medicine and 267 physicians trained in internship programs. ... familiale et 267 formes par des programmes d'internat. ..... Conseil des Universites. Rapport du.
I
smosommum
Claude Beaudoin, MD, CCFP, PhD Brigitte Maheux, MD, PhD Fransois Beland, PhD
Influence of Training in Family Medicine Residency on Physicians' Attitudes Toward Comprehensive Care SUMMARY RESUME Un sondage effectue aupres d'un echantillon The authors assessed the influence of representatif de medecins quebecois a permis aux residency training in family medicine on auteurs de mesurer l'influence de la formation physicians' attitudes toward comprehensive postdoctorale en medecine familiale sur les attitudes care by surveying a representative sample of des medecins en ce qui a trait a la globalite des soins. Quebec family physicians. The sample L'echantillon comprenait 290 medecins formes par le consisted of 290 physicians trained in family biais de programmes de residence en medecine familiale et 267 formes par des programmes medicine and 267 physicians trained in d'internat. Une analyse de regression multivariee a internship programs. Multivariate mesure l'influence de la formation sur les attitudes regression analysis was performed to des medecins, independamment des caracteristiques measure the influence of training on sociodemographies et de la pratique. Les medecins physicians' attitudes independently of issus des programmes de medecine familiale ont physicians' sociodemographic and practice affiche une attitude plus positive que les autres generalistes dans trois aspects des soins globaux, characteristics. Graduates of family meme apres avoir corrige en fonction des medicine had more positive attitudes than caracteristiques de la pratique. other generalists toward three aspects of comprehensive care, even after controlling for sociodemographic and practice characteristics. (Can Fam Physician 1989; 35:2413-2416.) Key words: family medicine, family physicians, medical education, physician attitudes Dr. Beaudoin is a family physician at Hospital Cite de la Sante de Laval and is Associate Member, Department
of Family Medicine, University of Montreal. Dr. Maheux is Associate Professor in the Department of Social and Preventive Medicine, University of Montreal. Dr. Beland is Associate Professor in the Department of Health Administration, University of Montreal. Drs. Beaudoin, Maheux, and Beland are members of the Groupe de recherche interdisciplinaire en sante, Universite de Montreal. Requests for reprints to: Claude Beaudoin, MD, Groupe de recherche interdisciplinaire en sante, Universite de Montreal, Casier postal 6128, succursale "A," Montreal, Que. H3C 3J7
DURING THE last two decades,
residency programs in family
CAN. FAM. PHYSICIAN Vol. 35: DECEMBER 1989
medicine have taught physicians in training to take a comprehensive approach to care. This endeavour has recently generated considerable debate in the medical profession, mainly because of the growing pressure to adopt the family medicine training model as the unique route to obtaining licensure for delivering primary medical care in Canada.' 2 There are many objections to the project; one enduring argument has been that we lack evidence that the emphasis on comprehensiveness of care in family medicine has a significant effect on physician practice. It is easier to assess these training programs now that a sufficient number of trained family physicians are in practice. Although only a few evaluative studies have been conducted in Canada,-' there is some evidence that training in family medicine is
beneficial. Recent studies indicate that graduates in family medicine adhere more closely to screening procedure recommendations.3 These graduates also seem more likely to practise in settings devoted to comprehensive care, such as public community health centres,4 and settings devoted to chronic health problems, such as hospitals providing long-term care.5 A comprehensive approach is supported by evidence from the threeyear residency program in family medicine offered in the United States. American studies indicate that, compared with general practitioners, graduates in family medicine are more involved with the psychosocial aspects of care, give patients more information about their health problems, and intervene more often to promote compliance with 2413
treatment.89 These results are questioned, however, because there is a considerable generation gap between these groups of physicians; graduates in family medicine are generally younger than general practitioners. Further, graduates in family medicine do not seem to counsel patients about their lifestyles more than general practitioners. 10,1 1 So far, most evaluative studies have focused on physicians' clinical Table 1
practices. Very few studies have examined the extent to which attitudes of graduates in family medicine are consistent with a comprehensive approach to patient care, although developing such attitudes is one of the major objectives of the training program in family medicine and is often the prime target of everyday interaction between instructors and residents. We evaluated training in compre-
Characteristics of Sample Populati4 Stratifacation of Target Population (N = 4488) Men (n = 3603) Family Medicine (n= 166) Private CLSC Other (n = 3437) Private CLSC Women (n = 885) Family Medicine (n = 128) Private CLSC Other (n = 757) Private CLSC Total
Sample Size
N
P
137 29
1.00 1.00
137 29
3311 126
0.33 1.00
100 126
90 38
1.00 1.00
90 38
649 108 4488
0.16 1.00 -
108 108 736
Table 2
