ORIGINAL RESEARCH * NOUVEAUTES EN RECHERCHE
Why are clinical problems difficult? General practitioners' opinions concerning 24 clinical problems Helene Leclere,* MD, MA; Marie-Dominique Beaulieu,t MD, CCFP, MSc; Georges Bordage,* MD, PhD; Andre Sindon,4 MD, FRCPC; Martine Couillard,* MD This study was conducted to describe the difficulties perceived by general practitioners concerning 24 common clinical problems and to compare their perceptions with those of faculty members in family medicine. A random sample of 467 general practitioners and all- 182 faculty members in family medicine in Quebec were sent one of four open-ended questionnaires, each of which dealt with six clinical problems; 214 general practitioners and 1 14 faculty members participated. A total of 5111 difficulties were reported; the number reported by each subject varied from 0 to 13 (mean 2.6 [standard deviation 2.09]) per problem. The problems that generated the most difficulties were depression, confusion in the elderly, chronic back pain, loss of autonomy in the elderly and sexually transmitted diseases. The most frequent difficulties were with the patient's noncompliance with treatment, clinical diagnosis, failure of a specific treatment, inadequate health care resources and the physician's own emotional reactions. The difficulties for each problem were the same in the two groups 70% of the time. Physicians' perceptions of their difficulties can be useful in the planning of initial training and continuing medical education. Notre etude visait a decrire les difficultes percues par les praticiens generalistes relativement a 24 problemes cliniques courants et de comparer leur perceptions avec ceux de professeurs universitaires en medecine familiale. Nous avons expedie a un echantillon aleatoire de 467 medecins generalistes et aux 182 professeurs d'universite en medecine familiale au Quebec l'un de nos quatre questionnaires a questions de developpement, chacun traitant de six problemes cliniques; 214 medecins generalistes et 1 14 professeurs d'universite ont participe au sondage. Au total, 51 1 1 difficultes ont ete signalees; le nombre mentionne par sujet variait de 0 a 13 (moyenne de 2,6 [ecart type de 2,09]) par probleme. Les problemes qui suscitaient le plus de difficulte etaient la depression, la confusion chez les personnes agees, les douleurs dorsales chroniques, la perte d'autonomie chez les aines et les maladies transmises sexuellement. Les medecins se heurtaient le plus frequemment aux obstacles causes par le non-respect du traitement par le malade, le diagnostic clinique, l'echec d'un traitement specifique, l'inadequation des ressources de soins de sante et leurs propres reactions affectives. Les difficultes pour chaque probleme etaient les memes dans les deux groupes, dans 70% des cas. Les perceptions qu'ont les medecins de leurs difficultes peuvent constituer un renseignement utile dans la planification de la formation initiale et de l'education permanente.
From *the Bureau de pedagogie des sciences de la sante, Faculte de medecine, Universite Laval, Ste-Foy, PQ, tthe Departement de medecinefamiliale, Universite de Montreal, and $the Corporation professionnelle des medecins du Que6bec, Montreal
Reprint requests to: Dr. Hikbne Leckre, Bureau de pedagogie des sciences de la sante, Faculte de medecine, Universite Laval, Ste-Foy, PQ GIK 7P4 -
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CAN MED ASSOC J 1990; 143 (12)
1305
T he contents of general practice have been the subject of several studies. 1-4 These studies have shown the relative frequency of the different health problems encountered in primary care but have not delved into the difficulties that physicians may have in dealing with them. Needsassessment studies in continuing medical education (CME) have also overlooked specific difficulties associated with the diagnosis and management of clinical problems. The needs are most often expressed as lists of topics representing clinical problems or techniques (e.g., management of hypertension or diabetes, performance of vasectomy or operation of a ventilator).5-7 Physicians may have many and varied difficulties, such as dealing with a patient's noncompliance, lack of time, deciding who, when and how to investigate, and dealing with a patient's family. A better comprehension of the nature of the difficulties that they experience in the day-to-day management of patients is essential to improve the planning of initial training and CME. The difficulties can be analysed either from the outside (actual needs) or as perceived by the physicians themselves. Physicians' perception of their difficulties may differ from the actual ones encountered. Therefore, although perception measurement is only one aspect, it is an important one, especially if educational interventions are to be relevant. No study has yet attempted to measure the perceptions of general practitioners and faculty members in family medicine or to determine whether these two groups have similar perceptions.' Our study addresses two questions: How do general practitioners and faculty members in family medicine perceive their difficulties? Are the perceptions of faculty members similar to those of their non-
teaching colleagues?
Methods A mail survey among general practitioners and faculty members in family medicine in Quebec was planned with the use of an open-ended questionnaire to determine the difficulties they were having with clinical problems. Four questionnaires, representing six problems each, were prepared, for a total of 24
problems.
Questionnaire Preset, forced-choice questions were not included in the questionnaire from the outset, since the goal of the study was to determine physicians' perceptions of their difficulties with as few biases as possible. Instead, we used an open-ended question as follows. 1306
CAN MED ASSOC J 1990; 143 (12)
Describe very concretely the difficulties you encounter in your practice when you deal with each clinical problem presented in the following pages. Describe as many difficulties as come to mind for each problem, but remember, it is your difficulties in your practice that are the subject of this study and not the difficulties of medical doctors in general.
A draft of the questionnaire was tested through a trial run and a pilot study so that we could refine the question and assess the time needed to complete the questionnaire. It took 3 to 6 minutes on average to respond to a problem. It was determined a priori that the maximum amount of time needed would not exceed 30 to 40 minutes. Thus, each participant was asked to respond to six clinical problems.
Selection of clinical problems Three independent sources were used to select the problems. The first was a publication by the Faculte de medecine, Universite Laval, Ste-Foy, PQ, in which training objectives in general practice were described.9 The document listed problems encountered in general practice. Each problem was weighted according to its frequency (5 points), seriousness (5) and amenability to treatment (5), as compiled by the College of Family Physicians of Canada.10 The leading problems in each body system were included, for a total of 30 problems. The second source was observations of the members of the Department of Professional Inspection and of the Receiving Office (Bureau du Syndic) of the Corporation professionnelle des medecins du Quebec (CPMQ), Montreal. The third source was six experienced general practitioners who worked in both urban and rural settings. Using a nominal group approach we asked the second and third groups to identify the clinical problems they considered difficult for general practitioners. The second group identified 22 problems (1 5 of which were on the first list) and the third 24 problems (17 of which were on the first two lists). The three sources led to the identification of 44 clinical problems. We decided to select only 24 of the problems, 6 per questionnaire, because of the limited number of faculty members, the minimum number of subjects needed per problem and the time allowance of 6 problems per subject (Table 1). We chose the problems most likely to generate varied difficulties but at the same time ensure that all patient age groups would be represented and that there would be an even distribution between acute and chronic as well as organic and psychosocial problems. Each subject was asked to complete only one of the question-
naires.
Selection ofsubjects ofsubjectsCoding Coding the responses the
responses
To be eligible a physician had to hold a licence from the CPMQ, have practised medicine for at least 3 years (therefore physicians who were very recent graduates would be eliminated) and practise at least 20 hours per week. However, the faculty members had to practise only 10 hours per week, with direct patient contact, and supervise residents at least three times per week for a minimum of 6 months per year. A questionnaire was sent to a random sample (as determined through random number selection) of 467 of 3945 eligible general practitioners in Quebec (total registration 7421) and to the 182 eligible part-time and full-time faculty members in the four family medicine programs. We estimated the sample size of general practitioners for each questionnaire using an assumed prevalence of physicians with perceived difficulties of 0.50 (worst case), a confidence level of 95% and a precision of 0.10. The total number of participants needed was 300 subjects (75 per questionnaire). This size was considered to be manageable. Given an attrition rate of 35%, 467 general practitioners were randomly selected from the 3945 eligible candidates.
