participant's scores.

Results: Ten interviews have already been conducted and three of them coded (June 2010). Participants offer well-reflected explanations based on specific experiences, providing new insight into how medical education can motivate students better to become patient-centred doctors. The most prominent preliminary hypothesis concerns the huge gap between the ideal, protected training ground and medical practice reality. The more ‘experienced’ these trained young doctors get, the more differentiated and nuanced their reflections on patient care. This results, contradictory, in more neutral (lower) scale scores.

Conclusion: Completed findings will be presented at the conference.

One-on-one tutorials in private practices and clinics – a path to improving medical students’ professional motivation and relationships with patients

Ruedi Isler, Silvana Romerio, Ursina Halter, Simon Heiniger, Malte Persike, Bodo Röers, Benedict Martina, Peter Tschudi, Klaus Bally

Dept. Primary Care, Institute for Primary Care, University of Basel, Basel, Switzerland E-mail: [email protected]

Background: Since 1997, all University of Basel medical students participate in one-on-one tutorials. Until 2009 they spent a total of 30 half days over the course of two years with their personal tutor in a general practitioner's office, in a specialist's practice or in a clinic. Since 2010, tutorials are only offered in general practitioners’ offices. Attendance is required for all fourth-year students.

Research question: This study compared general practice tutorials with tutorials in specialists’ practices, analyzing the development of professional motivation, awareness of patients’ social environments, trust in patient-doctor relationships and an empathic approach to patients’ fears.

Method: The survey is based on a questionnaire, which was given to 236 third and fourth year students during the 2005 academic year. Students could answer the questions on a Lickert scale with a range of answers from 1 (strongly disagree) to 7 (strongly agree).

Results: Professional motivation increased/ partly increased in 81%, remained unchanged in 17% and decreased in 2% of all students. Students who had their tutorials in a clinic had their awareness of patients’ social environment raised significantly less than those tutored in general practitioner's offices and in specialists’ practices. In addition, students in general practices were better capable of constructing a trusting relationship with their patients than those tutored in specialists’ practices and in clinics. Students learned an empathic approach to patients’ fears equally well in general practices and specialists’ practices. However, nearly one third of all students tutored in specialists’ practices were tutored with paediatricians.

Conclusion: One-on-one tutorials in practices and clinics improve medical students’ professional motivation. General practitioners’ and perhaps paediatricians’ practices are suited for acquainting students with patients’ social environment, constructing a trusting relationship and learning an empathic approach to patients’ fears.

Place of general practitioners in sex education for teenagers in countryside areas

Thibaut Raginel, J.Y. Le Reste, I. Asselin, L. Capdepon

Dept. Médecine Générale, Faculté de Médecine de Caen, Caen, France E-mail: [email protected]

Background: Sex education is a legal obligation in schools as part of child welfare. It was strengthened in French law in 2007. Deficiencies were perceived during sex educational campaigns in countryside schools. Teenagers experienced difficulties locating acute information and resources. All existing work on the subject has been carried out mainly in troubled suburbs.

Research question: What is the place of general practitioners between healthcare and other professionals in charge of sex education and teenagers’ welfare in rural areas?

Method: Descriptive observational study using questionnaires with 51 to 54 questions according to the type of respondent. After an inventory of the resources proposed by the institutions in the domain, we carried out a survey of needs among teenagers in the rural schools of Basse-Normandie (France). A sample of professionals is in progress using two methods: self-administered questionnaires for the GPs and interviews or semi-structured interviews for the other professionals.

Results: On going study with further results available at the Zurich meeting. An important lack of means was evident at institutional level. There is a need for further working professionals. We are currently processing the analysis of the data collected from the 291 teenagers. We are still collecting the data concerning the other professionals - 41 general practitioners and 22 chemists. On a first glance, GPs appear to be left outside sex education in schools.

Conclusion: GPs are left outside sex education in school. Our first results confirm a recent report of the ‘Cour des Comptes’ on the deficiencies on this subject pointing to bigger deficiencies in rural areas.

Understanding reputation and professional identification with family, medicine practice among medical students: A Spanish Case Study

Sofia Lopez-Roig, Maria Angeles Pastor-Mira, Charo Rodriguez

Dept. Health Psychology, Miguel Hernandez University, Alicante, Spain E-mail: [email protected]

Background: for the last decade, medical students have progressively discarded family medicine as a career choice in many developed countries. The objective of this investigation has been to contribute to a better understanding of this phenomenon by examining reputation and identification processes with family medicine by medical trainees in a Spanish medical school.

Research question: What do medical students think about family medicine practice? What are the reasons why medical students stick to or separate from family medicine as a career choice?

Method: This was qualitative case study in which focus groups and documentary analysis were the techniques used for generating data. Participants were 2nd and 6th year undergraduate medical students trained in a 25-year old faculty of medicine in a Spanish university. Six focus groups were conducted in 2008 and 2009, which were transcribed verbatim and submitted to a thematic analysis.

Results: Among medical students, family medicine appears largely devaluated as a professional activity, being viewed as a monotonous and non-technological medical practice without intellectual challenge. Such a negative view, which already appears in early stages of medical training, encourages trainees’ de-identification with this medical practice.

Conclusion: Misconceptions about what the practice of family medicine is are created and reproduced in the health care system and societal contexts that privilege the practice of specialized medicine, as well as in an academic context that foster organ- and disease-based medical knowledge. To improve the reputation of family medicine, and its appeal as a career path, not only the development of family medicine as academic medical field should be encouraged, but also the conditions of the practice in the health care system need to be improved.

A declining interest for family medicine or a rejection of a practice model?

François-Xavier Schweyer, Gwénola Levasseur, Sandrine Hugé

Dept. of general practice, Université de Rennes1 Faculté de Médecine, Rennes, France E-mail: [email protected]

Background: Only 50% of French GPs practice family medicine. GPs are invisible during the first six years of medical training and family medicine is less often chosen than other specialties. There are significant geographical disparities and a shared feeling of an unattractive discipline.

Research question: In France, is the declining interest for general practice so obvious?

Method: Three focus groups involving 29 students and 12 face-to-face interviews with lecturers and teaching staff were conducted.

Results: We found an ambiguous attitude towards family medicine, which is rarely the first choice. Medical students look for a job compatible with a good way of life. Contact with patients is appreciated but also seen as demanding with many constraints. The symbolic medical hierarchy is seen as an arguably unjustified fact but is sustained by society and families. Students reject hospital work, its hierarchy and an overspecialized activity. They are not attracted to general practice while numerous GPs complain about their job. The absence of hierarchy, and the presence of initiative and autonomous decision-making are seen as the great advantages of general practice. However, family medicine suffers from an absence of image compared with the more technical specialties. Newly qualified GPs have a wide choice of practice, independent practice being only one of them. Feminization has altered the professional ethos; work is no longer the core of life for the younger generations. The best students from the affluent, urban areas are not tempted by the rural, working class areas.

Conclusion: An alternative way of working? Is it the end of the liberal model? Maybe not but it is the rejection of independent practice and permanent availability; salaried practice does appeal. The key questions on the agenda are those concerning the division of work and relationship with health professionals.

Exploring the professional identification and reputation of family medicine among medical students and educators: A Canadian case study

Charo Rodriguez, Pierre-Paul Tellier, Emmanuelle Belanger

Dept.Family Medicine, McGill University, Montreal, Canada E-mail: [email protected]

Background: Canadian students’ interest in family medicine as a career choice has been declining. Many factors have been considered to explain this decrease, e.g. the gap between the incomes of family physicians and other specialists. This research addresses the process of professional identity formation occurring in medical schools as an under-explored and potentially important contributing factor.

Research question: What do medical students and educators think about the discipline of family medicine? What is the influence of these views on medical students’ career choice?

Method: A case study research design was adopted, the case being one medical academic institution. Data was generated through six focus groups with second and fourth year medical students (total 36 students), 15 individual semi-structured interviews with educators, and documents about the context of research. The material was transcribed verbatim and analysed using a discursive thematic approach, considering four different contextual levels.

Results: Four themes were identified as motivating students’ career choices: the practice of family medicine, the knowledge and skills necessary to be a family doctor, the prestige of the profession, and finally the attitudes that they hold toward family medicine. Unless students have a strong personal preference for the practice of family medicine or the values that it upholds, students report not choosing family medicine because of its low prestige in academic institution. Educators attribute the decline of interest to the shortage of family doctors and regulations imposed on them by the health care system, as well as to the lack of competitiveness of the residency programme.

Conclusion: Family medicine practice exhibits a bad professional reputation, which prevents medical students from identifying with this career path. Recommendations are made to promote a better reputation for the discipline, both in academic (e.g. accurate selection criteria) and health care contexts (e.g. improved working conditions).

General Practice: A qualitative study into the motivation of medical students in the UK when making their career choice

Sarah Spencer, Ian Whitehead, Teresa Pawlikowska

Institute of Clinical Education, Warwick Medical School, The University of Warwick, Coventry, UK E-mail: [email protected]

Background: the World Health Organisation describes Family medicine as integral to the efficient running of healthcare systems. In many countries however, family medicine is significantly undersubscribed. The United Kingdom by contrast has seen interest in general practice as a career increase markedly. An understanding of the factors influencing this phenomenon have yet to be explored and will aide worldwide workforce planning.

Research question: What are the origins of students’ attitudes towards general practice and the motivation behind career choice?

Method: This study used a qualitative approach. Nineteen final year students were recruited from Warwick Medical School to participate in three focus group discussions. Twenty-one members of teaching staff were selected at random for semi-structured interviews. Both focus groups and interviews were recorded and transcribed verbatim. The transcripts were coded using thematic analysis.

Results: Most final year students had developed career aspirations while at medical school.

Exposure to general practice throughout training and the impact of role models emerged as strong themes and will be discussed further. Prestige also appeared as a strong theme. We will examine reasons for a recent change in status of general practice and will discuss conflict amongst students and educators when referring to the place of general practice in a perceived hierarchy. The factors influencing such hierarchy will be presented and include perceived knowledge of general practitioners along with their emerging role in business and healthcare management. Students were concerned about the reduced training time associated with the introduction of European Working Time Directive, but otherwise denied their opinions were influenced by recent governmental changes.

Conclusion: Knowledge of the complex factors affecting perceptions of general practice determined by this study will assist work force planners to motivate medical students to select family medicine as a career choice in countries where it is undersubscribed.

Reputation of and professional identification with family medicine among medical students: An international cross-case analysis

Charo Rodriguez, Sofia Lopez-Roig, Teresa Pawlikowska, Francois-Xavier Schweyer, Pierre-Paul Tellier, Emmanuelle Belanger Sandrine Huge, Gwenola Levasseur, Maria Angeles Pastor-Mira, Sarah Spencer, Ian Whitehead

Dept. Family Medicine, McGill University, Montreal, Canada E-mail: [email protected]

Background: While there is an international consensus that family medicine is critical to provide accessibility and continuity of care, a decline in medical students’ interest for the profession has been observed in many Western countries. A comparison of the different processes of professional identity formation occurring in medical schools in Canada, France, Spain and the UK could help better understand this phenomenon.

Research question: What do medical students and educators think about the discipline of family medicine? What is the influence of these views on medical students’ career choice in these different countries?

Method: The results of four case study investigations were submitted to a cross-case analysis. Data was generated through a total of 18 focus groups with second and fourth year medical students (total 132 students), 67 individual interviews with educators, and documents about the four contexts of research. Thematic analysis supported the identification of patterns contributing positively and negatively to students’ preference for family medicine as a career choice across different academic and national contexts.