Categories of Questionnaire Statements Psychosocial aspects of care Many health problems are better dealt with by psychosocial rather than biomedical approaches. Biological sciences are more useful to study health than psychosocial sciences. Some health problems should rapidly be demedicalized. Funds set aside for care should be transferred to prevention. Multidisciplinary care I prefer to function alone rather than in a multidisciplinary group. I see more drawbacks than real advantages to multidisciplinary work in health. A multidisciplinary approach helps develop better quality of care. In my opinion, too much importance is attached to multidisciplinary cooperation in health. Patient education Certain decisions about treatment have too many potential consequences to be left to patients. Patients should have a good understanding of their illnesses. I would like patients to adopt a critical attitude toward their treatment. It is better not to give patients too much information about their state of health for fear that they will worry. I prefer that patients know less rather than more about their illnesses. Patients should not contest their physicians orders. It is important to make sure that patients understand their health problems as much as possible. Patients should always make the ultimate decision about treatment. 2414
hensive care by assessing the impact of residency programs in family medicine on three aspects of comprehensive care: psychosocial aspects of care, multidisciplinary co-operation, and patient education. Specifically, the purpose of the study was to determine whether family physicians trained in family medicine are more positive toward the three aspects listed above than non-residency-trained family physicians, and if so, to determine whether physicians' sociodemographic and practice characteristics were responsible for their attitudes. To distinguish between these two groups, we will refer to family physicians trained in family medicine as "graduates in family medicine" and to non-residency-trained family physicians as "general practitioners."
Methods Data for the study were collected in 1983-1984 as part of a mail survey of a representative sample of Quebec physicians. The goal of the survey was to determine physicians' interest in various themes emphasized during the last 15 years in Quebec, such as health promotion, a biopsychosocial approach, patient education, and multidisciplinary co-operation. The sample of physicians was drawn from the computerized files of the Federation of General Practitioners of Quebec. At the time of the study, 4488 physicians were listed as practising medicine in Quebec and as providing direct patient care. Physicians were selected by stratified random sampling. The sample of physicians was stratified according to sex, type of practice (private practice versus practice in a public community health centre), and type of postgraduate training (family medicine residency versus mixed or rotating internship). Simple random sampling was used within the various strata of the sample. Of the 736 physicians randomly selected, 616 returned their questionnaire, for a total response rate of 83.7%. The characteristics of the sample are listed in Table 1. The study reported here is based on a sub-sample of the survey, consisting only of physicians who graduated after the implementation of residency programs in family medicine, which began after 1970 in Quebec. The population sample was limited to CAN. FAM. PHYSICIAN Vol. 35: DECEMBER 1989
reduce the possibility of generation being a confounding variable when comparing graduates in family medicine with other family physicians. Accordingly, 59 of the 616 physicians in the original sample were excluded. The study sample consisted of 290 graduates in family medicine and 267 graduates of internship programs. Response rates in the two groups were 88.8% and 80.3%, respectively. Physicians' attitudes were compared on multi-item scales constructed from physicians' answers to 16 statements in the questionnaire. For each statement, four possible responses were provided, ranging from "strongly disagree" to "strongly agree." Using factor analysis, the statements listed in Table 2 were regrouped under the three categories: psychosocial aspects of care, multidisciplinary care, and patient education. Based on psychometric literature,12 attitudinal scales were constructed using factor scores from the factor analyses of the items composing each scale. Reliability coefficients (Cronbach's Alpha) were computed for the three scales, and their value was 0.60 for the scale measuring the psychosocial aspects of care and 0.80 for the two other scales. The sociodemographic characteristics (sex, age, sociodemographic origin, and country of birth) of the two groups of physicians; their profile of medical practice, namely geographic location, organization of practice, and involvement in various settings of care (hospital, emergency room, private office, and public community health centre); and their involvement in various professional activities (patient care, administration, teaching, research, or community health) were also compared. Comparisons were made on weighted data to take into account the stratification of the sample design and to yield measures that truly represented the populations of graduates in family medicine and general practitioners. Depending on the level of measurement of the variables, chisquare tests or Student's t tests were used to analyse the survey data. Multiple regression analyses were performed to measure the effect of training in family medicine on physicians' attitudes while controlling for physician sociodemographic and practice characteristics. Data were analysed CAN. FAM. PHYSICIAN Vol. 35: DECEMBER 1989
using sPss (Statistical Program for the Social Sciences) software.