Coding was determined not a priori but, rather, on the basis of the actual difficulties expressed. Three of us (H.L., M.-D.B. and M.C.) developed a coding sheet with data from the trial run (1 5 participants) and the pilot study (25 participants). The final coding sheet was established following the first interrater reliability study, early in the analysis. Ninety-four distinct difficulties were grouped into 11 categories; examples of the difficulties and the categories are in tables 2 and 3. The categories were determined according to well-established aspects of clinical practice and health care delivery. All of the questionnaires were coded by one of us (M.C.), a general practitioner with 8 years of clinical experience. All of the responses were coded, regardless of whether they expressed a difficulty or a general opinion. If a physician expressed the same difficulty repeatedly for a given problem the difficulty was tallied only once. Although all the data were coded by one person three interrater reliability studies were conducted between two of us (H.L. and M.-D.B.) and the coder. These studies were meant to test the reliability of the coding process throughout the coding period. The kappa coefficients for the interrater analysesl2 varied from 0.62 for the first sample to 0.70 for the third; these levels of reliability were considered to be quite Survey good.'3 The intrarater reliability for the main rater The survey was conducted by mail with follow- was excellent: 0.78 for the first sample and 0.95 for up by telephone, as described by Dillman." A the second. four-step procedure was used: the questionnaire was mailed, a reminder postcard was sent 1 week later, Results another reminder was sent 1 month after the first Of the 467 general practitioners 260 (56%) mailing, and, finally, nonrespondents were telephoned 2 months after the first mailing. The main completed one of the four questionnaires. Forty-six reasons given for not participating were lack of time subjects were excluded because their practice profile and being solicited to complete too many question- did not comply with the inclusion criteria. The naires. analyses were thus performed on the basis of reTable 1: Clinical problems selected to determine difficulties among general practitioners and faculty members in family medicine in Quebec
Anemia
Hypertension
Cardiorespiratory arrest
Loss of autonomy in the
Chronic back pain Chronic obstructive pulmonary disease Confusion in the elderly Depression Diabetes mellitus Drug addiction (except alcohol) Family and marital problems Fatal diseases Functional problems Headache Healthy adult with multiple risk factors
elderly Neglected or abused child Obesity Periarticular problems (tendinitis, fibrositis and bursitis) Pregnancy follow-up or delivery or both Problems related to sexuality
Sexually transmitted diseases Thyroid problems Urinary tract infection Work-related problems CAN MED ASSOC J 1990; 143 (12)
1307
sponses from 214 general practitioners. There were no differences between the participants and the nonparticipants in geographic location or language. However, the participants were slightly younger than the nonparticipants (mean age 38.9 and 42.4 years respectively; x2 = 15.98, p < 0.005), and the proportion of women was greater among the participants than among the nonparticipants (27% and 18% respect.ively; xj = 4.57, p < 0.05). Of the 182 faculty members 120 (66%) completed one of the questionnaires. Six were excluded
because their practice profile did not comply with the inclusion criteria; this left 114 respondents. There was no difference in the characteristics between the participants and the nonparticipants. A total of 328 general practitioners and faculty members participated. The four questionnaires were evenly distributed among them.
Nondifficulties Of the 5832 coded answers 721 (12.4%) did not
fable 2: The 17 most frequent difficulties physicians had with the 24 clinical problems No. of difficulties (n-- 5111)
Difficulty with Patient s noncompliance with treatment and follow-up
336
'-Iinlcal diagnosis ailure or absence of specific
234
180
treatment (not only medication) inadequate resources in health care system (quantity or quality) wn emotional reaction to problem (excluding s;e nse of helplessness) ; ack of time, too many patients indications and methods of specific treatment ARquiring and maintaining knowledge and competence Access to diagnostic investigations. rncluding waiting time Aecess to nonmedical professional
169 167 162
161
152 1;41 1.41
0Qrv.. I.)tferneces .n expecttations between physician ini patient (difficult to reconcile)
134
S>haring understanding of problem with patient
128 119
Access to medical specialty services Training for this problem Costs and travel needed by patient for service or treatment Sense of helplessness F:inding etiologic diagnosis
115
109 102 101
Table 3. D:istribution of the 5111 reported difficulties by category .':
.
........'
... -. "...
Categor\ Relation of physician with health care system and different intervenors Physician-patient relationship Treatment and follow-up Relation of physician with himself or herself Clinical diagnosis Initial training and continuing medical education Diagnostic investigation Practice organization Relation of physician with family or friends Prevention Psychosocial dimension of problems, including work 1308
CAN MED ASSOC J 1990; 143 (12)
-. .
...... ..:.
No. (and %) of difficulties 881 (17.2) 878 (17.2) 787 (15.4)
539 (10.5) 518 (10.1) 395 (7.7) 381 (7.5) 244 (4.8)
200 (3.9) 191 (3.7) 97 (1.9)
represent actual difficulties; 413 (7.1%) were general opinions on the subject, and 141 (2.4%) indicated that the physician did not have any difficulty with the given problem. The problems considered most often to pose no difficulties were anemia, thyroid problems, hypertension, urinary tract infection and headache. In addition, some of the participants indicated that they never encountered certain problems in their practice. This was particularly true for pregnancies and deliveries: 51% of the general practitioners and 39% of the faculty members indicated that they did not manage pregnancies or deliver babies. Lastly, 25% of the general practitioners and 16% of the faculty members reported that they did not perform cardiopulmonary resuscitation.
Difficulties Of the coded responses 5111 (87.6%) representactual difficulties. The number of difficulties per ed problem expressed by each respondent varied from 0 to 13 (mean 2.6 [standard deviation 2.09]). The problems that generated the greatest number of difficulties in the two groups were depression, confusion in the elderly, chronic back pain, loss of autonomy in the elderly and sexually transmitted diseases. There was a high degree of correlation between the mean number of difficulties for each problem in the two groups (Spearman rank-order correlation coefficient 0.87, p < 0.001). The total number of difficulties expressed for a given problem varied from 86 (pregnancy follow-up or delivery or both) to 356 (depression) (median 216). The number of distinct difficulties for a given problem varied from 30 (healthy adult with multiple risk factors) to 63 (confusion in the elderly) (median 46). Overall, half of the responses dealt with 17 of the 94 distinct difficulties (Table 2). The difficulties most frequently listed for each problem represent the very essence of the present study and are presented more extensively in Appendix 1. The "most frequent" difficulties for each problem were set according to a natural dropoff point in the distribution of difficulties. The dropoff point was most often between the fourth and fifth difficulty. The nature of the difficulties varied substantially from one clinical problem to another. However, there were more similarities than differences between the general practitioners and the faculty members. The actual difficulties for each problem were the same in the two groups 70% of the time. The number of difficulties for each category is presented in Table 3. The three categories with the greatest number of difficulties were the relation of the physician with the health care system and the different intervenors, the physician-patient relationship, and treatment and follow-up. For each problem
the categories with the greatest number of difficulties the categories with the greatest number of difficulties were similar 82% of the time in the two groups.