Results: The fact that family medicine is patient-centred and requires good interpersonal skills favours the discipline as a career choice across all settings. In countries where (1) students are exposed early and abundantly to family medicine, (2) family medicine is recognised as a ful-respected academic discipline and (3) working conditions are better (e.g. in the UK) family medicine has a better reputation, which facilitates students’ identification with this career path.

Conclusion: The study highlights the importance of professional prestige in medical students’ career choice. Furthermore, it sheds light on measures that would encourage students’ identification with family medicine, such revaluing the bio-psycho-social approach, promoting communication skills as an important technology, improving the working conditions of family physicians, making them visible in decision-making positions in medical schools, and supporting specific research agendas in family medicine.

Motivational training improves self-efficacy but not short-term adherence with asthma self-management behaviour: a randomized controlled trial

Claudia Steurer-Stey, Maja Storch, Susanne Benz, Barbara Hobi, Barbara Steffen-Bürgi J. Steurer, Milo A. Puhan

Dept. of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland E-mail: [email protected]

Background: Adherence to self-management in asthma is poor. We investigated the effect of motivational training added to asthma patient education on self-management adherence.

Research question: Can an unspecific training, based on motivation and behavioural science principles, the ‘Zurich Resource Model’ training (ZRM) help patients to improve their asthma-specific self-management.

Method: We randomized patients with partly controlled asthma-to-asthma education with or without the Zurich Resource Model (ZRM) training. The primary outcome was adherence to self-monitoring and to a written personal action plan during the first three months. Secondary outcomes included patient-reported self-efficacy.

Results: Since control patients (n = 30) were younger, more often male and had better asthma control compared to the intervention group (n = 30) we adjusted the analyses for these imbalances. Both groups showed excellent adherence to self-monitoring over three months (27 patients [90.0%] in intervention and 25 patients [83.3%] in control group, adjusted odds ratio: 1.28 [0.24 – 6.78], p = 0.78)). Patients in the ZRM group tended to adjust their medication more often (median 36% days with action [IQR 11-62%]) than control patients (9% [0 – 43], p = 0.18) but in both groups actions were rarely in accordance with the action plan (median 20% of actions appropriate [IQR 0 – 37] in intervention and 11% [IQR 0 – 56] in control group, p = 0.92). After three months, self-efficacy was significantly better with ZRM (adjusted difference on self-efficacy scale 2.31, 95% CI 0.31 – 4.31, p = 0.02).

Conclusion: Unspecific self-management training had no short-term effect on self-management adherence in asthma patients. However, self-efficacy improved and may translate into better outcomes in the long-term.

The Vediclis project: the impact of a multidimensional intervention on the performance of GPs in the management of type II diabetes

Giulio Rigon, A. Vaona, S. Girotto, C. Andreoli, A. Micchi, L. Adami, A. Dalle Vedove, F. Del Zotti

Dept. Primary Care, ASL 20 Verona, Verona, Italy E-mail: [email protected]

Background: In Italy the role of primary care in diabetes management needs to be re-qualified. In Verona, an audit process started in 2006 to test the impact of a multidimensional intervention on a selected group of 30 GPs.

Research question: Could a multidimensional audit intervention improve the adherence a group of GPs to the guidelines’ recommendations for type II diabetes?

Method: We exposed the selected group to a multisession educational intervention, consisting of a mix of face-to face lessons and online services. We provided a web site and a discussion list to share material and to animate the debate on diabetes. During data extraction, ECR group members used a remote help (SQL phrases) facility. At the end of process, the participants received structured feedback on their performance level compared with a control group (35 GPs of Netmedica Database, in the same province, with optimal indicators of data-entry quality). The impact of this multi-dimensional intervention was analyzed by the modification of performance indicators in the selected group versus the control group in the period before beginning of audit process (2006) and at the end of the intervention (2009).

Results: Comparisons on the indicators show: blood pressure measure increased from 50.6% in 2006 to 55.9% in 2009 in the selected group and from 42.2% to 43.9% in the control group; glycosylated haemoglobin measure increased from 52.4% in 2006 to 69.1% in 2009 in the selected group and from 48.9% to 63.7% in the control group; hospitalization of the diabetes patient seems to have decreased from 11.7% in 2006 to 11.2% in 2009 in the selected group despite an increase from 9.3% to 10.5% in the control group.

Conclusion: Our multi-dimensional intervention in the context of a structured audit process seems to substantially modify the performance level of GPs.

Does a multifaceted intervention increase the rate of detection of skin cancer by general practitioners? A randomized controlled trial

Nina Badertscher, Ralph Braun, Thomas Rosemann

University of Zurich, Institute for General Practice, Zurich, Switzerland E-mail: [email protected]

Background: Skin cancer is one of the most common neoplasms in Switzerland. From skin cancers, melanoma is the most aggressive one and often lethal if not removed early. Nonmelanoma skin cancer is more frequent than melanoma; it is seldom lethal but can disfigure patients in advanced stadiums. Since consultation capacities of dermatologists aren't sufficient to check up every suspicious skin lesion, general practitioners (GPs) play a key role in the detection of skin cancer.

Objective: To determine whether a multifaceted intervention leads to higher rates of detection of skin cancer by GPs.

Outcome: Primary outcome: Difference in excision rates of malignant skin lesions by GPs with intervention compared to control group of GPs without intervention.

Secondary outcomes: change of the ratio “malignant to benign lesions” in histopathology during study; rate of performed whole-body-examinations.

Method: Design: Randomised controlled trial.

Population: 50 primary care practices, randomized into intervention group and control group. Patients in the practices belonging to the intervention group receive a screening-questionnaire containing four screening-questions.

Intervention: screening-questionnaire, dermatologic training session, special dermoscopic camera and continuous feedback on all uncertain lesions. The control group of GPs do not obtain any intervention.

Every patient considered as ‘risk patient’ according to the questionnaire is given a skin examination. Equivocal lesions are removed by GPs; uncertain lesions are rated by a dermatologist and only removed if he rates them as equivocal. GPs in the intervention group get continuous feedback on every lesion they send to the dermatologist. Histopathological reports are collected.

Expected results/conclusion: We expect an increase of detection rate of skin cancer in the intervention group. Additionally, with increasing diagnosis security of GPs, there should be less unnecessary biopsies. We guess that within the intervention group, the rate of whole body examination as an efficient clinical diagnostic tool will be higher than in the control group.

Transcultural validation of the Diabetes Obstacle Questionnaire

Anneli Rätsep, Karin Täht, Davorina Petec, on behalf of the DOQ – EGPRN research group, Ruth Kalda, Etienne Vermeire

Dept. of family medicine, University of Tartu, Tartu, Estonia E-mail: [email protected]

Background: Treatment of patients with type 2 diabetes (T2D) is a challenge for doctors as well as for patients because of the complexity of the treatment regime. Patients are responsible for the decisions they make related to their chronic condition but often they face different obstacles following doctors’ recommendations. The Diabetes Obstacles Questionnaire (DOQ) has been validated in the United Kingdom (UK) and Belgium for type 2 diabetes populations but its cross-cultural validity has not yet been established. The DOQ has been used in some countries, but the comparability of the results is unknown.

Research question: Has the DOQ comparable internal factorial structure and measurement properties across nations?

Methods: The DOQ is based on qualitative research using focus group discussions of T2D patients from seven European countries. The English version of the DOQ questionnaire was validated in the UK and 78 items were assigned in eight different thematic subscales: medication, self-monitoring, knowledge and beliefs, diagnosis, relationship with health-care professionals, lifestyle changes, coping, advice and support. The items were worded as statements providing responses on a 5-point scale from ‘strongly agree’ to ‘strongly disagree.’ The GPs were asked to include five consecutive T2D patients in Belgium, Serbia, Estonia, France, Slovenia and Turkey; 860 responses were included in the analysis.

Method of analysis: Confirmatory factor analysis (CFA) is used for fitting hypothetical models on different countries’ data separately. There are also CFA-based methods of estimating scale reliability. Multiple-group confirmatory factor analysis (MGCFA) is used for analysis of invariance of models on different countries’ data.

Results: At this moment we are analysing the data obtained and expect to be able to present the results at the conference.

Conclusion: Because of the validation analysis, we will be able to detect the items of the DOQ that can be used for cross-cultural comparisons.

Is there an association between relationships with Healthcare Professionals and coping with living with type-2 diabetes? Does it influence the clinical outcomes?

Liina Pilv, Anneli Rätsep, Marje Oona, Ruth Kalda

Dept. of Polyclinic and Family Medicine, University of Tartu, Tartu, Estonia E-mail: [email protected]

Background: Type 2 diabetes (DM2) is a chronic progressive disease. One of the main interests and one of the most important aims of medical care for patients is to learn to cope with and accept this disease.

Research question: The aim of this study is to assess the obstacles for patients with DM2 in terms of their relationships with healthcare professionals (RHCP) and to analyze if there is an association between the RHCP and coping with living with type-2 diabetes. To seek, if the RHCP influences clinical outcomes.

Method: Participants were recruited from a pragmatic sample of general practices in Estonia. Responders completed the Estonian version of the Diabetes Obstacles Questionnaire (DOQ) to assess obstacles in living with DM2 and the Problem Areas in Diabetes (PAID) scale. Some biomedical and clinical variables were measured.

The questions of the “Obstacles in Relationships with Health Care Professionals Scale” were divided into two subscales according to the observed means; the first subscale contains questions that assess the obstacles of active negotiations and partnership between a patient and a physician and the other subscale contains features of passive and paternity relationships.

Results: There were 138 diabetic patients enrolled in this study. A total of 61 (45%) were male; aged between 34 and 88 years (mean age 66.7) and the mean duration of DM2 was 8.6 years. Obstacles of active negotiations between a patient and a physician were related to all other seven obstacles in coping with DM2 (OR 3.9–5.6).

The comparison of means of clinical outcomes between two types of relationship with healthcare professionals did not reveal statistically significant differences.

Conclusion: Can we research with described methods relationships between a patient and healthcare professionals? Can we conclude that one type of relationship is more tightly connected with obstacles in coping with living with type-2 diabetes than the other?

The Chronic CARe for diAbeTes study (CARAT): a cluster randomized controlled trial

Anja Frei, Corinne Chmiel, Piotr Dziunycz, Stephanie Herzog, Thomas Rosemann

University of Zürich, Institute of General Practice and Health Services, Research, Zürich, Switzerland E-mail: [email protected]

Background: Diabetes is a major challenge for the health care system, and especially for the primary care provider. The Chronic Care Model (CCM) represents an evidence-based framework for the care of the chronically ill. However, most of these findings have been performed in settings different from the Swiss healthcare system, which is dominated by single-handed practices. Furthermore, there is little data available describing the clinical state of diabetes patients in Switzerland.

Research question: Does the implementation of several elements of the CCM via a specially trained practice nurse significantly improve the HbA1c level of diabetes type 2 patients, increase the proportion of patients who achieve the recommended targets of cardiovascular risk factors and improve patients’ quality of life?

Method: CARAT is a cluster randomized controlled trial with general practitioners as the unit of randomization. According to the power calculation, 28 general practitioners were randomized either to the intervention group or to the control group. Each general practitioner included 12 patients suffering from diabetes type 2. In the intervention group, the general practitioner as well as the practice nurse, are trained to perform care for diabetes patients according to the CCM in teamwork. In the control group, no intervention is applied at all and patients are treated as usual. Measurements (pre-data-collection) took place in months II-IV, starting in February 2010. Follow-up data will be collected after one year.

Results: Based on the broad baseline assessment we will be able to present wide baseline characteristics of a Swiss patient population with diabetes type 2 in primary care including clinical parameters like current diagnostic findings (HbA1c, BD, LDL-cholesterol, weight, pulse etc.), co-morbidities, medication and diabetes associated complications, as well as patient reported outcomes like quality of life.