Results The sociodemographic and practice profiles differed among graduates in family medicine and general practitioners (Table 3). Family physicians were significantly younger than general practitioners, although this study was restricted to physicians who graduated after 1970. They were also more likely to be born in Canada. Family physicians were more likely than general practitioners to be involved in group practice and the training of primary care physicians. They were also more likely to look after hospitalized patients and to work on a salaried basis in a public community health centre. By contrast, a greater number of general practitioners were involved in a solo practice, had settled in large communities (over 100 000 people), and practised on a fee-for-service basis in private practice. The other variables studied, including sex, sociodemographic origin, and the number of physicians involved in emergency room care, patient care, administration, research, and community health were similar in the two groups.
The raw scores show that graduates in family medicine had significantly more favourable attitudes to the three concepts of comprehensive care measured in this study (psychosocial aspects of care, multidisciplinary care, and patient education) than general practitioners (Table 4). Although the results suggest a positive effect of training in family medicine, many confounding factors were identified when we examined how the various characteristics of physicians correlated with their attitudes. Most of the characteristics of graduates in family medicine were associated with positive attitudes, which could account for the differences between the groups.
Multiple regression analyses were performed to clarify the specific effect of training in family medicine. These factors were analysed step-bystep; sociodemographic variables were entered first in the regression model, followed by type of training and by practice characteristics. Significant interactions between variables were also integrated in the regression model. This statistical procedure made it possible to estimate mean score values adjusted for all significant factors associated with physician
Table 3
Sociodemographic and Practice Characteristics of Graduates in Family Medicine and General Practitioners Graduates in Other Family Family Characteristics (N = 557) Medicine Physicians 33.3 ± 5.0 Age (mean ± SD)a 30.0 ± 2.8 Birth of Country (%)b 96.2 86.7 Canada 3.8 13.3 Outside Canada Type of Practice (%)b 78.8 69.0 Group 21.2 Solo 31.0 Size of Practice Community (%)b 18.3 8.0 Fewer than 5000 5000 to 19 999 20 000 to 49 000 50 000 to 99 999 100 000 and more Involvement (%) in:b Teaching Hospital care Private office Public community health centre a. p S 0.01 (ttest). b. p 0.01 (x2test).
25.6 21.7 15.3 19.1
30.4 17.4 12.7 31.5
38.5 63.7 65.4
19.2 51.2 80.1
21.9
7.6
2415
References
tors are undoubtedly present, such as senile dementia, terminal illness, low back pain, and neurosis.13 Thus, the attitudes of graduates in family medicine toward psychosocial aspects of care, multidisciplinary care, and patient education are consistent with the aspects of their practice for which they were best prepared by their training. Our results do not necessarily imply, however, that graduates of family medicine residencies have a better approach to patients than other family physicians. Many situational and normative factors in clinical settings may restrain physicians from expressing their personal inclinations; therefore, caution must be exercised in generalizing the findings of this study beyond physicians' attitudes. In fact, evidence in the literature is still unclear whether graduates of family Discussion medicine are more involved than othCompared with general practition- er generalists in psychosocial aspects ers, graduates in family medicine had of care and patient education. Almore favourable attitudes toward though American studies provide psychosocial aspects of care, multidis- some evidence,8'9 data on Canadian ciplinary care, and patient education. graduates are inconclusive.4'6 7 FurTheir greater involvement in medical ther research is needed on Canadian education, group practice, and public populations. The cross-sectional design of the community health centres seemed to contribute to their positive attitudes. study also may affect the interpretaOur main finding is that, even after tion of the results. It is possible that controlling for these characteristics, the differences in physicians' attithe attitudes of graduates in family tudes reported in our