Discussion Our study shows that it is possible to gather useful information from a large number of physicians through a qualitative survey. The response rates were within accepted limits for studies of this type.'4 Five sources of potential bias related to the participant-nonparticipant factor were analysed: physician's age, sex, language, geographic location and distribution of the four questionnaires. The average age was slightly lower among the participants than among the nonparticipants, especially because of an underrepresentation among those 45 years or older; this was also noted in a survey done by the CPMQ in the same population (Leon Tetreault and associates, Montreal: personal communication, 1981). Women were slightly overrepresented among the participants. There were no differences between the two groups in language or geographic distribution. The latter factor is important since the different contexts of care, namely urban and rural settings, can potentially influence the nature of the difficulties expressed. The questionnaires were distributed evenly among the participants. Thus, there was no selection bias for the 24 problems studied. How was the precision of the estimates affected by the lower than expected response rate among the general practitioners? The number of general practitioners who responded represented 71% of the initial estimated sample. We recalculated the confidence intervals using the actual number of participants and holding the confidence level at 95% and found that the precision went from 0.10 to 0.15. Overall the results were considered to be generalizable to the 24 problems despite the factors of age and sex. Two important findings emerged from the study. First, the difficulties listed by the general practitioners and the faculty members were much more similar than different. If a large difference had been found it might have been because the faculty members were no longer in tune with their colleagues in the field. Second, despite the use of open-ended questions and the wide range of distinct difficulties over half of the difficulties expressed were limited to 17 of the 94 distinct difficulties. Similarly, of the 33 distinct difficulties expressed on average for each problem 5 were common to 44% of the respondents. From a needs-assessment perspective these five difficulties represented collective needs. On the other hand, the distribution of the 28 other distinct difficulties among the remaining 56% of the respondents represented a wider array of individual needs. Finally, difficulties with the physician-patient relationship were widespread, regardCAN MED ASSOC J 1990; 143 (12)
1309
less of the type of problem. This type of difficulty, along with difficulties with the health care system, illustrates Nowlen's extended concept of CME that includes personal impairments, contexts of practice and events of adulthood.'5 Although some of the difficulties had clear educational implications others had organizational, institutional and political ramifications. A critical factor that ensures quality activities in CME is the inclusion of educational content that meets the needs and expectations of physicians that is, addresses their perceived difficulties.'5-'8 Our findings constitute a wealth of information concerning physicians' needs that can be used to plan appropriate educational activities for initial training and CME. This is especially true for the four or five leading difficulties for each problem. (The complete list of difficulties for each problem is available from the authors upon request.) Many types of difficulty (e.g., physician's own emotional reactions) challenge traditional methods of instruction and call for innovative and participative activities. To use the frequency of each difficulty to rank the difficulties is but one aspect of their degree of importance. We did not attempt to quantify directly the degree of importance of each difficulty encountered by the physicians. Indeed, a single "overwhelming" difficulty with a clinical problem for one or two physicians would be given a score of only 1 or 2, whereas other frequent yet possibly "insignificant" difficulties could have received greater scores and consequently higher rankings. Thus, the ranking of the difficulties is not necessarily an indication of their overall importance. Careful attention should be paid to the significance of each difficulty for physicians and clinical practice. The need to quantify the degree of importance of each difficulty was considered during the planning of our study; however, the logistics of asking physicians to list their difficulties and to rate them in order of importance in one study was felt to be too demanding. This issue should be a topic for future research. The difficulties brought to light in our study also have implications for the assessment of clinical competence. They can help define the few critical elements associated with clinical competence; that is, the difficult aspects of clinical practice. This is in sharp contrast to many current methods of assessment that overly reward the candidates for thoroughness of examination and management and that compensate for the omission of essential items with a large number of harmless, slightly positive actions. A more appropriate method of assessment may be to focus on specific areas of difficulty, especially since these areas vary from problem to problem. The desire to focus the evaluation on the critical elements of clinical practice, the problem's key features, 1310
CAN MED ASSOC J 1990; 143 (12)
corresponds to the orientation taken by the Medical Council of Canada in the last paper (Q4) of its qualifying examination, which assesses the candidate's problem-solving and decision-making performance."9 Our study raises new research questions. For example, what are the specific causes of difficulties associated with the physician-patient relationship? Which types of educational and organizational interventions are most likely to help general practitioners overcome their difficulties? How important are the difficulties to the quality of health care? We hope that our findings will be used for the planning of initial training and CME and as a stepping stone for further research into what makes clinical problems difficult in practice. We thank Dr. Tim Allen, mddecine d'urgence, Faculte de mddecine, Universitd Laval, for translating the questionnaires into English and the general practitioners and faculty members who participated in the study. This project was supported by a grant from the
CPMQ.
References 1. Clute K: The General Practitioner. Study of Medical Education in Practice in Ontario and Nova Scotia, U of Toronto Pr, Toronto, 1963 2. Cartwright A: Patients and Their Doctor. A Study of General Practice, Atherton Pr, New York, 1967 3. Geyman JP (ed): A statewide study in Virginia with its clinical educational and research implications. J Fam Pract
1976; 3: 22-69 4. Schneewiess R, Rosenblatt RA, Cherkin DC et al: Diagnosis clusters: a new tool for analyzing the content of ambulatory health care. Med Care 1987; 21: 105-122 5. Craig J: Perceived learning needs of family physicians in British Columbia. Can Fam Physician 1990; 36: 262-265 6. Barnham P, Benseman J: Determining continuing medical education curricula for general practitioners - a survey of self-perceived needs. NZ Med J 1983; 96: 395-397 7. Williams AR, Davis RC, Hale CD et al: Patterns of concern: needs assessment and continuing education needs among public health physicians. J Contin Educ Health Prof 1989; 9: 131-139 8. Lessner JR, Driscoll CE: Family practice and practitioner assessment of CME needs. Conn Med 1982; 138: 114-117 9. Bernard L, Beaulieu MD, Bordage G et al: L'internat en vue de la pratique g'ne'rale: les objectifs de formation et les situations d'apprentissage. Rapport du groupe de travail, Faculte de medecine, Universite Laval, Ste-Foy, PQ, 1985 10. Educational Objectives for Certification in Family Medicine, College of Family Physicians of Canada, Toronto, 1981 11. Dillman DA: Mail and Telephone Survey: the Total Design Method, Wiley, New York, 1978 12. Fleiss JL: Statistical Methods for Rates and Proportions, Wiley, New York, 1981: 211-236 13. Landis JR, Koch GG: The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-174 14. Warwick DP, Lininger CA: The Sample Survey: Theory and Practice, McGraw, New York, 1975: 69-110 15. Nowlen PM: New expectations, new roles: a holistic approach to continuing education for the professions. In Cervero RM,
Azzaratto JF (eds): Visions for the Future of Continuing Professional Education, Georgia Center for Continuing Education, Athens, Ga, 1990: 15-23 16. Sibley JC, Sackett DL, Neufeld V et al: A randomized controlled trial of continuing medical education. N Engl J Med 1982; 306: 511-515 17. Curry L, Putnam RW: Continuing medical education in Maritime Canada: the methods physicians use, would prefer
and find most effective. Can Med Assoc J 1981; 124: 563-566 18. Knowles MS: The Modern Practice ofAdult Education: from Pedagogy to Andragogy, Assn Pr, Wilton, Conn, and Follett Publ, Chicago, 1980: 82-118 19. Bordage G, Page G: An alternative approach to PMP's: the key feature concept. In Hart I, Harden R (eds): Further Developments in Assessing Clinical Competence, Can-Heal Publ, Montreal, 1987: 59-75
Appendix 1: Difficulties reported most frequently for each clinical problem* No. of respondentst (and
Problem; difficulty with Anemia No difficulty One or more difficulties Most frequent Finding etiologic diagnosis Access to diagnostic investigations, including waiting time Deciding who and when to investigate and to what extent Patient's noncompliance with treatment and follow-up Cardiorespiratory arrest No difficulty One or more difficulties Most frequent Acquiring and maintaining knowledge and competence Deciding to not start or to stop treatment Own emotional reaction to problem Chronic back pain No difficulty One or more difficulties
Most frequent Doubts about whether patient history is true Clinical diagnosis (nonspecific)t Failure or absence of specific treatment Patient's noncompliance with treatment and follow-up Chronic obstructive pulmonary disease No difficulty One or more difficulties
no. of
distinct difficulties)
Total
GP
FM
18 63
13 40
5 23
(38)
(31)
(26)
25
16
9
16
9
7
15
12
3
14
13
1
4
(32)
38 (24)
1 25 (22)
40 19 16
19 11 11
21 8 5
2 73 (55)
1 48 (44)
1 25 (44)
24 22 17
18 16 10
6 6 7
15
10
5
6 70 (46)
4 45 (31)
2 25 (35)
39 12 12 10
28 7 7 4
11 5 5 6
0 76
0 50
0 26
(63)
(52)
(43)
28 24
20 13
8 11
24
15
9
5 63
Most frequent
Patient's noncompliance with treatment and follow-up Failure or absence of specific treatment Indications and methods of specific treatment Sense of helplessness Confusion in the elderly No difficulty One or more difficulties
Most frequent Access to emergency services and hospitalization, including specialized institutions and long-term care
Finding etiologic diagnosis Inadequate resources in health care system (quantity or quality)
CAN MED ASSOC J 1990; 143 (12)
1311
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li
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I.
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-f. !C.
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:3*-_2
.t
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" f
tJ
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; 5
vi
o2; r_.