The role and power of nurses in cardiovascular risk management: a qualitative study in primary care

Marije S. Koelewijn–van Loon, Nicolle Knoops, Henk van Dam†, Ben van Steenkiste, Glyn Elwyn, Richard Grol, Trudy van der Weijden

CAPHRI School for Public Health and Primary care, Dept of General Practice, Maastricht, the Netherlands E-mail: [email protected]

Background: Cardiovascular Risk Management (CVRM) in primary care is increasingly delegated to practice nurses. The IMPALA study tried to improve lifestyle through nurse-led clinics using a risk communication tool, a decision support tool and adapted motivational interviewing. However, we do not know how nurses experience this task.

Research question: How do practice nurses perceive their ‘new’ task in CVRM?

Method: This qualitative study used both focus-group interviews and in-depth interviews with 18 nurses of general practices in the southern parts of the Netherlands. Interviews were conducted with the help of an interview guide with questions about how nurses experienced risk assessment, patient education and guiding patients in risk reduction. Data were analysed by directive content analysis.

Results: The overarching theme ‘the nurses’ attitude’ described that nurses were very positive about undertaking CVRM, and viewed it as an important task for them. The key-themes ‘Risk assessment’ and ‘Risk communication and proving information’ described that nurses extensively assess and communicate the cardiovascular risk. The key-theme ‘Guiding the patient in risk reduction’ described that nurses agreed with the principles of shared decision-making and motivational interviewing. However, applying these principles was reported to be difficult since they were used to give options for risk reduction themselves. Nurses especially, who were not extensively trained in motivational interviewing as part of CVRM, reported the tendency to start arguing when a patient was not motivated for lifestyle change.

Conclusion: Cardiovascular risk management is a good task to delegate to practice nurses as they view it as an important task for them. Nurses reported that they take time for risk assessment and communication, and they have the aspiration to do it following the principles of shared decision making and motivational interviewing. However, more training is needed as nurses find it difficult to act according to these principles.

Palliative care programme – students’ willingness to participate

Gergana Foreva, Radost Asenova, Luybima Despotova-Toleva

Dept. General Practice, Medical University Plovdiv, Plovdiv, Bulgaria E-mail: [email protected]

Background: The WHO claims that palliative care has to be ‘compulsory in courses, leading to a basic professional qualification.’ This requirement has still to be fulfilled in Bulgaria. With the grant from the Ministry of Education and Science, the project whose purpose was to develop and implement the program for interns in palliative medicine, was carried out in the University of Plovdiv.

Research question: The aim of the study was to investigate willingness to participate, motivation influencing factors and expectations among medical students.

Method: The possibility to participate in 30 days/8hours rotation in palliative care unit, neurology and surgery wards, paediatric onco-haematology and general practice and to perform palliative care was presented to sixth-year students. The number of students in the sixth year of education was 118 students; 48 of them male. Cohort 1 (68) refused and Cohort 2 (50) enlisted, wrote motivation letters and filled in a cross sectional questionnaire.

Results: The principal motivations were the acquisition of skill (32; 64%); the desire to support patients (22; 44%); to gain knowledge (14; 28%); to complement the lack of palliative care teaching (8; 16%) and to forward one's professional career (4; 8%). Expectations (professional and personal) were on mastering emotions and increasing self-awareness in establishing a suitable physician-patient relationship in end-of-life care. Overall, 73.3% of the students had been entirely informed and 93.3% had never thought, before the involvement in the project, about work in palliative care; 71.1% changed their attitude and approach to palliative patients and 35.6% declared readiness to care for them.

Conclusion: A palliative care programme was recognized as a necessity and 42.4% of the sixth-year medical students were motivated to complete it hoping it would have a great impact on their professional and personal development.

The perspective of peer educators: What are their experiences, feelings and thoughts?

Dilek Guldal, Vildan Mevsim, Tolga Gunvar, Nilgun Ozcakar

Dept. of Family Medicine, Dokuz Eylül Üniversitesi Tıp Fakültesi Aile Hekimliği AD, Izmir, Turkey E-mail: [email protected]

Background: Prevention of unwanted pregnancies and STDs in young people is an important target for many countries. Peer education is accepted as a good educational method. Although there are many studies investigating the results of peer education, how peer educators are affected is not well understood.

Research question: What are the experiences of university students educated in reproductive health about consulting their peers?

Method: This phenomenological study was conducted in Izmir as a part of the “Modern Stork Legends” project supported by the European Union. Two focus group interviews were carried out with 18 participants, purposively selected out of 263 peer educators. All focus groups were recorded and then transcribed. Data was analyzed with nVivo 8 software.

Results: Peer educators thought that their peers would not take them seriously. They were also afraid of difficulties of consulting unfamiliar people. In the beginning, due to the subject being reproductive health, one of the taboos of society, they blushed a little and worried about negative thoughts. Mistrust and socially determined roles for both sexes were important barriers. They began their consultations nearby and expanded gradually. Although some reactions were rough or sarcastic, requests for consultations one by one increased their motivation to a great extent. The reduction of their prejudices, expansion of their surroundings and circle of friends are considered acquisitions. Being a peer educator also influenced their attitudes towards their own health. They expressed that they gained a prospect about the role of NGO's in social transformation.

Conclusion: Although there are many difficulties for educators, peer education provides advancement of educators as well as the target population. Peer educators are learning with the best learning method: ‘teaching.’ During this process, they also gain self-confidence and improve their communication, problem solving and information-giving skills.

Incentives and motivation of Irish GPs in respect of CME

Claire Collins, Joseph Richardson, Henry Finnegan.

Research Centre, Irish College of General Practitioners, Dublin, Ireland E-mail: [email protected]

Background: Continuing Medical Education (CME) consists of lifelong educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession. From the beginning of institutionalized medical instruction, health practitioners continued their learning by meeting with their peers. Good quality patient care requires each registered medical practitioner to continuously participate in learning activities. While the value of CME is often extolled, little work has been carried out to determine what motivates GPs to participate in CME activities.

Research question: To better understand the general practice continuing medical education market in Ireland.

Method: A postal survey of a random sample of 600 members of the Irish College of General Practitioners (ICGP) was conducted. A response rate of 47.8% was achieved (n = 287).

Results: For external learning (i.e. that is supplied outside of the practice setting), 43.8% of respondents reported attending in excess of 10 courses/meetings per year. The courses attended are most often provided by the ICGP training body (85%) and pharmaceutical companies (65.9%). Six out of ten GPs spend less than € 500 per annum on external learning courses with only 10.6% spending in excess of € 1000. Courses are chosen based on the following criteria: topic of interest (79.8%), chance to learn with peers (59.2%), ICGP training body provided (57.7%), CME points available (46.3%), provider of repute (36.2%). The value of these courses is primarily assessed by their applicability to regular clinical work (79.8%).

Conclusion: The primary aim of CME is to assist one to maintain competence and learn about new and developing areas of one's field in the interest of patient safety and healthcare. The results show that Irish GPs judge courses/meetings based primarily on aspects related to these factors.

Teenager's contraception: how French GPs miss it?

Marie Barais, C. Breuilly-Leveau, S. Cadier, B. Chiron, P. Nabbe, B. Le Floch, P. Barraine, J.Y. Le Reste

Dept. Finistere, Université de Bretagne Occidentale, Brest, France E-mail: [email protected]

Background: In France contraception is very medicalized. GPs are the prime health support for teenagers. Their contributions are essential to prevent unwanted pregnancy. The multiplicity of efficient ways of contraception should permit a shared decision between patient and physician. However, since 2002 the abortion rate among teenagers and young adults (15 and 19 years old) is rising in France.

Research question: To identify the barriers to the family physician helping teenagers with their contraception.

Method: Thematic analysis of 11 semi structured interviews with general practitioners. Purposive sampling based on socio-demographical standards and practical observations. Interviewed practitioners had to relate one outstanding consultation about contraception with a teenager and had to describe encountered difficulties. Theoretical saturation was achieved.

Results: Three GPs’ barriers were identified: 1/ GPs avoid confrontation with teenagers: independence is not recognized and sexuality is not mentioned. 2/ GPs’ normative view both on what is a proper contraception and what is the mission of the family physician in this situation. 3/ Lack of knowledge: physicians are not fully aware of the specific details of each contraceptive method.

Conclusion: These three obstacles highlight that choosing contraception is a process focused on the physician instead of the teenager. Lack of physician knowledge compounds this picture. Modifying this approach for care centred on the teenager and increasing our knowledge would improve contraception choice and thus reduce the number of unwanted pregnancies.

Why do parents consult the GP for their child with ORL infectious symptoms?

Benoit Cambon

Family practice departement of Clermont Ferrand, Medecine University, Gannat, France E-mail: [email protected]

Background: ORL infectious symptoms (runny nose, sore throat, cough, otalgia, fever) in childhood are a frequent demand in general practice in winter. The large number of consultations can decrease the GP practice quality: short consultation, increased duration of daily work, tiredness and inappropriate prescription of antibiotics.

Research question: The aim of the study was to analyze the parents’ expectations when they consult the GP for their child with ORL infectious symptoms.

Method: This qualitative study has analyzed six individual interviews and two focus groups during the winter 2009-2010. A purposive sample of 20 persons (19 mothers and one father) with children between one and 10 years old has been interviewed with a list of themes. Two parents’ websites have been analyzed to provide another point of view. Data were recorded, coded and analyzed using grounded theory.

Results: The parents of young children and novice parents were afraid of meningitis, convulsion and suffocation. They were seeking reassurance and information. When the child was older, and for subsequent children, parents were less afraid. The experienced parents – more than one child, or child > 3 years - were looking for a fast recovery. The illness of their child unbalanced the family life. They didn't like to see their child suffer. They were unaware that a curative treatment didn't exist in most cases and were seeking it. The mother was the referring person for the child's health in every case.

Conclusion: When the GP knows parents’ expectations, they could inform, assure and educate them to consult only when necessary. Their practice quality may improve with less inappropriate antibiotic prescription, longer consultations and less tiredness. A study analyzing inappropriate antibiotic use in ORL infectious childhood after educating of parents may be interesting.

Adolescents consulting a GP accompanied by a third party: comparative analysis of representations and how they evolve through consultation

Philippe Binder, Carine Caron, Vianney Jouhet, Daniel Marcelli, Pierre Ingrand

Dept. Médecine Générale, Université de Poitiers, Lussant, France E-mail: [email protected]

Background: Adolescents are frequently accompanied by a third party in consultation. Their stated reason for consulting is rarely psychological. However, many adolescents experience distress or impaired well being, which practitioners fail to detect.

Research question: To study the ability of adolescents to express personal concerns in general practice consultations depending on whether or not they were accompanied, and to explore perceptions of participants and how they evolve.

Method: In total, 674 adolescent consultations with 53 GPs were studied. The adolescents and any persons accompanying them completed self-administered questionnaires before and after the consultation; the GPs completed a questionnaire after the consultation only. Analyses compared responses before and after the consultation, and between participants.

Results: Overall, 6% of the adolescents were consulting for a psychological reason, but, among the others, 17% reported having personal concerns they would like to talk about. Among adolescents aged 14 to 17, those consulting alone more frequently reported personal worries, but were more satisfied with the consultation than the others. A third party's presence did not appear to hinder expression. The representations of the third party and practitioner concerning the adolescent differed, although they tended to converge following the consultation: accompanies overestimated the adolescents’ well-being and freedom to talk, while GPs underestimated their well-being, readiness to confide and feelings of being understood.