study were almedicine remain significantly more ready present before training. In fact, positive than those of general practi- some evidence suggests that one reationers, supporting the hypothesis son medical students choose a family that residency training in family med- medicine residency is their greater icine has a positive effect on physi- openness to comprehensive care.'4'15 The question left unanswered by our cians' attitudes. Our results are consistent with oth- study is whether the attitudes of grader Canadian studies, indicating that uates in family medicine are due to graduates of family medicine feel well self-selection or to physicians' specific prepared to use community re- training. Future research could adsources, promote patient compliance, dress this question by assessing physicounsel patients, and to deal with cians' attitudes both before and after U problems in which psychosocial fac- postgraduate training. Table 4 Attitudes of Graduates in Family Medicine and General Practitioners Adjusted Scoresa Raw Scores Graduates Graduates in Family General General in Family Medicine Practitioners Medicine Practitioners Attitude Scales Psychosocial - 0.09b 0.13 0.12 -0.13b aspects of care -0.21 b 0.10 -0.20b 0.16 Multidisciplinary care - 0.0gb 0.12 -0.15b 0.13 Patient education a. Scores adjusted for the sociodemographic and practice characteristics significantly correlated with the physicians' attitudes. b. p 0.01 (ttest).
1. Canadian Medical Association. Family practice training: an evolutionary plan. Report of the Canadian Medical Association Task Force on Education for the provision of primary care services to CMA. Ottawa, Ont.: General Council, 1984. 2. Conseil des Universites. Rapport du Comite d'etude sur la formation en medecine. Quebec: Gouvernement du Quebec, 1985. 3. Borgiel AEM, Williams JI, Bass MJ, et al. Quality of care in family practice: does residency training make a difference? Can Med Assoc J 1989; 140:1035-43. 4. Maheux B, Lambert J, Pineault R, Beaudoin C, Berthiaume M. Generalists trained in family medicine: a distinctive type of medical practice? Can Fam Physician 1988; 34:1693-8. 5. Frenette J. Qu'advient-il des diplomes de medecine familiale? Une etude comparative. Can Fam Physician 1984; 30:2291-5. 6. Brennan M, Stewart M. Attitudes and patterns of practice: a comparison of graduates of a residency program in family medicine and controls. J Fam Pract 1978; 7:741-8. 7. Curry L. Postgraduate training route and content of subsequent practice. Can Fam Physician 1985; 31:1417-20. 8. Rosenblatt RA, Cherkin DC, Schneeweiss R, et al. The structure and content of family practice: current status and future trends. J Fam Pract 1982; 15:681-722. 9. Radecki SE, Menhenhall RC. Patient counseling by primary care physicians: results of a nationwide survey. Patient education and counseling. 1986; 8:165-77. 10. Attarian L, Fleming M, Barrow P, et al. A comparison of health promotion practices of general practitioners and residency trained family physicians. J Community Health 1987; 12:31-9. 11. Weschler H, Levine S, Idelson RK, et al. The physician's role in health promotion: a survey of primary care practitioners. N Engl J Med 1983; 308:97-100. Carmines EG. 12. Zeller RA, Measurement in the social sciences-the link between theory and data. Cambridge, England: Cambridge University Press, 1980. 13. Curry L, Woodward C. A survey of postgraduate training for family practice. Can Med Assoc J 1985; 132:245-349. 14. Askew MJ, Strock RK. Expressed reasons for the choice of a residency in family practice. J Fam Pract 1978; 6:809-13. 15. Wilson JL, Hallett J. Students' attitudes toward career choice: a family practice perspective. J Med Educ 1985; 60:56-8.
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attitudes (Table 4). The attitudes of graduates in family medicine remained significantly more positive than those of general practitioners, even after controlling for confounding factors. Multiple regression analyses also showed that four factors besides training contributed to more positive attitudes among graduates in family medicine. These factors were their greater involvement in medical education, group practice, and salaried practice in public community health centres, coupled with their lesser likelihood to settle in private practice. Sociodemographic characteristics exerted a negligible confounding effect because variables significantly related to physician attitudes, namely sex and sociodemographic origin, were similar in the two groups.
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