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42
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r;;
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( 3 2)
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45
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CAN MED ASSOC J 1990; 143 (12)
s
,.
il,
Headache No difficulty One or more difficulties Most frequent Failure or absence of specific treatment Overuse of drugs Clinical diagnosis (nonspecific) Finding etiologic diagnosis Healthy adult with multiple risk factors No difficulty One or more difficulties
Most frequent Use of counselling as preventive measure Patient's lack of motivation to look after self from beginning Patient's noncompliance with treatment and follow-up Sharing understanding of problem with patient Lack of time, too many patients Hypertension No difficulty One or more difficulties
Most frequent Patient's noncompliance with treatment and follow-up Training related to new drugs and treatment Indications and methods of specific treatment Side effects of drugs Complexity in choosing medication Loss of autonomy in elderly No difficulty One or more difficulties Most frequent Inadequate resources in health care system (quantity or quality) Access to emergency services and hospitalization, including specialized institutions and long-term care Lack of cooperation of patient's family and friends with diagnosis and follow-up Lack of time, too many patients Access to nonmedical professional services Neglected or abused child No difficulty One or more difficulties Most frequent
Clinical diagnosis (nonspecific) Inadequate resources in health care system (quantity or quality) Own method of interaction with patient's family and friends Access to nonmedical professional services Obesity No difficulty One or more difficulties Most frequent Patient's noncompliance with treatment and follow-up Patient's lack of motivation to look after self from beginning Failure or absence of specific treatment
10 77 (45)
8 48 (33)
2 29 (34)
33 21 20 19
17 17 8 13
16 4 12 6
3 72
3 45
0 27
(30)
(1 9)
(24)
38
25
13
19
11
8
16 10 10
14 7 6
2 3 4
15 62 (36)
11 38
4 24
(27)
(28)
38 19
23 9
14
4 7
15 10 10 6 6
13 12
I 73
6 1
0 27
(54)
46 (48)
(36)
49
30
19
38
25
13
12 12 12
5 5 6
7 7 6
3 66
(39)
3 40 (31)
0 26 (29)
37
18
19
17
10
7
13 13
5 8
8 5
5 81
4 51
1 30
(42)
(39)
(28)
25
13
12
24 22
11 12
13 10
CAN MED ASSOC J 1990; 143 (12)
1313
Differences in expectations between physician and patient (difficult to reconcile) Periarticular problems (tendinitis, fibrositis and bursitis) No difficulty One or more difficulties Most frequent Failure or absence of specific treatment Clinical diagnosis (nonspecific) Executing therapeutic technique Pregnancy follow-up or delivery or both No difficulty One or more difficulties Most frequent Acquiring and maintaining knowledge and competence Differences in expectations between physician and patient (difficult to reconcile) Lack of time, too many patients Energy involved, especially in long-term follow-up of patient Problems related to sexuality No difficulty One or more difficulties
Most frequent Training for this problem Access to nonmedical professional services Own emotional reaction to problem Costs and travel needed by patient for service or treatment Sexually transmitted diseases No difficulty One or more difficulties Most frequent Access to diagnostic investigations, including waiting time Patient's noncompliance with treatment and follow-up Screening techniques, including screening of contacts Costs and travel needed by patient for service or treatment Thyroid problems No difficulty One or more difficulties Most frequent Clinical diagnosis (nonspecific) Interpreting results of diagnostic examinations, excluding imaging Access to diagnostic investigations, including waiting time Urinary tract infection No difficulty One or more difficulties Most frequent Indications and methods of specific treatment Access to diagnostic investigations, including waiting time Patient's noncompliance with treatment and follow-up Clinical diagnosis (nonspecific) Diagnostic investigation (nonspecific) 1314
CAN MED ASSOC J 1990; 143 (12)
21
14
7
-7
5 46
2 26
(39)
(30)
17 16
17 8 9
8 9 7
8 34 (36)
7 18 (25)
16
(25)
7
3
4
6
4 3
3
5,
3
5 80 (52)
3
2
51
29
(39)
(41)
29 26
18 12
11 14
17
7
10
16
11
5
1 70
1 43
0 27
(47)
(37)
(37)
37
25
12
26
11
15
25
10
15
15
12
3
16 60 (32)
12 36 (24)
4 24
(25)
20
13
7
18
10
8
17
12
5
14 73
(40)
11 45 (31)
3 28 (31)
44
26
18
29
17
12
29 22
16
13
72 (45)
25
17
t
11 10
Deciding who and when to investigate and to what extent Work-related problems No difficulty One or more difficulties Most frequent Relation with workplace, employers and insurance companies Relation with Workers' Compensation Board Doubts about whether patient history is true Clinical diagnosis (nonspecific)
14
5
9
1 74
1 48
0 26
(41)
(30)
(31)
33 18 16 14
15 10
18 8 5 7
11 7
The number of most frequent difficulties was set according to a natural dropoff point observed in the distribution of difficulties for each clinical problem. The dropoff point was most often between the fourth and fifth most frequent
difficulty. tGP general practitioner; FM = faculty member. $Like other "nonspecific" difficulties this one represents a "general" difficulty within the category that could not be coded by other, specific codes. =
Conferences continuedfrom page 1294 Apr. 21-24, 1991: Canadian Organization for the Advancement of Computers in Health (COACH) 16th Annual Conference Sheraton Centre, Toronto Steven A. Huesing, executive director, Canadian Organization for the Advancement of Computers in Health, 1200-10460 Mayfield Rd., Edmonton, Alta. T5P 4P4; (403) 489-4553, FAX (403) 489-3290
Apr. 24, 1991: 4th Annual Conference on Education in Aging and Health - Educational Implications of the Provincial Long Term Care Reform Sheraton Hotel, Hamilton, Ont. Educational Centre for Aging and Health, Faculty of Health Sciences, McMaster University, PO Box 2000, Stn. A, Hamilton, Ont. L8S 3N5; (416) 525-9140, ext. 84-4011, FAX (416) 574-2838 Apr. 25-26, 1991: Ontario Gerontology Association 10th Annual Conference - Choices for the 1990s: Economics, Practice and Ethics Sheraton Hotel, Hamilton, Ont. Ontario Gerontology Association, 7777 Keele St., 2nd Fl., Concord, Ont. L4K 1Y7; (416) 660-1056 or 660-1076, FAX (416) 660-7450
Apr. 27-May 1, 1991: Annual Meeting of the Association of Canadian Medical Colleges, the Association of Canadian Teaching Hospitals and the Canadian Association for Medical Education Ramada Renaissance Hotel, Saskatoon Janet Watt-Lafleur, Association of Canadian Medical Colleges, 1006-151 Slater St., Ottawa, Ont. KIP 5N1; (613) 237-0070
Les 2 et 3 mai 1991: Congres annuel de la Societe pour la m6decine de l'adolescence (section de l'est du Canada) - Travailler ensemble pour la sante des adolescents Hotel Ritz Carlton, Montreal Mme Sylvie Lavigueur-Morin ou Mme Danielle Boivin-Ouimet, Formation pediatrique continue de Montreal, Hopital Sainte-Justine, 3175, cote Sainte-Catherine, Montreal (Que.) H3T IC5; (514) 345-4781 ou 345-4782 May 12-14, 1991: Canada's National Safety Conference - Safety Starts in Your Community Hamilton, Ont. Canada Safety Council, 6-2750 Stevenage Dr., Ottawa, Ont. KIG 3N2; (613) 739-1535, FAX (613) 739-1566 May 13-16, 1991: 7th World Congress on Emergency and Disaster Medicine (sponsored by the World Association of Emergency and Disaster Medicine, the Canadian Association of Emergency Physicians and la Societe intemationale de m6decine de catastrophe) Abstract deadline is Dec. 31, 1990. Palais de Congres, Montreal Ms. Ursula Schwarz, Meeting Secretariat, Kush Medical Communications, 61-6100 Montevideo Rd., Mississauga, Ont. L5N 2N8; (416) 821-3541, FAX (416) 821-8863
May 21-22, 1991: Basic Cardiac Arrhythmia Interpretation Palliser Hotel, Calgary Conference and Seminar Services, Humber College, 205 Humber College Blvd., Etobicoke, Ont. M9W 5L7; (416) 675-5077, FAX (416) 675-0135 May 27-28, 1991: Advanced Cardiac Arrhythmia
Interpretation Palliser Hotel, Calgary Conference and Seminar Services, Humber College, 205 Humber College Blvd., Etobicoke, Ont. M9W 5L7; (416) 675-5077, FAX (416) 675-0135 CAN MED ASSOC J 1990; 143 (12)
1315