Conclusion: GPs could be more optimistic about adolescent consultations: their role is viewed more positively than they think, especially by adolescents consulting alone. Most adolescents wishing to say something do so, even when accompanied to the consultation.

A randomized, controlled clinical trial about the effect of exercise education on knee osteoarthritis patients

Sabah Tüzün, Serap Çifçili, Pemra C.Ünalan

Dept. Family Medicine, Marmara University Medical Faculty, İstanbul, Turkey E-mail: [email protected]

Background: Exercise programs play an important role in the treatment of knee osteoarthritis, which is the most common cause of disability in the elderly.

Research question: This is a randomized controlled, educational intervention study. Sixty-four patients who were admitted to the family medicine outpatient clinic of Marmara University Hospital were enrolled in the study. Half of the participants were allocated randomly to the intervention group and the other half to the standard care group. Participants in the intervention group were given leaflets and gradual exercise education was applied by demonstration. The control group also received leaflets about exercises along with standard care. We assessed participants’ adherence with patients’ diaries and telephone contact. We also determined the WOMAC score of the participants at each follow-up visit.

Results: Mean age of the participants was 54.6 ± 9.85 years and 98.4% of them were women. Adherence to exercise in the intervention group was high (median 100%). Pain and WOMAC scores improved significantly. Exercise adherence of the control group was good but long-term adherence was only moderate. Improvement of pain and WOMAC scores was lower than the intervention group.

Conclusion: Patients with osteoarthritis do not generally adhere well to exercise programs. Gradual exercise education with demonstration might improve adherence.

Adolescent consumers of cannabis and general practitioners (GP): how to communicate?

Kailash Bahadoor, M. Rude, V. Picard-Bernard, L. Marty, P. Vorilhon C. Laporte

Dept. Médecine Générale, Faculté de Médecine, Clermont Ferrand, France E-mail: [email protected]

Background: Adolescence is a time of intense change both physically and psychologically. Attitudes to health during this period tend to be distinctive, as individuals generally perceive good health and therefore have minimal engagement with medical advice. Effects on health of cannabis use in adolescents are not fully understood.

Research question: The aim of this study was to assess the barriers to communication on the topic of cannabis use by adolescents with GP.

Method: Qualitative semi-structured interviews were carried out, amongst 13 cannabis users aged between 16 to 25 years. The interviews were recorded and subsequently transcribed and systematically analysed by two researchers.

Results: Adolescents had little and vague concept of what constitutes “bad health” other than “serious” medical illnesses. General practitioners were perceived as representing moral standards and authority. Both anticipated, and in some cases actual, lack of understanding and empathy, and also the feeling of judgement from the GP, resulted in a distant relationship with the adolescent. In the midst of a period of uncertainty and impulsivity, these adolescents reported responding to societal pressure to test cannabis use. Subsequently, continuation of use was more internally driven. Actual interactions with law or the threat of it, or lack of money were major motives to stop. However, the overriding motive was reported to be an internal decision to cease consumption.

Conclusion: The GP by practising an open and receptive approach, by showing empathy and tolerance can help adolescents to better understand the impact on health of cannabis use. The findings of this study have led to the development of a brief intervention program in the GP setting, to improve communication with adolescents over cannabis use and the management of those using it.

When patient-centred care is perceived as a lack of physician competence: Are patients more severe with female physicians?

Gaëtan Cousin, Marianne Schmid-Mast, Lilli Herzig, Nicole Jaunin-Stalder

Dept. General Internal Medicine, Policlinique Médicale Universitaire, Lausanne, Switzerland E-mail: [email protected]

Background: Patient-centred care implies that the physician adopts a non-directive communication style and discusses with the patient the diagnosis, the treatment's efficacy, the risks associated with it, and the best option to choose (Mead & Bower, 2002). When patients do not know their physicians, this communication style may be interpreted as uncertainty and incompetence. This effect may be stronger in female physicians than in male physicians because in traditionally male professions women are generally judged as less competent than men (Biernat & Kobrynowicz, 1997; Boldry, Wood & Kashy, 2001; Heilman, 2001).

Research question: The present research aims to test whether certain aspects of a physician's patient-centred communication are perceived as a lack of physician competence in female physicians more so than in male physicians.

Method: Forty general practitioners will interact with one male and one female patient each. Patients included in the study will face different medical problems and will be patients of different age groups. The physicians will be filmed during the consultation and independent raters will rate their communication style. A questionnaire will be given to the patients after the consultation, asking them about their perception of the physicians’ competence.

Results: We expect to show that male and female physicians who display the same patient-centred communication style are perceived differently. We expect that some aspects of patient-centeredness will be perceived as a lack of competence when they are expressed by female physicians more than when they are expressed by male physicians.

Discussion: Training in physician-patient communication should take into account the fact that the same communication style is perceived differently whether it is expressed by male or by female physicians.

Video-assisted education program for patients under oral anticoagulant treatment in primary care – a cluster randomized controlled study

Thanh Duc Hua, Stefan Viktor Vormfelde, Manar Abu Abed, Hannelore Schneider-Rudt, Jean-François Chenot

Dept. General Practice, University Medicine Göettingen, Göettingen, Germany E-mail: [email protected]öettingen.de

Background: Safe oral anticoagulant treatment (OAT) requires patients’ knowledge and cooperation. Serious complications arise from insufficient or excessive anticoagulation. Studies show that insufficient adherence and a low level of patient knowledge about OAT are the primary causes for complications. Therefore, it is necessary to increase patients’ knowledge.

Research question: Is a video-assisted education program more effective than a brochure to improve the knowledge of patients receiving OAT? Can a video-assisted education program stabilize coagulation results (INR) and reduce complications?

Method: A cluster-randomized controlled study of 360 patients receiving OAT will be divided into an intervention group and a control group (180 patients each). A baseline questionnaire will assess knowledge about OAT. The intervention group will take part in a video-assisted education programme, which will consist of a video (15 minutes), a brochure and personal training by a practice nurse followed up 4 - 6 weeks later with a short knowledge assessment questionnaire. The video gives important information about OAT, nutrition, and instructions for managing in critical situations. The control group will receive the brochure only. After six months, both groups will take part in a final questionnaire to evaluate knowledge level and time spent in the therapeutic range.

Results: This study will start in the fall. We expect that the intervention group will have better knowledge of OAT after six months and spend more time in the therapeutic range.

Discussion: We expect that the video-assisted education program is effectively increasing lasting basic knowledge about OAT. Previous studies evaluated knowledge mostly directly after the educational intervention. The number of subjects is insufficient to observe differences in adverse effects. However, we expect to see differences in the secondary outcome of time of the INR in the therapeutic range.

FREESTANDING PRESENTATIONS

Development and validation of a questionnaire for assessment of attitudes regarding family medicine

Marija Petek Šter, Igor Švab and Marko Kolšek

Dept. for family medicine, University of Ljubljana, Ljubljana, Slovenia E-mail: [email protected]

Background: Assessment is a key element of every curriculum. Although assessment methods of students have been extensively studied, assessment of the curricula is equally important, because it guides the teaching process. While assessing a curriculum, one needs to consider the changes of learner's attitudes, which is often difficult, because there is a relative lack of adequate tools for assessment.

Research question: To develop and validate a tool for the assessment of students’ attitudes towards family medicine based on EURACT's (European Academy of Teachers in General Practice) teaching agenda.

Method: Experienced family physicians were asked to describe their attitudes regarding family medicine by using the teaching agenda as a template for brainstorming. The statements were paraphrased and developed into a 164-items questionnaire, which was administered to 176 final-year students in the academic year 2007/08. A seven point Likert scale was used as a measure of agreement.

The third phase consisted of the development of a final tool using statistical analysis. Finally, the 60-items questionnaire was distributed to 171 students in the academic year 2008/09 and the internal consistency compared between the first and the second distribution.

Results: The final 60-items questionnaire contained 26 statements from the competence of primary care management, which was well described in the teaching agenda, but only one statement about person-cantered care and four statements about holistic approach. The authors got similar results regarding the internal consistency between the first and the second distribution (Cronbach alpha = 0.828 vs. 0.878 for the first distribution). The test/retest coefficient of temporal stability was 0.448.

Conclusion: This article reports on the first attempt to develop a valid and reliable questionnaire for measuring attitudes toward family medicine based on EURACT's teaching agenda. The questionnaire could be used to evaluate changes in undergraduate curricula.

Delphi methodology as a research strategy to improve primary mental health care

Karen Smets, E. Cornelis, L. De Deken, L. Pas

Research Institute Domus Medica, Berchem, Belgium E-mail: [email protected]

Background: The generally holistic view of primary health care requires well-developed strategies to deal with mental health problems. Due to limited research evidence on primary care for mental health problems, we used a Delphi methodology as a first step in developing intervention research for dealing with alcohol problems, depression and family violence.

Research question: 1. What problems are met when dealing with mental health in primary care? 2. Which possible solutions can be considered? 3. How should collaborative care be conceived with mental health services?

Method: For each theme, a postal questionnaire was sent during a first Delphi round to a random sample of 200 general practitioners, 400 psychologists and an opportunistic sample of all existing mental health services in Flanders (Belgium). For family violence, additionally social services and representatives of justice and police were contacted. Problems and suggestions were listed and feedback was collected from respondents to refine statements and score feasibility during a second round. Amended statements were retained during the third round when 75% of respondents agreed.

Results: Apparently a mayor communication gap exists between general practice, social care and mental health services in Flanders. Different views on confidentiality hinder exchange of information.

A consensus was reached indicating that communication about tasks of each caregiver and caregiver-patient agreements are generally well acceptable and need always to be transmitted spontaneously. Although specific concerns exist for each topic, similar communication principles between primary care and psychosocial services evolved independently for each theme supporting the reliability of this methodology to develop a good model for further action research.

Conclusion: Application of this methodology can lead to a widely acceptable protocol for improved communication and collaborative mental health care. It could be considered a strategy to further develop guidance and intervention protocols. It even might be applied in a European context.

Validation of a GP's gut feelings questionnaire

Erik Stolper, Margje Van de Wiel, Henrica de Vet, Lex Rutten, Paul Van Royen, Marloes Van Bokhoven, Trudy Van der Weijden, Geert Jan Dinant

Dept. of General Practice, Maastricht University, Maastricht, the Netherlands E-mail: [email protected]

Background: Research shows that gut feelings, i.e. a sense of alarm or a sense of reassurance, play a substantial role in the diagnostic reasoning of general practitioners (GPs). A consensus on a definition of gut feelings enabled us to operationalize the gut feelings concept by designing a questionnaire to record (the use of) gut feelings.

Research question: Assessing the validity of this questionnaire in a Dutch population of experienced GPs.

Method: No reference standard for gut feelings is available. We used the concept of construct validity, and designed 16 vignettes, based on real practice cases where a sense of alarm (n = 10) or a sense of reassurance (n = 6) played a major role in the policy of the attending GP, whether a clear role (group A) or an unclear role (group B). We postulated four major hypotheses and several subordinate hypotheses about the questionnaire scores in different vignettes, e.g. ‘There is a moderate to strong correlation between the group A vignettes and questions relating to a sense of reassurance or sense of alarm’ and ‘The correlation between the group B vignettes and questions relating to a sense of reassurance or sense of alarm is weak or absent’. Fifty GPs were invited to evaluate 10 of the randomly assigned vignettes and to complete questionnaires. Kappa, with quadratic weighting, was calculated for the agreement between the intended outcome of the vignettes and the gut feeling ratings.

Results: Forty-nine participants completed the questionnaires. Most hypotheses were confirmed. The Kappa was 0.62. The vignettes seemed to be a useful reference standard.

