To which non-physician health professionals do French general practitioners refer their patients to and what factors are associated with these referrals? Secondary analysis of the French national cross-sectional ECOGEN study

Background Multiprofessional practice is a key component in primary care. Examining general practitioner (GP) referral frequency to non-physician health professionals (NPHP) can provide information about how primary care is organised and works which is useful for policymakers. Our study aimed to describe French GP referral frequency to various NPHPs in France and identify associated factors. Methods This is an ancillary study to the observational, cross-sectional (ECOGEN) study conducted in 2011/2012 in France among 128 GPs. Data about consultations using the standardised International Classification of Primary Care (ICPC-2), and patient and GP characteristics were collected from 20,613 GP consultations. Referrals were identified through inductive and deductive approaches using ICPC-2 codes, keywords, and deep, open manual searches. Referral frequency was described overall and per NPHP. Patient, GP, and consultation-related factors associated with referral rates were described for the three most frequently identified NPHPs. To minimise potential sources of bias, this observational study followed the STROBE guidelines. Results French GPs referred 6.8% of patients to NPHPs, with physiotherapists, podiatrists, and nurses accounting for 85.2% of referrals. Older patients, retired patients, multiple health problems managed, and longer consultation durations were found to be associated with higher referral rates (p < 0.001). Specific trends were observed for nurse, physiotherapist, and podiatrist referrals. Women (p < 0.001) and regular patients (p = 0.002) were more likely to receive physiotherapy referrals while people with no professional activity were less likely (p < 0.001). Female GPs and those working in urban practices were more likely to issue a physiotherapy referral (p < 0.001), while GPs working in rural practices (p < 0.001) and those with higher annual consultation numbers (p = 0.002) were more likely to refer to a nurse. Working in multiprofessional centres appeared to have little impact on referral rates, being only slightly associated with podiatrist referrals (p = 0.003). Conclusions Referral frequency is more associated with patient characteristics and clinical situations than GP-related factors suggesting patients needing referral most are most often referred. Furthermore, the three NPHPs that GPs refer to the most are those for which a referral is required for reimbursement in France, suggesting that health system legislation and NPHP reimbursement are strong determinants for referrals.

Stakeholder perspectives to inform adaptation of a hypertension treatment program in primary healthcare centers in the Federal Capital Territory, Nigeria: a qualitative study

Background Implementing an evidence-based hypertension program in primary healthcare centers (PHCs) in the Federal Capital Territory, Nigeria is an opportunity to improve hypertension diagnosis, treatment, and control and reduce deaths from cardiovascular diseases. This qualitative research study was conducted in Nigerian PHCs with patients, non-physician health workers, administrators and primary care physicians to inform contextual adaptations of Kaiser Permanente Northern California's hypertension model and the World Health Organization’s HEARTS technical package for the system-level, Hypertension Treatment in Nigeria (HTN) Program. Methods Purposive sampling in 8 PHCs identified patients (n = 8), non-physician health workers (n = 12), administrators (n = 3), and primary care physicians (n = 6) for focus group discussions and interviews. The Primary Health Care Performance Initiative (PHCPI) conceptual framework and Consolidated Framework for Implementation Research (CFIR) domains were used to develop semi-structured interviews (Appendix 1, Supplemental Materials) and coding guides. Content analysis identified multilevel factors that would influence program implementation. Results Participants perceived the need to strengthen four major health system inputs across CFIR domains for successful adaptation of the HTN Program components: (1) reliable drug supply and blood pressure measurement equipment, (2) enable and empower community healthcare workers to participate in team-based care through training and education, (3) information systems to track patients and medication supply chain, and (4) a primary healthcare system that could offer a broader package of health services to meet patient needs. Specific features of the PHCPI framework considered important included: accessible and person-centered care, provider availability and competence, coordination of care, and proactive community outreach. Participants also identified patient-level factors, such as knowledge and beliefs about hypertension, and financial and transportation barriers that could be addressed with better communication, home visits, and drug financing. Participants recommended using existing community structures, such as village health committees and popular opinion leaders, to improve knowledge and demand for the HTN Program. Conclusions These results provide information on specific primary care and community contextual factors that can support or hinder implementation and sustainability of an evidence-based, system-level hypertension program in the Federal Capital Territory, Nigeria, with the ultimate aim of scaling it to other parts of the country.

Occupational Challenges in Physicians with Substance Use Disorder: A Qualitative Study

Background: Substance use disorders (SUDs) in physicians impact their professional responsibilities toward patients. Understanding the difficulties of physicians with SUDs would facilitate early identification and reduce the complications they face in various domains, particularly in settings where there are no physician-health care programs. In this background, we aimed to understand the challenges physicians with SUDs face at their workplace. Methods: Qualitative in-depth interviews of 21 physicians receiving treatment from a tertiary care addiction medicine center for their SUD were conducted and, based on the transcripts from the interview after coding and recoding, through inductive content analysis, themes and subthemes were identified. Results: The following occupational challenges were identified: direct consequences of the psychoactive effect of the substance, adverse effects on clinical care and service delivery, impairment in regularity and punctuality, changes in the physicians’ behaviors, changes in the work environment and diverse responses of colleagues and the hospital administration toward substance use-related actions, ethical issues at workplace, and effects on career growth. Conclusions: SUDs in physicians have a significant impact on their functioning at work, affecting patient care, interpersonal relationships as well as career growth. Knowledge of occupational challenges among physicians with SUD will help us in understanding the severity of the problem.