Why are clinical problems difficult? General practitioners' opinions concerning 24 clinical problems Helene Leclere,* MD, MA; Marie-Dominique Beaulieu,t MD, CCFP, MSc; Georges Bordage,* MD, PhD; Andre Sindon,4 MD, FRCPC; Martine Couillard,* MD This study was conducted to describe the difficulties perceived by general practitioners concerning 24 common clinical problems and to compare their perceptions with those of faculty members in family medicine. A random sample of 467 general practitioners and all- 182 faculty members in family medicine in Quebec were sent one of four open-ended questionnaires, each of which dealt with six clinical problems; 214 general practitioners and 1 14 faculty members participated. A total of 5111 difficulties were reported; the number reported by each subject varied from 0 to 13 (mean 2.6 [standard deviation 2.09]) per problem. The problems that generated the most difficulties were depression, confusion in the elderly, chronic back pain, loss of autonomy in the elderly and sexually transmitted diseases. The most frequent difficulties were with the patient's noncompliance with treatment, clinical diagnosis, failure of a specific treatment, inadequate health care resources and the physician's own emotional reactions. The difficulties for each problem were the same in the two groups 70% of the time. Physicians' perceptions of their difficulties can be useful in the planning of initial training and continuing medical education. Notre etude visait a decrire les difficultes percues par les praticiens generalistes relativement a 24 problemes cliniques courants et de comparer leur perceptions avec ceux de professeurs universitaires en medecine familiale. Nous avons expedie a un echantillon aleatoire de 467 medecins generalistes et aux 182 professeurs d'universite en medecine familiale au Quebec l'un de nos quatre questionnaires a questions de developpement, chacun traitant de six problemes cliniques; 214 medecins generalistes et 1 14 professeurs d'universite ont participe au sondage. Au total, 51 1 1 difficultes ont ete signalees; le nombre mentionne par sujet variait de 0 a 13 (moyenne de 2,6 [ecart type de 2,09]) par probleme. Les problemes qui suscitaient le plus de difficulte etaient la depression, la confusion chez les personnes agees, les douleurs dorsales chroniques, la perte d'autonomie chez les aines et les maladies transmises sexuellement. Les medecins se heurtaient le plus frequemment aux obstacles causes par le non-respect du traitement par le malade, le diagnostic clinique, l'echec d'un traitement specifique, l'inadequation des ressources de soins de sante et leurs propres reactions affectives. Les difficultes pour chaque probleme etaient les memes dans les deux groupes, dans 70% des cas. Les perceptions qu'ont les medecins de leurs difficultes peuvent constituer un renseignement utile dans la planification de la formation initiale et de l'education permanente.
From *the Bureau de pedagogie des sciences de la sante, Faculte de medecine, Universite Laval, Ste-Foy, PQ, tthe Departement de medecinefamiliale, Universite de Montreal, and $the Corporation professionnelle des medecins du Que6bec, Montreal
Reprint requests to: Dr. Hikbne Leckre, Bureau de pedagogie des sciences de la sante, Faculte de medecine, Universite Laval, Ste-Foy, PQ GIK 7P4 -
For prescribing information
see
page 1373
CAN MED ASSOC J 1990; 143 (12)
1305
T he contents of general practice have been the subject of several studies. 1-4 These studies have shown the relative frequency of the different health problems encountered in primary care but have not delved into the difficulties that physicians may have in dealing with them. Needsassessment studies in continuing medical education (CME) have also overlooked specific difficulties associated with the diagnosis and management of clinical problems. The needs are most often expressed as lists of topics representing clinical problems or techniques (e.g., management of hypertension or diabetes, performance of vasectomy or operation of a ventilator).5-7 Physicians may have many and varied difficulties, such as dealing with a patient's noncompliance, lack of time, deciding who, when and how to investigate, and dealing with a patient's family. A better comprehension of the nature of the difficulties that they experience in the day-to-day management of patients is essential to improve the planning of initial training and CME. The difficulties can be analysed either from the outside (actual needs) or as perceived by the physicians themselves. Physicians' perception of their difficulties may differ from the actual ones encountered. Therefore, although perception measurement is only one aspect, it is an important one, especially if educational interventions are to be relevant. No study has yet attempted to measure the perceptions of general practitioners and faculty members in family medicine or to determine whether these two groups have similar perceptions.' Our study addresses two questions: How do general practitioners and faculty members in family medicine perceive their difficulties? Are the perceptions of faculty members similar to those of their non-
teaching colleagues?
Methods A mail survey among general practitioners and faculty members in family medicine in Quebec was planned with the use of an open-ended questionnaire to determine the difficulties they were having with clinical problems. Four questionnaires, representing six problems each, were prepared, for a total of 24
problems.
Questionnaire Preset, forced-choice questions were not included in the questionnaire from the outset, since the goal of the study was to determine physicians' perceptions of their difficulties with as few biases as possible. Instead, we used an open-ended question as follows. 1306
CAN MED ASSOC J 1990; 143 (12)
Describe very concretely the difficulties you encounter in your practice when you deal with each clinical problem presented in the following pages. Describe as many difficulties as come to mind for each problem, but remember, it is your difficulties in your practice that are the subject of this study and not the difficulties of medical doctors in general.
A draft of the questionnaire was tested through a trial run and a pilot study so that we could refine the question and assess the time needed to complete the questionnaire. It took 3 to 6 minutes on average to respond to a problem. It was determined a priori that the maximum amount of time needed would not exceed 30 to 40 minutes. Thus, each participant was asked to respond to six clinical problems.
Selection of clinical problems Three independent sources were used to select the problems. The first was a publication by the Faculte de medecine, Universite Laval, Ste-Foy, PQ, in which training objectives in general practice were described.9 The document listed problems encountered in general practice. Each problem was weighted according to its frequency (5 points), seriousness (5) and amenability to treatment (5), as compiled by the College of Family Physicians of Canada.10 The leading problems in each body system were included, for a total of 30 problems. The second source was observations of the members of the Department of Professional Inspection and of the Receiving Office (Bureau du Syndic) of the Corporation professionnelle des medecins du Quebec (CPMQ), Montreal. The third source was six experienced general practitioners who worked in both urban and rural settings. Using a nominal group approach we asked the second and third groups to identify the clinical problems they considered difficult for general practitioners. The second group identified 22 problems (1 5 of which were on the first list) and the third 24 problems (17 of which were on the first two lists). The three sources led to the identification of 44 clinical problems. We decided to select only 24 of the problems, 6 per questionnaire, because of the limited number of faculty members, the minimum number of subjects needed per problem and the time allowance of 6 problems per subject (Table 1). We chose the problems most likely to generate varied difficulties but at the same time ensure that all patient age groups would be represented and that there would be an even distribution between acute and chronic as well as organic and psychosocial problems. Each subject was asked to complete only one of the question-
naires.
Selection ofsubjects ofsubjectsCoding Coding the responses the
responses
To be eligible a physician had to hold a licence from the CPMQ, have practised medicine for at least 3 years (therefore physicians who were very recent graduates would be eliminated) and practise at least 20 hours per week. However, the faculty members had to practise only 10 hours per week, with direct patient contact, and supervise residents at least three times per week for a minimum of 6 months per year. A questionnaire was sent to a random sample (as determined through random number selection) of 467 of 3945 eligible general practitioners in Quebec (total registration 7421) and to the 182 eligible part-time and full-time faculty members in the four family medicine programs. We estimated the sample size of general practitioners for each questionnaire using an assumed prevalence of physicians with perceived difficulties of 0.50 (worst case), a confidence level of 95% and a precision of 0.10. The total number of participants needed was 300 subjects (75 per questionnaire). This size was considered to be manageable. Given an attrition rate of 35%, 467 general practitioners were randomly selected from the 3945 eligible candidates.