Conclusion: The construct validity of the questionnaire was moderate to good. The Dutch GPs’ gut feelings questionnaire can be used to record the use of gut feelings in general practice and the effect of educational interventions about gut feelings.

Cross-cultural validation of the Polish 4DSQ using DIF analysis

Berend Terluin, Slawomir Czachowski, Adam Izdebski

Dept. of General Practice, VU University Medical Centre, Amsterdam, the Netherlands E-mail: [email protected]

Background: The Four-Dimensional Symptom Questionnaire (4DSQ) has been translated into Polish. It is unknown if the Polish version is cross-culturally valid so that scores of Polish subjects can be compared with scores of Dutch subjects.

Research question: Does the Polish 4DSQ measure the same constructs (distress, depression, anxiety and somatization) in the same way as the Dutch 4DSQ?

Method: 4DSQ data were collected from a mixed sample of students and primary care attendees. The data were compared with the 4DSQ data of a matched sample of Dutch students and primary care attendees. Two methods of differential item functioning (DIF) analysis, ordinal logistic regression and generalized Mantel-Haenszel, were used to detect items with DIF, and linear regression analysis was used to estimate the scale level impact of DIF.

Results: The sample comprised 254 Polish and 262 Dutch subjects of which 66% were female. The mean age was 34.0 and 33.2 years, respectively. Four of the 16 items of the distress scale demonstrated DIF that caused Polish subjects with mild-moderate distress to score 1 point less than Dutch subjects. The depression items were free of DIF. Two of the 12 items of the anxiety scale exhibited DIF causing Polish subjects with moderate anxiety to score 0.7 points less. Three of the 16 items of the somatization scale were identified with DIF. However, on the scale level there was no significant effect of DIF on the somatization score.

Conclusion: There was little DIF in the Polish 4DSQ in comparison with the Dutch version suggesting that the Polish 4DSQ measures the same constructs as the Dutch 4DSQ. Dutch cut-off points can validly be transposed to Polish settings, except for the cut-off point for moderate distress. The distress cut-off point ≥ 12 in Polish subjects is equivalent to the cut-off point ≥ 11 in Dutch subjects.

Why teenagers don't start smoking?

Gozde Gursoy, Anil Dogan, Eda Yasar, Vildan Mevsim, Selin Bozdag

Dept. Family Medicine, Dokuz Eylul Univercity, Izmir, Turkey E-mail: [email protected]

Background: Smoking prevalence increases among teenagers. Researches in this field generally aim to determine the causes that make teenagers start smoking. To fight effectively against smoking, it is important to know the reasons that prevent young people from starting to smoke. Learning the thoughts of teens is essential for this goal.

Research question: Why teenagers don't start smoking?

Method: This work was planned as a cross sectional analytical research project. The research was applied to all 1st grade high-school students in Balçova, Izmir. The research was conducted in two phases. In the first phase, the questionnaire was constructed with a Delphi technique using focus group interviews with the high school students. In the second phase, this questionnaire was applied to the 1st grade high school students of four schools in Balçova. The questionnaire consists of demographic data, and triple likert scale questions investigating reasons to start and stop and to never start smoking. Variables were analyzed by SPSS 15.0 software using descriptive and Chi-square analyses.

Results: There were 493 participants; 40.56% of which were male and 9.03% smokers. Students mentioned that to prevent teenagers from starting to smoke and to give up smoking they should be channelled to social activities (81.8% and 86.3%, respectively) and informed about the harms of smoking (80.6% and 87.8% respectively). Also strict enforcement of prohibition of selling tobacco products to teenagers under 18 years old age seems to be important for preventing them from starting to smoke (78.5%).

Conclusion: Prevention of smoking commencement seems to be an effective strategy in the struggle against smoking, especially in teenagers. According to the results of this research, we aimed to write a theatre script for 1st grade high school students and to act it out for those in high schools.

Depressive symptoms among 13-year-old adolescents: prevalence and associated characteristics

Elisabete Ramos, Jutta Lindert, Sónia Dias, Henrique Barros, Cláudia Bulhões

Dept. of Hygiene and Epidemiology, Institute of Public Health, University of Porto, Braga, Portugal E-mail: [email protected]

Background: Until recent years, depressive symptoms were not considered a major problem among adolescents. Nowadays, studies reveal that 17 to 50% of teenagers report depressive symptoms, being one of the most prevalent health problems in adolescence.

Research question: Assess the prevalence of depressive symptoms in 13-year-old adolescents and identify their associated characteristics.

Method: We analyzed 1988 adolescents (52.2% females) aged 13 years, enrolled in public and private schools of Porto. At school, health professionals measured weight and height and adolescents completed a structured questionnaire including the Beck Depression Inventory, second edition (BDI-II). One was considered as having depressive symptoms when the BDI total score was ≥ 13. Parents answered a questionnaire about their socio-demographic and clinical characteristics. Exposure to parental depression was considered when at least one parent reported a previous diagnosis of depression. Data were analyzed separately by gender and the risk of having depressive symptoms was estimated by unconditional logistic regression, using odds ratio (OR) and confidence intervals (95%), and adjusted for parental history of depression and education level of parents.

Results: The prevalence of depressive symptoms was 18.8% in girls and 7.6% in boys (p < 0.001). Among boys, positive parental history of depression was associated with depressive symptoms (OR = 2.18, 95%CI: 1.00–4.71). This positive association was also present among girls, although not statistically significant (OR = 1.41, 95%CI: 0.90–2.20). Among girls, depressive symptoms were also associated with tobacco consumption and menarche at early age. There were no significant associations between depressive symptoms and categories of body mass index, hours of sleep, alcohol consumption and frequency of physical exercise in either gender.

Conclusion: This study showed a high prevalence of depressive symptoms in 13 year old. Parental history of depression was the most strongly associated factor with depressive symptoms.

How can the need for washout be curtailed in patients with earwax?

Ozlem Ilbi, Vildan Mevsim

Dept. Family Physician, Dokuz Eylul University, Izmir, Turkey E-mail: [email protected]

Background: Earwax is one of the most common ear complaints and 95% of the treatments are carried out via irrigation process. Irrigation results in many complications such as eardrum perforation and infection. Earwax can easily be cleaned in a short time without leading to any complications with the help of ceruminolytic drop.

Research question: Ceruminolytic drop use in patients with earwax can decrease ear wash need and earwax scores compared to glycerine drop use.

Method: A total of 171 patients (274 ears) were involved in this study; 86 patients (138 ears) were administered glycerine drop and 85 patients (136 ears) were administered a mixture of 6% hydrogen peroxide glycerine (v/v; 1/1) compatible with block randomization. The earwax of the patients was scored as between 0-3 prior to intervention and following one week of medicine use. Descriptive analyses, Chi Square and t-tests were utilized in the data analysis. NNT analysis was also performed.

Results: Earwax scores in the intervention group declined 30.87% following the intervention compared to the earwax scores prior to intervention. The reduction in the earwax scores of the control group was 14.45% (p = 0.002). Earwax of 10 ears (6.91%) administered glycerine drop was entirely opened and the earwax of 26 ears (19.11%) administered 6% hydrogen peroxide glycerine was completely opened (p = 0.004). NNT was determined as 8.42. There was no statistically significant difference observed in the complaints of patients prior to and following the treatment such as pain, hearing loss, itching, humming or dizziness in the intervention and control groups (p > 0.05).

Conclusion: The ratio of total reduction in the patients who used a mixture of 6% hydrogen peroxide glycerine and the ratio of complete opening of ears were higher when compared to patients using glycerine only. Particularly the use of a mixture of 6% hydrogen peroxide glycerine appears to be more preferable to lavage, which has many complications.

Integrated medical care for elderly patients affected by chronic obstructive pulmonary disease and heart failure

Francesco Chiumeo, Marco Cambielli, Ferdinando Petrazzuoli, Nicola Buono, Giandomenico Nollo

SNAMID Trento, Civezzano, Italy E-mail: [email protected]

Background: Chronic Obstructive Pulmonary Disease (COPD) and Heart failure (HF) are commonly associated chronic conditions that require attentive care. According to the literature, at least 25% of patients affected by COPD suffer also from HF and vice versa. Symptoms (dyspnoea, weakness and fatigue) are common in both diseases and therefore a precise diagnosis is often difficult to reach in the primary care setting, especially in the early stages of HF; moreover some drugs, which are useful for HF can be contraindicated for COPD and vice versa. A thorough clinical assessment of these patients is therefore necessary to avoid therapeutic incongruence.

Research question: Can a project based on early detection of COPD and HF, agreed clinical pathways and facilitated access to secondary care investigations, improve the care of HF-COPD patients?

Method: The settings of our proposed study are primary care practices in the Province of Trento, Northern Italy. A programme based on reinforcement of the knowledge and skills for early detection of COPD and HF will include 50 GPs recruited on a voluntary basis. An agreement upon easy access to secondary care facilities for appropriate additional tests (e.g. echocardiography) will be reached with the hospital department in each area involved in the project.

Results: Patients considered for evaluations will be over 65 years old, affected by both HF and COPD. Effectiveness of the project will be assessed by measurement of process indicators such as prevalence of COPD and HF, reduction in therapeutic incongruence, and outcome indicators such as functional class improvement and emergency hospital admissions rate for COPD and HF. The results will be compared with an equal group of GPs performing usual care.

Conclusion: The results of the project will be useful for further decision and evaluation on the feasibility to implement this approach on a wider scale.

The primary care frequent attender profile

Sofia Esquível, Alexandra Machado, Hermínia Teixeira, Joana Gomes José Agostinho Santos, Luís Filipe Cavadas, Marlene Sousa, Paulo Pires

Unidade Local de Saúde de Matosinhos, Centro de Saúde Senhora da Hora, Porto, Portugal E-mail: [email protected]

Background: Frequent attenders are believed to represent a problem in primary care, with a human, economic and social impact. Most existing studies refer to emergency departments. Understanding these patients’ characteristics and consultation motives may contribute to strategies to provide a better distribution of health resources and improve individual medical care.

Research question: What are the socio-demographic and pathological characteristics of our frequent attenders?

Method: A cross-sectional study was conducted in the population of frequent attenders in a Portuguese primary healthcare practice between January 2007 and December 2009, allocated to six general practitioners (GP). Frequent attenders were defined as the top 10% of attenders over the study period. Socio-demographic characteristics (gender, age, level of education, occupation, marital status and type of family) as well as data related to physical and mental illness were collected from clinical records retrospectively. Associations between variables were tested with χ-square, t-test and Kruskal-Wallis. The adopted significance level was 0.05.

Results: From the 582 individuals evaluated, 444 were females (76.3%). The mean age was 55.4 years. Frequent attenders have a mean educational level of 6.6 years, with 46.2% active workers. Seventy-five percent of the individuals live as a couple and 70% belong to a nuclear family. About 85% have chronic physical illness and 42% have chronic mental illness. Individuals with physical illness are older (mean age: 58.0 vs. 40.1; p < 0.001) and with psychiatric illness are younger (mean age: 53.7 vs. 56.6; p = 0.035). The greatest consultation consumers have more chronic psychiatric illness (p < 0.001) and multiple physical illnesses (p = 0.01).

Conclusion: Primary Care frequent attenders are female individuals in their sixties, with low educational level, coming from a nuclear family and with chronic illness. Mental illness particularly affects the high consultation consumers. These results are in accordance with previous studies and may help the GP in consultation management and planning.

Advisory and technical services requested by frequent contacting or chronic patients of different age groups – a secondary data analysis from routine GPs’ EHR.

Johannes Hauswaldt, U. Junius-Walker, E. Hummers-Pradier

Institute of General Practice and Family Medicine, Hannover Medical School, Hannover, Germany E-mail: [email protected]

Background: Elderly patients request different services from general practice compared to middle aged or younger patients.