Coding was determined not a priori but, rather, on the basis of the actual difficulties expressed. Three of us (H.L., M.-D.B. and M.C.) developed a coding sheet with data from the trial run (1 5 participants) and the pilot study (25 participants). The final coding sheet was established following the first interrater reliability study, early in the analysis. Ninety-four distinct difficulties were grouped into 11 categories; examples of the difficulties and the categories are in tables 2 and 3. The categories were determined according to well-established aspects of clinical practice and health care delivery. All of the questionnaires were coded by one of us (M.C.), a general practitioner with 8 years of clinical experience. All of the responses were coded, regardless of whether they expressed a difficulty or a general opinion. If a physician expressed the same difficulty repeatedly for a given problem the difficulty was tallied only once. Although all the data were coded by one person three interrater reliability studies were conducted between two of us (H.L. and M.-D.B.) and the coder. These studies were meant to test the reliability of the coding process throughout the coding period. The kappa coefficients for the interrater analysesl2 varied from 0.62 for the first sample to 0.70 for the third; these levels of reliability were considered to be quite Survey good.'3 The intrarater reliability for the main rater The survey was conducted by mail with follow- was excellent: 0.78 for the first sample and 0.95 for up by telephone, as described by Dillman." A the second. four-step procedure was used: the questionnaire was mailed, a reminder postcard was sent 1 week later, Results another reminder was sent 1 month after the first Of the 467 general practitioners 260 (56%) mailing, and, finally, nonrespondents were telephoned 2 months after the first mailing. The main completed one of the four questionnaires. Forty-six reasons given for not participating were lack of time subjects were excluded because their practice profile and being solicited to complete too many question- did not comply with the inclusion criteria. The naires. analyses were thus performed on the basis of reTable 1: Clinical problems selected to determine difficulties among general practitioners and faculty members in family medicine in Quebec
Anemia
Hypertension
Cardiorespiratory arrest
Loss of autonomy in the
Chronic back pain Chronic obstructive pulmonary disease Confusion in the elderly Depression Diabetes mellitus Drug addiction (except alcohol) Family and marital problems Fatal diseases Functional problems Headache Healthy adult with multiple risk factors
elderly Neglected or abused child Obesity Periarticular problems (tendinitis, fibrositis and bursitis) Pregnancy follow-up or delivery or both Problems related to sexuality
Sexually transmitted diseases Thyroid problems Urinary tract infection Work-related problems CAN MED ASSOC J 1990; 143 (12)
1307
sponses from 214 general practitioners. There were no differences between the participants and the nonparticipants in geographic location or language. However, the participants were slightly younger than the nonparticipants (mean age 38.9 and 42.4 years respectively; x2 = 15.98, p < 0.005), and the proportion of women was greater among the participants than among the nonparticipants (27% and 18% respect.ively; xj = 4.57, p < 0.05). Of the 182 faculty members 120 (66%) completed one of the questionnaires. Six were excluded
because their practice profile did not comply with the inclusion criteria; this left 114 respondents. There was no difference in the characteristics between the participants and the nonparticipants. A total of 328 general practitioners and faculty members participated. The four questionnaires were evenly distributed among them.
Nondifficulties Of the 5832 coded answers 721 (12.4%) did not
fable 2: The 17 most frequent difficulties physicians had with the 24 clinical problems No. of difficulties (n-- 5111)
Difficulty with Patient s noncompliance with treatment and follow-up
336
'-Iinlcal diagnosis ailure or absence of specific
234
180
treatment (not only medication) inadequate resources in health care system (quantity or quality) wn emotional reaction to problem (excluding s;e nse of helplessness) ; ack of time, too many patients indications and methods of specific treatment ARquiring and maintaining knowledge and competence Access to diagnostic investigations. rncluding waiting time Aecess to nonmedical professional
169 167 162
161
152 1;41 1.41
0Qrv.. I.)tferneces .n expecttations between physician ini patient (difficult to reconcile)
134
S>haring understanding of problem with patient
128 119
Access to medical specialty services Training for this problem Costs and travel needed by patient for service or treatment Sense of helplessness F:inding etiologic diagnosis
115
109 102 101
Table 3. D:istribution of the 5111 reported difficulties by category .':
.
........'
... -. "...
Categor\ Relation of physician with health care system and different intervenors Physician-patient relationship Treatment and follow-up Relation of physician with himself or herself Clinical diagnosis Initial training and continuing medical education Diagnostic investigation Practice organization Relation of physician with family or friends Prevention Psychosocial dimension of problems, including work 1308
CAN MED ASSOC J 1990; 143 (12)
-. .
...... ..:.
No. (and %) of difficulties 881 (17.2) 878 (17.2) 787 (15.4)
539 (10.5) 518 (10.1) 395 (7.7) 381 (7.5) 244 (4.8)
200 (3.9) 191 (3.7) 97 (1.9)
represent actual difficulties; 413 (7.1%) were general opinions on the subject, and 141 (2.4%) indicated that the physician did not have any difficulty with the given problem. The problems considered most often to pose no difficulties were anemia, thyroid problems, hypertension, urinary tract infection and headache. In addition, some of the participants indicated that they never encountered certain problems in their practice. This was particularly true for pregnancies and deliveries: 51% of the general practitioners and 39% of the faculty members indicated that they did not manage pregnancies or deliver babies. Lastly, 25% of the general practitioners and 16% of the faculty members reported that they did not perform cardiopulmonary resuscitation.
Difficulties Of the coded responses 5111 (87.6%) representactual difficulties. The number of difficulties per ed problem expressed by each respondent varied from 0 to 13 (mean 2.6 [standard deviation 2.09]). The problems that generated the greatest number of difficulties in the two groups were depression, confusion in the elderly, chronic back pain, loss of autonomy in the elderly and sexually transmitted diseases. There was a high degree of correlation between the mean number of difficulties for each problem in the two groups (Spearman rank-order correlation coefficient 0.87, p < 0.001). The total number of difficulties expressed for a given problem varied from 86 (pregnancy follow-up or delivery or both) to 356 (depression) (median 216). The number of distinct difficulties for a given problem varied from 30 (healthy adult with multiple risk factors) to 63 (confusion in the elderly) (median 46). Overall, half of the responses dealt with 17 of the 94 distinct difficulties (Table 2). The difficulties most frequently listed for each problem represent the very essence of the present study and are presented more extensively in Appendix 1. The "most frequent" difficulties for each problem were set according to a natural dropoff point in the distribution of difficulties. The dropoff point was most often between the fourth and fifth difficulty. The nature of the difficulties varied substantially from one clinical problem to another. However, there were more similarities than differences between the general practitioners and the faculty members. The actual difficulties for each problem were the same in the two groups 70% of the time. The number of difficulties for each category is presented in Table 3. The three categories with the greatest number of difficulties were the relation of the physician with the health care system and the different intervenors, the physician-patient relationship, and treatment and follow-up. For each problem
the categories with the greatest number of difficulties the categories with the greatest number of difficulties were similar 82% of the time in the two groups.