Research question: To discriminate annual frequency of contact according to age group.

To identify frequent users and patients with a chronic condition. To relate findings to technical or advisory services.

Method: Data from 155 German general practices’ electronic health records (EHR) in respect of 472,775 patients (53.6% female) was extracted via the BDT software interface; were analyzed for fee-for-service information, excluding incomplete or incongruent data cases, periods outside 1996 to 2006, and practices with less than 300 patients annually or with no continuous coverage. Variables indicating frequent user status (24 annual contacts) and chronic illness (contact each quarter) for five age groups, and practice properties were related to indices for distinct forms of medical advice or technical performance.

Results: Data from 281 688 patients (54.5% female) and 547 624 patient-years from 81 practices were applicable. Mean annual frequency of contact remained stable around 7.1 over 11 years, but differed considerably between age groups. We found 25.8% of the very old were frequent users, compared to 16.0% of the elderly, 7.5% of the middle aged, and 2.8% of the younger patients. For chronic illness, elderly and very old patients did not differ much from each other but did from the rest of patients. Elderly patients, followed by the very old, and then by the middle aged and younger, requested technical and advisory services predominantly. Practice properties (rural vs. urban, single handed vs. group practice, size) had a significant but marginal impact.

Conclusion: Annual patient contact increases with age, but request for technical, and especially for advisory services cumulates for elderly patients, and declines for the very old, except for home visits or emergency calls. Results from this study confirm expectations but allow for clear quantification.

Prevalence and risks factors of vitamin D deficiency in an adult male population in primary care

Christian Dupraz, C. Pigache, A. Martin, A. Gerard, M.F. Le Goaziou

Dept. Medecine Generale, University Claude Bernard Lyon, Lyon, France E-mail: [email protected]

Background: Vitamin D status is widely studied in the world and it appeared that deficiency is common and appeared as an important public health issue. Several studies concerned women or old people but few studies concerned young men.

Research question: The aim of this study was to evaluate the vitamin D deficiency status of an adult male population in primary health care.

Method: All the men aged from 19 to 59 years old, who consulted their GP between February and April 2009, were included in the study. Participants gave a blood sample and answered questions about their quality of life (Wonca scales) and their lifestyle (sports, sun exposure, food, work…). Levels of vitamin D2 and D3 were measured. Univariate and multivariate analysis were carried out with a significance threshold of 5%.

Results: Overall, 281 subjects were recruited from two French regions (Rhône-Alpes and Gironde); 94% of subjects (N = 264/281) had serum 25(OH) D ≤ 75 nmol/l, which represents the lower limit of vitamin D insufficiency; and 27% of those had 25(OH) D values ≤ 30 nmol/l (12 ng/ml). The univariate analysis showed that risk factors of vitamin D deficiency are dark skin, low social level, no summer sunlight exposure or small skin surface exposed, and no outdoor hobbies or sport. In a multivariate analysis, vitamin supplement consumption (OR = 0.5 CI95% = 0.36-0.72, p < 0.001) and asuntan (OR = 0.4 CI95% = 0.19-0.87, p = 0.02) are demonstrated to be protection factors.

Vitamin D deficiency was associated with a lower quality of life (physical activity (p = 0001); social activity (p = 0.008) and health status (p = 0.012)).

Conclusion: It is important to focus general practitioners’’ attention on the high prevalence of vitamin D deficiency in the male population, to diagnose it earlier, prevent it and avoid musculoskeletal pains and osteoporosis.

Vitamin D Status of postmenopausal women in general practices

Marie France Le Gaoziou, E. Morel, A. Martin, M.C. Carlier, C. Dupraz

Dept. Medecine Generale, University Claude Bernard Lyon, Lyon, France E-mail: [email protected]

Background: Many publications are actually published about vitamin D deficiency worldwide. Vitamin D deficiency is a cause of musculoskeletal pains, tiredness and osteoporosis. In France, one recommendation concerns nursing home old people for a vitamin D supplementation. The general practice department of Lyon (DMG) have conducted different studies about veiled young women, young women and young men.

Research question: What is the vitamin D status of old women at home? To answer these questions, the DMG of LYON carried out a new research project; a descriptive study with generalist practitioners in the Rhône Alp area.

Method: All women aged 50 to 80 years old who consulted the GP were included by 25 GPs between January and March 2009. Participants completed forms about food intake, sun exposure, quality of life (with Wonca scales), and lifestyle and have a blood test in their usual laboratory. Statistical analysis was carried out using SPSS and SAS. Wilcoxon and chi² test were used.

Results: Overall, 457 women were included. For 88% of them, vitamin D was under 75 nmol/ L, for 61% under 50 nmol/L and for 25% under 30 nmol/L. Contrary to what one might think, the younger the women, the lower the vitamin D level.

Well known risks factors were found: obesity and covered garment. Protective factors were summer sun exposure, outdoors sport practice and supplementation of vitamin D.

Vitamin D level was correlated with the risk of chronic pains; 25% of these women had an osteoporosis risk factor.

Quality of life was lower where vitamin D level was under 50 nmol/L

Conclusion: French GPs should search for risk factors for vitamin D deficiency among all post menopausal women, not only the older ages, and give them vitamin D supplementation.

They have to educate about sunshine exposure, food intake and outdoor sports.

Referral Study in ACES Gondomar

Miguel Azevedo, Miguel Melo

Dept. USF Fânzeres, ACES Gondomar, Gondomar, Portugal E-mail: [email protected]

Background: Referral from general practitioners for secondary care is a practice with significant costs to healthcare systems. Referral studies are lacking in Portugal; the referral rates vary between 5.56% and 10.11%. It is therefore useful to perform an updated study, with a large population group to determine the referral rate.

Research question: What is the referral rate in ACES Gondomar (ACESG) in the year 2009? What factors are associated with the referral process?

Method: Observational, cross-sectional study in three primary health-centers in North Portugal. Study population: all referrals made to secondary care in 2009, in the ACESG (175 603 users, 97 GPs). A census was carried out on the study population. We consulted the databases SINUS, SIARS and Alert for the ACESG - all referrals were made through electronic communication. The main variables measured were the number of consultations, medical specialty referred, referral rate and GP's sex and number of years of clinical practice. Univariate and bivariate analysis were carried out.

Results: The referral rate in 2009, in ACESG, was 3.7% (20 323 referrals / 548 707 consultations). There is a higher referral rate among female users and greater referral in the age group between 20 and 65 years. The most referred specialties are Ophthalmology (19.7%), General Surgery (11.0%) and Orthopaedics (7.9%). There is a weak association (r = −0.18) between the referral rate and the number of years the GP's was in clinical practice.

The value of the referral rate doubles (7.74%) if the referrals to physical medicine and rehabilitation are included.

Conclusion: The referral rate in 2009 in ACESG is slightly lower than reported in Portuguese studies. Years in clinical practice are a minor confounding factor. More research is needed to verify if this figure suggests a decreasing trend in referral or reflected a better GP experience.

ABPMS-2: resurgence of end-digit preference in blood pressure measurement

Jean-Pierre Lebeau, Denis Pouchain, Clarisse Dibao-Dina, Florent Boutitie, Dominique Huas

Dept. General Practice, University of Tours, Vendome, France E-mail: [email protected]

Background: ESCAPE-ABPMS-1 showed that general practitioners (GP) still practised end-digit preference (EDP) although provided with an electronic blood pressure (BP) measurement device. The results also suggested that EDP was time-dependant: after nearly disappearing with the acquisition of an electronic device, it was likely to come back as time went by.

Research question: For GPs newly provided with an electronic BPM device, did EDP become more frequent after two years of use of the device?

Method: Cluster RCT. The intervention group (IG) used a provided electronic device vs. usual care for the control group (CG), i.e. manual measurement for 75% of the GPS (MCG), and electronic for 25% (ECG). ABPMS-2 final data was gathered after two years. Statistical analysis used mixed effect linear model comparison of the mean BP values, and Chi² comparison of EDP rates, and of the number of GPs practising EDP in the three groups.

Results: Overall, 3 305 BP measurements, performed by 125 GPs in the IG, 98 in the MCG, and 32 in the ECG were analysed. After two years, mean systolic BP was significantly higher in the IG (139.6 vs. 137.2 mmHg; p = 0.002). The rate of GPs practising EDP was significantly higher in the CG vs. IG: 93.8% vs. 38.2 % (RR = 2.2; CI95%: 1.8 - 2.8). From inclusion to two years, EDP increased in the IG from 29.6% to 38.2%, while it decreased in the ECG from 65.6% to 56.7%. This difference over time was not significant according to the logistic model (p = 0.11). Systematic rounding increased from 18.8% to 20.0% of the GPs in the ECG, and from 4.8% to 10.6% in the IG, again with no significant difference over time.

Conclusion: EDP increased after two years, but not significantly. Further qualitative research is needed to understand the reasons for EDP.

Psychosocial risk factors for transition from acute to chronic low back pain in primary health care - review of the literature

Aline Ramond, Céline Bouton, Isabelle Richard, Jean-François Huez

Dept. of General Practice, University of Angers, Angers, France E-mail: [email protected]

Background: Low back pain (LBP) is a major public health problem, often encountered in primary care. Recent guidelines recommend early identification of psychosocial factors, which could prevent rapid recovery from acute LBP.

Research question: To systematically review the evidence of the prognostic value of psychosocial factors for the transition from acute to chronic non-specific LBP in an adult population in primary health care.

Method: A systematic search for prospective studies dealing with psychosocial risk factors for poor evolution in LBP was conducted, screening Pubmed, PsychInfo and Cochrane Library databases. Cohort studies were selected if adults with (sub)acute (<3 months) LBP in primary care were followed-up for at least three months, and evaluated with patient-centred outcome criteria. Two reviewers using standardized criteria before analysing their main results assessed methodological quality of studies independently.

Results: In total, 23 papers fulfilled the inclusion criteria, related to 18 different cohorts. 16 psychosocial factors were analyzed, belonging to three domains: social and socio-occupational, psychological, and cognitive and behavioural fields. Depression, emotional distress, passive coping strategies and fear-avoidance beliefs were sometimes found to be independently linked with poor outcome, whereas most social and socio-occupational factors didn’t. The somewhat high predictive ability of patient's self-perceived general health at baseline was difficult to interpret because of likely biomedical confounders. Initial patient's or caregiver's perceived risk for LBP persistence was the factor most constantly linked with actual evolution.

Conclusion: This study found few independent psychosocial risk factors, which did not explain a large part of the observed variability in the evolution of episodes of LBP in primary health care. Randomized clinical trials aiming at modifying them have shown little impact on prognosis on a cohort scale. Deeper understanding about these psychosocial issues is probably needed before defining and evaluating new management strategies.

Variability in cardiovascular risk profile between Spanish and immigrant populations

Miguel-Angel Muñoz, Esther Pastor, Joan Pujol, Silvia Cordomi, Jose Luis del Val, Josemi Baena

Primary Health Care Research Unit of Barcelona, Primary Health Care Research Institute (IDIAP-JordiGol)

Sant Elies, Barcelona, Spain E-mail: [email protected]

Background: Little is known about the differences in cardiovascular risk factor prevalence between immigrants versus autochthonous population.

Research question: Are there any differences in the cardiovascular risk factor distribution between immigrant and non-immigrant populations in Spain?

Method: Cross-sectional multi-centre study. A database containing clinical information of 63 257 patients was analyzed to establish the distribution of classic cardiovascular risk factors (lipids, obesity, tobacco, hypertension, diabetes) among the immigrant population and the Spanish born population. Cardiovascular risk was calculated by using the Framingham score adapted to the Spanish population. All immigrants who used primary health care services at least once in the three previous years and a sample of the Spanish born population, paired by age and gender were included. A descriptive and bivariate analysis was performed.

Results: Average age was 35.2 years (SD 11.3), and 50.6% were women. The highest prevalence of obesity was found among the Spanish population (6.6%), followed by Latin-Americans (5.4%), and people coming from Western European countries (4.5%), p < 0.001.

Hypertension was more frequent in the Spanish (5.4%), and in people coming from Western European countries (4.5%), p < 0.001, and similar results occurred with lipid profile. Smoking was higher in the Spanish population (21.5 %), and in immigrants from Eastern European countries (12.8%) and Western European countries (11.8%), p < 0.001. Highest cardiovascular risk was found in people coming from Western European countries (4.53%), p < 0.001.

Conclusion: Spanish born people and immigrants coming from Western European countries have the worst cardiovascular profile. A more aggressive preventive approach in these populations, based in a communicative strategy of cardiovascular risk, is needed.

Using web service support to communicate and improve quality of care in family practice: a pilot project

Peter Burggraeve, K Thomeer, K Hillemans, Leo Pas

Dep. Research, Domus Medica (Flemish Institute of General Practitioners), Berchem, Belgium E-mail: [email protected]

Background: In Belgian primary healthcare more than 17 electronic health care record systems exist. To improve medical data communication, several initiatives were taken in the past, such as standardising the structure of medical records, labelling systems fulfilling criteria for reimbursement and defining syntax and content of summary records. They have been conceived by a top down process and do not take into account physicians’ needs.

Research question: What are physicians’ priorities for electronic record support oriented to quality of care and data collection for research purposes? How should confidentiality be guaranteed in such systems?

Method: Through an online Delphi methodology we asked open questions on priorities for data communication. In the first round, an opportunistic and random sample of French and Flemish GP's were approached. In the second round, suggestions were refined and further amendments requested. During a third round in the field, further amendments were requested to allow for better multidisciplinary communication. The possibilities of a web-based support system were introduced.

Results: A representative mix of responders was obtained form Flemish colleagues, while a smaller group of French respondents represented more specifically group practices and teaching colleagues. A consensus was reached in the second round among Flemish participants. Priorities are linked to the promotion of reimbursed care pathways. A more standardised approach of structuring healthcare data into the EMD is therefore needed and requested. French colleagues seem to be only willing to share anonymous data for research, while Flemish GPs accept the coding of patient and GP identity using a trusted third party.

Conclusion: The multitude of existing software in Belgium requires the creation of a central web service to view, integrate and complement information in the local practice software. We conceived such a web-based service to fulfil the communication needs of GPs.

Job perspectives on general practice as perceived by medical students – a cross sectional study

Katja Götz, Antje Miksch, Katja Hermann, Kathrin Kiolbassa, Andreas Loh, Joachim Szecsenyi, Stefanie Joos

Dept. General Practice and Health Services Research/Competence Centre General Practice Baden-Wuerttemberg, University Hospital Heidelberg, Heidelberg, Germany E-mail: [email protected]

Background: Decreasingly, German students are interested in careers in general practice. The factors influencing medical students toward general practice as a career choice are poorly understood.

Research question: The aim of this study was to explore opinions and attitudes of students at different stages of medical training towards general practice.

Method: The study was designed as a cross-sectional study. Students at the five medical schools in the federal state of Baden-Wuerttemberg (Germany) participated between January and February 2010 in an online-survey. A questionnaire with 32 items requesting opinions and attitudes towards different aspects of general practice was developed based on a literature search and previous qualitative studies. Answers were measured with 5-point-Likert-scales ranging from 1 (‘fully agree’) to 5 (‘fully disagree’).

Results: A total of 1 299 medical students participated in the survey, thereof 304 students were in their pre-clinical phase (year 1 – 2), 688 in their clinical phase (year 3 – 5) and 173 in the last year (‘practical year’). Overall, 43% of the students fully agreed with the statement ‘in general practice … you decide autonomously’ and 38% with ‘… you use a broad medical knowledge.’ In contrast, 41% of the students fully disagreed with the statement ‘in general practice … you get a good remuneration’ and 46% with ‘… you have a low mental burden.’ There were significant differences between students at a later stage of medical training compared to less advanced students.

Conclusion: Although there are common perceptions towards general practice in medical students, many characteristics of the work of general practitioners are regarded differently by students at different stages of their medical training. To raise the proportion of students opting for general practice, their expectations and priorities need to be addressed – preferably at an early stage of medical training.

When and why do young physicians decide to become GPs? A self-administered survey

Nina Badertscher, Miriam Schöni, Livia Berger, Marco Zoller

University Hospital of Zurich, Institute for General Practice, Zurich, Switzerland E-mail: [email protected]

Background: In Switzerland future GPs spend most of their postgraduate training in a hospital setting; little is known about the specific structure of this stage. We assessed among assistant physicians who declared to be interested in a career as a general practitioner (GP) the motivation of becoming a GP, determinants of the decision and important learning objectives.

Methods: In August 2009, we sent a semi quantitative questionnaire to 535 assistant physicians, working in departments of internal medicine and surgery of hospitals in the cantons Zurich and Berne; a reminder was sent one month later. After a descriptive analysis, correlations were examined by statistical analysis using Chi-Square, Mann Whitney U-Test and logistic regression.

Results: A total of 318 (62.4%) questionnaires were returned. We found that 144 (45.3%) of the surveyed assistant physicians considered becoming a GP. While 58 (40.3%) of (potential) future GPs took this decision in their undergraduate phase, 56 (38.9%) of them decided at the postgraduate stage. General interest in primary care (86, 59.7%) was the most important motivation, followed by undergraduate contact with the primary care setting and/or GPs (47, 32.6.%). Size of department as well as duration of postgraduate training was independently associated with the choice of a career in family medicine.

Conclusion: As in many countries, Switzerland is faced with an increasing shortage of primary care physicians. Our survey revealed that half of the assistant physicians who considered a career as a GP started to do so in their postgraduate stage and showed an intrinsic motivation that is dependent on the setting. This finding emphasizes the need for GP specific training, including frequent GP contact opportunities and specific learning objectives. GP specific educational programs, integrating structured practice tutorials could significantly increase attractiveness of entering ambulatory care as a GP.

CANABIC: CANnabis and Adolescents, a Brief Intervention to reduce their Consumption

Catherine Laporte, C. Dubray, V. Picard-Brenard, C. Huas, P.M. llorca P. Vorilhon

Dept. Médecine Générale, Faculté de Médecine de Clermont-Ferrand, Clermont Ferrand, France E-mail: [email protected]

Background: Cannabis (THC) is the most prevalent illegal drug used in France, with consequences arising from ‘casual consumers’ (1–10 joints/month). The general practitioner (GP) is the health professional most seen by adolescents. Brief interventions (BI) for adult alcohol use have been shown to be efficacious. Some BI to inspect adolescents and consumption of THC has been piloted, showing their feasibility, but they have not been validated.

Research question: Can a BI conducted with users of THC aged 15 to 19 years by their GP reduce its consumption?

Method: Two preliminary qualitative studies (with adolescents and GPs), were used to analyze the difficulties of communication around THC use. The scientific committee has analyzed the results and developed a BI adapted to adolescent THC users.

CANABIC is a quantitative study to validate the BI: randomized controlled trial, clustered study, comparing an intervention group (IG) and a control group (CG).

The intervention is the receipt of the IB during a specific consultation. The endpoint is the consumption of THC in number of joints/month.

The aim is to include 250 adolescents, five by each GP with 25 GPs in each arm. The sample size has been calculated to demonstrate a significant decrease of 30% of consumption. Attrition of GPs and patients has been estimated at 20% and 10% respectively, alpha risk and statistical power was calculated at 5% and 90%, the coefficient of intra-cluster correlation was calculated at 0.02. There are 3 follow-up consultations at three, six and 12 months.

A feasibility study is underway; results will be analyzed to optimize the controlled trial.

Results: A decrease of 30% of consumption is expected (joints per month). Perception of cannabis by adolescents will be reviewed.

Conclusion: Validate a BI appropriate to the consultation of the youth consumer of THC to provide a tool to support the MG.

Determinants of opiate intake among fishermen

Bernard Le Floch, Brice Zacharewicz, Denis Barba, Patrice Nabbe, Pierre Barraine, Benoit Chiron, Marie Barais, Sebastien Cadier, Jean-Yves Le Reste

Dept. de Médecine Générale de Brest, Université Bretagne Ouest, Le Guilvinec, France E-mail: [email protected]

Background: The consumption of opiates by sea fishermen is far above average. This has been emphasized in a report by the French Office for Drugs and Drug Addiction in 2007, and in other studies. One may wonder about the reasons for this excessive consumption.

Research question: The objective of this work is to investigate the relationship between fishermen and heroin.

Method: Qualitative survey using semi-structured interviews. Both communities of addicts and sailors are very closed. We have used a relationship of trust established by GPs to raise the barrier of secrecy. We interviewed sea fishermen, 23 – 56 years old, currently working or who left the profession in recent months, known to be addicts, and treated with opiates replacement therapy by their GP. The interview grid consisted of a series of open questions on drug and determinants that lead to drug abuse.

Results: We conducted seven interviews and reached saturation after five. The most innovative items found are the concept of ‘no limit’, prompting some fishermen to spend all their earnings on harmful substances. The emotional loneliness, lack of companionship for assistance and exchange on board, and violence and bullying (often including types of sexual harassment), add to the sea stress and individuals misuse behaviour. When at sea, facing the dangers, these sailors said they did not take opiates.

Conclusion: Prevention campaigns on addiction among fishermen could focus on human respect to be more effective. These innovative items could be relevant for other socio-professional categories and lead to different prevention campaigns.

Hungarian family physicians’ and residents’ knowledge of and attitude towards OSAS (obstructive sleep apnoea syndrome)

Péter Torzsa, Ajándék Eőry, Márta Novák, István Mucsi, László Kalabay

Dept. of Family Medicine, Semmelweis University, Budapest, Hungary E-mail: [email protected]

Background: Family physicians often do not recognize OSAS in spite of its high prevalence and clinical significance. Education of physicians is important to diagnose patients with OSAS earlier and to treat them in accordance with the proper recommendations.

Research question: What is the extent of Hungarian family physicians’ and residents’ knowledge of and their attitude towards OSAS? Can we use the OSAKA questionnaire for monitoring the efficacy of education about sleep medicine?

Method: A total of 533 practicing family physicians (age: 54 ± 9 years, mean ± SD, range: 27 – 79) completed the validated OSAKA questionnaire. Fifty residents of family medicine completed this questionnaire prior to and on completion of their course on sleep medicine.

Results: The average score of female respondents was significantly higher compared to male respondents (12.5 ± 2.4 vs. 11.4 ± 3.1 p < 0.001). The score decreased with respondents in higher BMI categories. Respondents exclusively treating adult patients obtained higher values than those treating only children or a mixed aged population (12.6 ± 2.7 vs. 11.1 ± 2.9, p < 0.01). Physicians working in the capital and larger cities had the highest scores (12.5 vs. 10.4, p < 0.01). Multivariate analysis revealed an inverse correlation between scores with family physicians’ knowledge and responders’ age and BMI value following adjustment for variables of the statistical model. A significant correlation between the number of specialties and physicians’ knowledge was observed (regression coefficient: 1.28 (0.99 – 1.57, p < 0.001). The residents’ average score 13.5 ± 1.8 did not differ significantly from that of the practicing family physicians. Residents, however, exhibited lower self-confidence about recognition and treatment of OSAS. Their knowledge and scores increased significantly after education (15.4 ± 1.9, p < 0.001).