Discussion Our study shows that it is possible to gather useful information from a large number of physicians through a qualitative survey. The response rates were within accepted limits for studies of this type.'4 Five sources of potential bias related to the participant-nonparticipant factor were analysed: physician's age, sex, language, geographic location and distribution of the four questionnaires. The average age was slightly lower among the participants than among the nonparticipants, especially because of an underrepresentation among those 45 years or older; this was also noted in a survey done by the CPMQ in the same population (Leon Tetreault and associates, Montreal: personal communication, 1981). Women were slightly overrepresented among the participants. There were no differences between the two groups in language or geographic distribution. The latter factor is important since the different contexts of care, namely urban and rural settings, can potentially influence the nature of the difficulties expressed. The questionnaires were distributed evenly among the participants. Thus, there was no selection bias for the 24 problems studied. How was the precision of the estimates affected by the lower than expected response rate among the general practitioners? The number of general practitioners who responded represented 71% of the initial estimated sample. We recalculated the confidence intervals using the actual number of participants and holding the confidence level at 95% and found that the precision went from 0.10 to 0.15. Overall the results were considered to be generalizable to the 24 problems despite the factors of age and sex. Two important findings emerged from the study. First, the difficulties listed by the general practitioners and the faculty members were much more similar than different. If a large difference had been found it might have been because the faculty members were no longer in tune with their colleagues in the field. Second, despite the use of open-ended questions and the wide range of distinct difficulties over half of the difficulties expressed were limited to 17 of the 94 distinct difficulties. Similarly, of the 33 distinct difficulties expressed on average for each problem 5 were common to 44% of the respondents. From a needs-assessment perspective these five difficulties represented collective needs. On the other hand, the distribution of the 28 other distinct difficulties among the remaining 56% of the respondents represented a wider array of individual needs. Finally, difficulties with the physician-patient relationship were widespread, regardCAN MED ASSOC J 1990; 143 (12)
1309
less of the type of problem. This type of difficulty, along with difficulties with the health care system, illustrates Nowlen's extended concept of CME that includes personal impairments, contexts of practice and events of adulthood.'5 Although some of the difficulties had clear educational implications others had organizational, institutional and political ramifications. A critical factor that ensures quality activities in CME is the inclusion of educational content that meets the needs and expectations of physicians that is, addresses their perceived difficulties.'5-'8 Our findings constitute a wealth of information concerning physicians' needs that can be used to plan appropriate educational activities for initial training and CME. This is especially true for the four or five leading difficulties for each problem. (The complete list of difficulties for each problem is available from the authors upon request.) Many types of difficulty (e.g., physician's own emotional reactions) challenge traditional methods of instruction and call for innovative and participative activities. To use the frequency of each difficulty to rank the difficulties is but one aspect of their degree of importance. We did not attempt to quantify directly the degree of importance of each difficulty encountered by the physicians. Indeed, a single "overwhelming" difficulty with a clinical problem for one or two physicians would be given a score of only 1 or 2, whereas other frequent yet possibly "insignificant" difficulties could have received greater scores and consequently higher rankings. Thus, the ranking of the difficulties is not necessarily an indication of their overall importance. Careful attention should be paid to the significance of each difficulty for physicians and clinical practice. The need to quantify the degree of importance of each difficulty was considered during the planning of our study; however, the logistics of asking physicians to list their difficulties and to rate them in order of importance in one study was felt to be too demanding. This issue should be a topic for future research. The difficulties brought to light in our study also have implications for the assessment of clinical competence. They can help define the few critical elements associated with clinical competence; that is, the difficult aspects of clinical practice. This is in sharp contrast to many current methods of assessment that overly reward the candidates for thoroughness of examination and management and that compensate for the omission of essential items with a large number of harmless, slightly positive actions. A more appropriate method of assessment may be to focus on specific areas of difficulty, especially since these areas vary from problem to problem. The desire to focus the evaluation on the critical elements of clinical practice, the problem's key features, 1310
CAN MED ASSOC J 1990; 143 (12)
corresponds to the orientation taken by the Medical Council of Canada in the last paper (Q4) of its qualifying examination, which assesses the candidate's problem-solving and decision-making performance."9 Our study raises new research questions. For example, what are the specific causes of difficulties associated with the physician-patient relationship? Which types of educational and organizational interventions are most likely to help general practitioners overcome their difficulties? How important are the difficulties to the quality of health care? We hope that our findings will be used for the planning of initial training and CME and as a stepping stone for further research into what makes clinical problems difficult in practice. We thank Dr. Tim Allen, mddecine d'urgence, Faculte de mddecine, Universitd Laval, for translating the questionnaires into English and the general practitioners and faculty members who participated in the study. This project was supported by a grant from the
CPMQ.
References 1. Clute K: The General Practitioner. Study of Medical Education in Practice in Ontario and Nova Scotia, U of Toronto Pr, Toronto, 1963 2. Cartwright A: Patients and Their Doctor. A Study of General Practice, Atherton Pr, New York, 1967 3. Geyman JP (ed): A statewide study in Virginia with its clinical educational and research implications. J Fam Pract
1976; 3: 22-69 4. Schneewiess R, Rosenblatt RA, Cherkin DC et al: Diagnosis clusters: a new tool for analyzing the content of ambulatory health care. Med Care 1987; 21: 105-122 5. Craig J: Perceived learning needs of family physicians in British Columbia. Can Fam Physician 1990; 36: 262-265 6. Barnham P, Benseman J: Determining continuing medical education curricula for general practitioners - a survey of self-perceived needs. NZ Med J 1983; 96: 395-397 7. Williams AR, Davis RC, Hale CD et al: Patterns of concern: needs assessment and continuing education needs among public health physicians. J Contin Educ Health Prof 1989; 9: 131-139 8. Lessner JR, Driscoll CE: Family practice and practitioner assessment of CME needs. Conn Med 1982; 138: 114-117 9. Bernard L, Beaulieu MD, Bordage G et al: L'internat en vue de la pratique g'ne'rale: les objectifs de formation et les situations d'apprentissage. Rapport du groupe de travail, Faculte de medecine, Universite Laval, Ste-Foy, PQ, 1985 10. Educational Objectives for Certification in Family Medicine, College of Family Physicians of Canada, Toronto, 1981 11. Dillman DA: Mail and Telephone Survey: the Total Design Method, Wiley, New York, 1978 12. Fleiss JL: Statistical Methods for Rates and Proportions, Wiley, New York, 1981: 211-236 13. Landis JR, Koch GG: The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-174 14. Warwick DP, Lininger CA: The Sample Survey: Theory and Practice, McGraw, New York, 1975: 69-110 15. Nowlen PM: New expectations, new roles: a holistic approach to continuing education for the professions. In Cervero RM,
Azzaratto JF (eds): Visions for the Future of Continuing Professional Education, Georgia Center for Continuing Education, Athens, Ga, 1990: 15-23 16. Sibley JC, Sackett DL, Neufeld V et al: A randomized controlled trial of continuing medical education. N Engl J Med 1982; 306: 511-515 17. Curry L, Putnam RW: Continuing medical education in Maritime Canada: the methods physicians use, would prefer
and find most effective. Can Med Assoc J 1981; 124: 563-566 18. Knowles MS: The Modern Practice ofAdult Education: from Pedagogy to Andragogy, Assn Pr, Wilton, Conn, and Follett Publ, Chicago, 1980: 82-118 19. Bordage G, Page G: An alternative approach to PMP's: the key feature concept. In Hart I, Harden R (eds): Further Developments in Assessing Clinical Competence, Can-Heal Publ, Montreal, 1987: 59-75
Appendix 1: Difficulties reported most frequently for each clinical problem* No. of respondentst (and
Problem; difficulty with Anemia No difficulty One or more difficulties Most frequent Finding etiologic diagnosis Access to diagnostic investigations, including waiting time Deciding who and when to investigate and to what extent Patient's noncompliance with treatment and follow-up Cardiorespiratory arrest No difficulty One or more difficulties Most frequent Acquiring and maintaining knowledge and competence Deciding to not start or to stop treatment Own emotional reaction to problem Chronic back pain No difficulty One or more difficulties
Most frequent Doubts about whether patient history is true Clinical diagnosis (nonspecific)t Failure or absence of specific treatment Patient's noncompliance with treatment and follow-up Chronic obstructive pulmonary disease No difficulty One or more difficulties
no. of
distinct difficulties)
Total
GP
FM
18 63
13 40
5 23
(38)
(31)
(26)
25
16
9
16
9
7
15
12
3
14
13
1
4
(32)
38 (24)
1 25 (22)
40 19 16
19 11 11
21 8 5
2 73 (55)
1 48 (44)
1 25 (44)
24 22 17
18 16 10
6 6 7
15
10
5
6 70 (46)
4 45 (31)
2 25 (35)
39 12 12 10
28 7 7 4
11 5 5 6
0 76
0 50
0 26
(63)
(52)
(43)
28 24
20 13
8 11
24
15
9
5 63
Most frequent
Patient's noncompliance with treatment and follow-up Failure or absence of specific treatment Indications and methods of specific treatment Sense of helplessness Confusion in the elderly No difficulty One or more difficulties
Most frequent Access to emergency services and hospitalization, including specialized institutions and long-term care
Finding etiologic diagnosis Inadequate resources in health care system (quantity or quality)
CAN MED ASSOC J 1990; 143 (12)
1311
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CAN MED ASSOC J 1990; 143 (12)
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,.
il,
Headache No difficulty One or more difficulties Most frequent Failure or absence of specific treatment Overuse of drugs Clinical diagnosis (nonspecific) Finding etiologic diagnosis Healthy adult with multiple risk factors No difficulty One or more difficulties
Most frequent Use of counselling as preventive measure Patient's lack of motivation to look after self from beginning Patient's noncompliance with treatment and follow-up Sharing understanding of problem with patient Lack of time, too many patients Hypertension No difficulty One or more difficulties
Most frequent Patient's noncompliance with treatment and follow-up Training related to new drugs and treatment Indications and methods of specific treatment Side effects of drugs Complexity in choosing medication Loss of autonomy in elderly No difficulty One or more difficulties Most frequent Inadequate resources in health care system (quantity or quality) Access to emergency services and hospitalization, including specialized institutions and long-term care Lack of cooperation of patient's family and friends with diagnosis and follow-up Lack of time, too many patients Access to nonmedical professional services Neglected or abused child No difficulty One or more difficulties Most frequent
Clinical diagnosis (nonspecific) Inadequate resources in health care system (quantity or quality) Own method of interaction with patient's family and friends Access to nonmedical professional services Obesity No difficulty One or more difficulties Most frequent Patient's noncompliance with treatment and follow-up Patient's lack of motivation to look after self from beginning Failure or absence of specific treatment
10 77 (45)
8 48 (33)
2 29 (34)
33 21 20 19
17 17 8 13
16 4 12 6
3 72
3 45
0 27
(30)
(1 9)
(24)
38
25
13
19
11
8
16 10 10
14 7 6
2 3 4
15 62 (36)
11 38
4 24
(27)
(28)
38 19
23 9
14
4 7
15 10 10 6 6
13 12
I 73
6 1
0 27
(54)
46 (48)
(36)
49
30
19
38
25
13
12 12 12
5 5 6
7 7 6
3 66
(39)
3 40 (31)
0 26 (29)
37
18
19
17
10
7
13 13
5 8
8 5
5 81
4 51
1 30
(42)
(39)
(28)
25
13
12
24 22
11 12
13 10
CAN MED ASSOC J 1990; 143 (12)
1313
Differences in expectations between physician and patient (difficult to reconcile) Periarticular problems (tendinitis, fibrositis and bursitis) No difficulty One or more difficulties Most frequent Failure or absence of specific treatment Clinical diagnosis (nonspecific) Executing therapeutic technique Pregnancy follow-up or delivery or both No difficulty One or more difficulties Most frequent Acquiring and maintaining knowledge and competence Differences in expectations between physician and patient (difficult to reconcile) Lack of time, too many patients Energy involved, especially in long-term follow-up of patient Problems related to sexuality No difficulty One or more difficulties
Most frequent Training for this problem Access to nonmedical professional services Own emotional reaction to problem Costs and travel needed by patient for service or treatment Sexually transmitted diseases No difficulty One or more difficulties Most frequent Access to diagnostic investigations, including waiting time Patient's noncompliance with treatment and follow-up Screening techniques, including screening of contacts Costs and travel needed by patient for service or treatment Thyroid problems No difficulty One or more difficulties Most frequent Clinical diagnosis (nonspecific) Interpreting results of diagnostic examinations, excluding imaging Access to diagnostic investigations, including waiting time Urinary tract infection No difficulty One or more difficulties Most frequent Indications and methods of specific treatment Access to diagnostic investigations, including waiting time Patient's noncompliance with treatment and follow-up Clinical diagnosis (nonspecific) Diagnostic investigation (nonspecific) 1314
CAN MED ASSOC J 1990; 143 (12)
21
14
7
-7
5 46
2 26
(39)
(30)
17 16
17 8 9
8 9 7
8 34 (36)
7 18 (25)
16
(25)
7
3
4
6
4 3
3
5,
3
5 80 (52)
3
2
51
29
(39)
(41)
29 26
18 12
11 14
17
7
10
16
11
5
1 70
1 43
0 27
(47)
(37)
(37)
37
25
12
26
11
15
25
10
15
15
12
3
16 60 (32)
12 36 (24)
4 24
(25)
20
13
7
18
10
8
17
12
5
14 73
(40)
11 45 (31)
3 28 (31)
44
26
18
29
17
12
29 22
16
13
72 (45)
25
17
t
11 10
Deciding who and when to investigate and to what extent Work-related problems No difficulty One or more difficulties Most frequent Relation with workplace, employers and insurance companies Relation with Workers' Compensation Board Doubts about whether patient history is true Clinical diagnosis (nonspecific)
14
5
9
1 74
1 48
0 26
(41)
(30)
(31)
33 18 16 14
15 10
18 8 5 7
11 7
The number of most frequent difficulties was set according to a natural dropoff point observed in the distribution of difficulties for each clinical problem. The dropoff point was most often between the fourth and fifth most frequent
difficulty. tGP general practitioner; FM = faculty member. $Like other "nonspecific" difficulties this one represents a "general" difficulty within the category that could not be coded by other, specific codes. =
Conferences continuedfrom page 1294 Apr. 21-24, 1991: Canadian Organization for the Advancement of Computers in Health (COACH) 16th Annual Conference Sheraton Centre, Toronto Steven A. Huesing, executive director, Canadian Organization for the Advancement of Computers in Health, 1200-10460 Mayfield Rd., Edmonton, Alta. T5P 4P4; (403) 489-4553, FAX (403) 489-3290
Apr. 24, 1991: 4th Annual Conference on Education in Aging and Health - Educational Implications of the Provincial Long Term Care Reform Sheraton Hotel, Hamilton, Ont. Educational Centre for Aging and Health, Faculty of Health Sciences, McMaster University, PO Box 2000, Stn. A, Hamilton, Ont. L8S 3N5; (416) 525-9140, ext. 84-4011, FAX (416) 574-2838 Apr. 25-26, 1991: Ontario Gerontology Association 10th Annual Conference - Choices for the 1990s: Economics, Practice and Ethics Sheraton Hotel, Hamilton, Ont. Ontario Gerontology Association, 7777 Keele St., 2nd Fl., Concord, Ont. L4K 1Y7; (416) 660-1056 or 660-1076, FAX (416) 660-7450
Apr. 27-May 1, 1991: Annual Meeting of the Association of Canadian Medical Colleges, the Association of Canadian Teaching Hospitals and the Canadian Association for Medical Education Ramada Renaissance Hotel, Saskatoon Janet Watt-Lafleur, Association of Canadian Medical Colleges, 1006-151 Slater St., Ottawa, Ont. KIP 5N1; (613) 237-0070
Les 2 et 3 mai 1991: Congres annuel de la Societe pour la m6decine de l'adolescence (section de l'est du Canada) - Travailler ensemble pour la sante des adolescents Hotel Ritz Carlton, Montreal Mme Sylvie Lavigueur-Morin ou Mme Danielle Boivin-Ouimet, Formation pediatrique continue de Montreal, Hopital Sainte-Justine, 3175, cote Sainte-Catherine, Montreal (Que.) H3T IC5; (514) 345-4781 ou 345-4782 May 12-14, 1991: Canada's National Safety Conference - Safety Starts in Your Community Hamilton, Ont. Canada Safety Council, 6-2750 Stevenage Dr., Ottawa, Ont. KIG 3N2; (613) 739-1535, FAX (613) 739-1566 May 13-16, 1991: 7th World Congress on Emergency and Disaster Medicine (sponsored by the World Association of Emergency and Disaster Medicine, the Canadian Association of Emergency Physicians and la Societe intemationale de m6decine de catastrophe) Abstract deadline is Dec. 31, 1990. Palais de Congres, Montreal Ms. Ursula Schwarz, Meeting Secretariat, Kush Medical Communications, 61-6100 Montevideo Rd., Mississauga, Ont. L5N 2N8; (416) 821-3541, FAX (416) 821-8863
May 21-22, 1991: Basic Cardiac Arrhythmia Interpretation Palliser Hotel, Calgary Conference and Seminar Services, Humber College, 205 Humber College Blvd., Etobicoke, Ont. M9W 5L7; (416) 675-5077, FAX (416) 675-0135 May 27-28, 1991: Advanced Cardiac Arrhythmia
Interpretation Palliser Hotel, Calgary Conference and Seminar Services, Humber College, 205 Humber College Blvd., Etobicoke, Ont. M9W 5L7; (416) 675-5077, FAX (416) 675-0135 CAN MED ASSOC J 1990; 143 (12)
1315