Conclusion: The knowledge of Hungarian GPs regarding the causes of OSAS is not sufficient. Our result also demonstrated that the OSAKA questionnaire is suitable for the follow-up of the efficacy of the educational intervention in interdisciplinary sleep medicine.

Life after radical prostatectomy for localized prostate cancer

Sophia Eilat-Tsanani, Ch. Tabenkin, Y. Shental, D. Steinmetz

Dept. Family Medicine, Emek Medical Center, Afula, Israel E-mail: [email protected]

Background: Radical prostatectomy (RP) is an optional treatment for men with localized prostate cancer (PC). Adverse effects of RP as malfunction of urogenital system are frequent. These men have to cope both with cancer disease and RP outcomes.

The research question: How do men with localized PC who went through RP cope with the disease and the surgery outcomes?

Method: A qualitative study, using structured interviews.

The participants were men who went through RP due to localized PC in one hospital during 2003 – 2005. The interviews took place in the participants’ homes a year after surgery. The interviews were audiotaped and transcribed. The text was analyzed, labelled and grouped into themes.

Results: The study population reached saturation on interviewing 20 men. A motive that dominated all the interviews was urogenital system malfunction: first and foremost urinary incontinence followed by impotence. Urine leakage interfered with social activities, self-esteem and caused shame. Impotence disturbed sexual function, relationship with women and masculine image. The information about the surgery and its potential implications was provided to the participants before surgery without involvement of their partners and without further support. The participants relied on their surgeons and felt confident with their decision. They used words like sadness and guilt to describe their feelings but not regret. They all considered that their symptoms were a reasonable price to survive cancer.

Conclusion: Men with localized PC who went through RP will suffer the adverse effects for many years due to the expected high survival rate. Fear of cancer dominated their decision to undergo the operation. Better preparation could perhaps empower them to avoid surgery, the necessity of which is questionable at that stage of the disease.

EGPRN and TRANSFoRm: assessing the capacity and readiness of European primary care networks, electronic health records’ systems and clinical data repositories

Paul Van Royen, Hulya Yikilkan, H. Bastiaens, P. Leysen, P. Ryckebosch, S. Coenen

Dept. Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium E-mail: [email protected]

Background: TRANSFoRm, supported by an EU FP7 grant, is a collaborative project for the integration of primary care clinical and research activities, to support patient safety and clinical research. It aims to develop the rich capture of clinical data in electronic health records (eHR), to research the interoperability of eHR data to enable large-scale studies/clinical trials, and to develop software tools and services to enable integration and reuse of clinical research data.

Research question: What is the capacity and readiness of existing national/regional health care databases for linkage to the project, their interactivity with high quality eHR-systems and their overlap with active research networks in primary care practices across Europe.

Method: All national representatives and institutional members within EGPRN were approached by mail/phone and details of eHR systems and clinical data repositories were collected. For every database, the survey gathered the aims and methods of data collection, the relationship with the GPs’ eHR, and the description of the dataset characteristics. We also collected details of contact persons responsible for the database management, so that we might ask them for more information in a second phase.

Results: Data from 28 European countries give an overview of 63 existing national/regional health care databases. Forty-three databases have a clear linkage with GPs’ electronic health record systems. According to the respondents, it is possible to reach 36 databases directly for research purposes. The coding system used is very different: ICPC in 20 databases, ICD9/10 in 41 databases and ‘read’ codes in five databases.

Conclusion: From this overview, we get a clear view of primary care's capacity for linkage to TRANSFoRm and other similar projects.

Register of clinical prediction rules, methodological quality assessment and implementation strategies

Emma Wallace, Claire Keogh, Susan Smith, Borislav D Dimitrov, Tom Fahey

HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI, Dublin, Ireland E-mail: [email protected]

Background: The potential of improving patient care by using clinical prediction rules (CPRs) is not yet realised. Challenges include finding, understanding and applying CPRs in clinical practice. It is difficult to identify relevant CPRs from electronic database resources due to the absence of indexing terms for both CPRs and primary care.

Research question: To develop an international register of CPRs relevant to primary care to be distributed through the Cochrane Primary Health Care Field.

Methods: The register is being developed by identifying relevant articles from (1) an electronic search string generated and tested in-house and (2) the personal libraries of clinical researchers. Relevant CPR articles are stored in a single EndNote file and classified according to: ICPC-2 coding; the level of evidence achieved by the article (derivation, validation or impact analysis) and the methodological quality of the article.

Results: The register currently comprises 252 CPRs relevant to primary care. These articles incorporate 21 broad clinical areas, with the largest number of articles identified for respiratory conditions (n = 56) and the least identified for infectious diseases (n = 2). These broad clinical areas are further classified according to specific conditions. Many of the articles present results for one or more levels of evidence (e.g. derivation and validation of the same rule). At present the register contains 146 derivation, 243 validation and three impact analysis articles.

Conclusion: Though the register will need to be maintained and updated regularly, it offers many potential benefits for primary care practice. Articles are presented with condition specific codes, level of evidence and quality of the research allowing the clinician to objectively assess the utility of the CPR for use with patients. The classification of rules according to diagnostic area and level of evidence also highlights areas for further research efforts.

The FPDM (family practice depression and multi-morbidity) Study: Project for multimorbidity and depression after 50

Patrice Nabbe, J.Y. Le Reste, H. Van Marwijk, B. Chiron, M. Barais, M. Cadier, B. Le Floch, M. Barraine

Dept. de Médecine Générale, Université de Bretagne Occidentale, Brest, France E-mail: [email protected]

Background: To motivate older patients with somatic illness to acknowledge and treat their depressive symptoms is frequently difficult. Depression and multi-morbidity are frequent after 50 years of age. A relationship exists between the onset of depression and the recent discovery of a second factor of multi-morbidity. GPs are the integrated entry point into health care for almost all European countries for older patients. We GPs, as generalists, may not define depression and multi-morbidity in the same way as other specialists.

Research question: The FPDM project will investigate more effective intervention to cure or prevent depression after discovering a second factor of multi-morbidity.

Method: A step-by-step program. First, the literature will be reviewed systematically for definitions of depression in and out of family practice, with a systematic review for definition of multi-morbidity at the same time. Second, two qualitative studies will be performed using focus groups with GPs. One on the definition of depression for GPs and one on the definition of multi-morbidity for GPs. Analysis will be carried out by three different researchers. Third, the differences between the responses of the systematic review and the focus groups will be compared. Fourth, a quantitative study will be carried out to validate the new data stemming from differences. We invite international colleagues to discuss the definition of depression in later life in the context of somatic illness.

Results: Study design; no results yet.

Discussion: With this step-by-step method, we hope to find a validated definition for depression and multi-morbidity in family practice. This will be a strong and essential foundation to find the more effective intervention to cure or prevent depression after discovering a second factor of multi-morbidity.

Serious pathologies are always addressed to emergencies with criteria, aren't they?

Pierre Barraine, Amélie Calvez, Marie Barais, Benoit Chiron, Bernard le Floch, Patrice Nabbe, Jean Yves Le Reste

Dept. Médecine Générale, Université de Bretagne Occidentale, Brest, France E-mail: [email protected]

Background: In an emergency situation, the General Practitioners’ (GP) medical decision is based on objective and subjective elements. While it is interesting to note the objective factors used to refer patients to the emergency room, it is exciting to explore the subjective elements. Stolper et al. have defined the consensus of ‘Gut Feelings in General Practice’. Is it found in the subjective elements employed by the GP in an emergency situation?

Research question: Do GPs use objective criteria to determine the seriousness of disease among patients they send to the emergency department? What are these objective criteria?

Do the criteria of the Gut Feeling consensus exist in the subjective elements? What is the distribution of each of these criteria?

Method: To study medical decision making of general practitioners in emergency situations, using 10 serious pathologies for which home care is impossible. GPs’ mails are selected and they are contacted by telephone to determine on which elements they have sent the patient to the emergency room. Two open questions are asked. The analysis of telephone interviews and letters was carried out in a thesis group. The objective elements first listed with the literature review are collected. For the subjective elements, a systematic search of the Gut Feeling consensus is being carried out and each criterion is rated from 0 - 5 by the group members.

Results: On-going study.

Discussion: On-going study.

Evaluation of efficacy of a web based intervention for drinking reduction

Aleksandra Visnovic Poredos, Marko Kolsek

Dept. of Family Medicine, University of Ljubljana, medical faculty, Ljubljana, Slovenia E-mail: [email protected]

Background: Slovenia has high registered alcohol consumption – 11.0 litres/year/inhabitant ≥ 15 years in 2007. There are few epidemiological studies about drinking in Slovenia, none of which has used the AUDIT questionnaire. Brief interventions are effective, but identification of hazardous or harmful drinkers is not frequent enough. Some studies have shown that web-based screening is likely to be acceptable for some social groups, e.g. young and heavy drinkers who are drinking less after the intervention.

Research question: The objectives are to evaluate the use of an alcohol screening website, to establish which demographic or other characteristics influence drinking of internet users; what is the impact of our intervention with feedback information; and which question is responsible for lower AUDIT score after intervention.

Method: Cohort intervention study over one year. Visitors of a free website will be offered the AUDIT questionnaire with some demographic determinants. Users who will complete the questionnaire will be classified into two groups: one control group that will receive only a short message, the other will receive a specially prepared message with the evaluation of their drinking. Both groups will be invited to answer a questionnaire again after three months. We will compare the AUDIT results of both groups.

Results: We expect about 5000 completed questionnaires with a majority of respondents being those who do not talk to their general practitioners (GPs). We will find out what are the drinking habits of the Internet users in Slovenia.

Discussion: Website intervention is acceptable and effective for Internet users who are hazardous or harmful drinkers and that they drink less after the intervention.

We hope to reach mostly those who do not talk about alcohol drinking with their GPs.

EchoSin: pragmatic cluster randomized comparative study on diagnosis of sinusitis

Thierry Gomis

Faculté de médecine Paris-Ile-de-France-Ouest, Université Versailles Saint-Quentin-en-Yvelynes, Boulogne sur Seine, France E-mail: [email protected]

Background: The meta-analysis of Gill (2008) on nursing practice confirms the overuse of antibiotics (ATB) in nasopharyngitis (NP) and acute sinusitis (AS) nonspecific at 65% and 81%, respectively. This contrasts with clinical trials on the usefulness of ATB in these diseases and the resulting recommendations. In Europe, where rhinosinusitis (RS, intermediate between NP and AS) and AS overprescribing ATB is between 92% (France) and 60% (the Netherlands). The difficulty of clinical diagnosis is one possible explanation for this overuse of ATB. Radiography and CT of the sinuses are not used during the consultation. Two studies in primary care, conducted at too low power (Laine; Varonen), suggest that the use of ultrasound, simple and accessible consultation improves diagnosis. In primary care, general medicine, where clinical diagnosis of RS or AS, a procedure using ultrasound treatment of the maxillary sinus might identify patients who would benefit most from antibiotic treatment.

Research question: At the stage of clinical diagnosis of RS or maxillary AS, a procedure using ultrasound treatment of sinus reduces the prescription of antibiotics?

Method: EchoSin is a prospective intervention trial; pragmatic cluster randomized intervention group, GI-practice of ultrasound vs. control group practice GT. Main outcome is the measurement of the frequency of prescription in the two groups. Secondary outcome is the rate of healing at day 30.

Results: Not available but the anticipated results are: A decrease of 30% of antibiotic use in the GI group versus the GT group. Non-inferiority of cure rate in the GI group versus the GT group.

Discussion: Not available yet.