Barriers and Facilitators to Seek Help for Substance Use Disorder among Dutch Physicians: A Qualitative Study

<b><i>Introduction:</i></b> Substance use disorders (SUDs) among physicians affect their health, quality of life, but potentially also their quality of care. Despite the availability of effective specific Physician Health Programs (PHPs), physicians with SUD often experience barriers when seeking professional help. Therefore, we studied barriers and facilitators when seeking help for SUD among physicians from a multiple perspective approach. <b><i>Methods:</i></b> A qualitative design was adopted for 2 sub-studies. First, answers of 2 open-ended questions (about anticipated barriers and facilitators) of an existing questionnaire were analyzed. This questionnaire was filled out by 1,685 general physicians (response rate = 47%). The answers of these open-ended questions were coded inductively. Second, 21 semi-structured interviews (about experienced barriers and facilitators) were performed with physician SUD-patients, significant others, and PHP employees. Themes identified in the first sub-study were used to deductively code the interview transcripts. Results were reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines. <b><i>Results:</i></b> Barriers were found at the level of the individual physician (negative feelings and lack of disease awareness), whereas facilitators were found at the level of social relationships (confrontation with SUD and social support) and health services (supportive approach, good accessibility, and positive image of services). The interviews emphasized the importance of nonjudgmental confrontation by social relationships in the process of seeking help for SUD. <b><i>Conclusion:</i></b> Physicians with SUD face barriers when seeking help for SUD mostly at the level of the individual physician. Health services and people around physicians with SUD could facilitate the help-seeking process by offering confidential and nonpunitive support. Future studies should explore whether the barriers and facilitators identified in this study also hold for other mental health issues.

Collaborative care in secondary prevention of cardiovascular disease in India: Findings from a multi-stakeholder, qualitative analysis

Background. Cardiovascular disease (CVD) is pervasive in India, and little is known about the perception of patients and providers about collaborative care in secondary prevention of CVD. To fill this gap, we performed a needs assessment and investigated the barriers and facilitators of the collaborative quality improvement (C-QIP) strategy for secondary prevention of CVD in India.Methods. Between September 2019 – February 2020, we conducted semi-structured in-depth interviews with providers, health administrators, patients and caregivers to understand the challenges and facilitators of the C-QIP strategy consisting of electronic health records-decision support system (EHR-DSS), non-physician health worker and text messages for healthy lifestyle. Also, data were analyzed from the lens of consolidated framework for implementation research (CFIR) to guide effective implementation of the C-QIP strategy. We used an iterative approach for qualitative data analysis based on the framework method. Results. We interviewed 38 physicians, 14 non-physician health workers (nurses, community health workers, pharmacists), 4 health administrators, 16 patients and their caregivers. Challenges perceived from providers’ and health administrators’ perspectives to implement quality in CVD care were related to CFIR actors and inner and outer settings: high patient volume, too few specialists, time-constraints, physician burnout, lack of robust communication system or referral linkage, paucity of electronic health records, lack of patient counsellors, polypharmacy and lack of sustainable financing schemes for outpatient services. In addition, low health literacy, high cost of treatment, misinformation bias, and difficulty in maintaining lifestyle changes were key barriers from patients’ and caregivers’ perspectives. Potential benefits of the C-QIP strategy emerged, such as standardized treatment protocol to minimize variation in care, reduced medication errors, improved physician-patient relationships, and enhanced self-care management. However, concerns were raised about feasibility, adoption, and implementation of EHR-DSS across heterogenous healthcare settings, including related to interoperability, patient confidentiality and data security, appropriateness across diverse patient groups, and care delivery costs.Conclusions. Our findings reveal context-specific, patient-, provider- and health system factors that will influence C-QIP strategy implementation in India. Strategies to optimize chronic care of CVD need to be low-cost, culturally acceptable, targeted, and integrated into existing systems and care pathways to be successful.

Collaborative Care in Secondary Prevention of Cardiovascular Disease in India: Findings From A Multi-Stakeholder, Qualitative Analysis

Background. Cardiovascular disease (CVD) is pervasive in India, and little is known about the perception of patients and providers about collaborative care in secondary prevention of CVD. To fill this gap, we performed a needs assessment and investigated the barriers and facilitators of the collaborative quality improvement (C-QIP) strategy for secondary prevention of CVD in India.Methods. Between September 2019 – February 2020, we conducted semi-structured in-depth interviews with providers, health administrators, patients and caregivers to understand the challenges and facilitators of the C-QIP strategy consisting of electronic health records-decision support system (EHR-DSS), non-physician health worker and text messages for healthy lifestyle. Also, data were analyzed from the lens of consolidated framework for implementation research (CFIR) to guide effective implementation of the C-QIP strategy. We used an iterative approach for qualitative data analysis based on the framework method. Results. We interviewed 38 physicians, 14 non-physician health workers (nurses, community health workers, pharmacists), 4 health administrators, 16 patients and their caregivers. Challenges perceived from providers’ and health administrators’ perspectives to implement quality in CVD care were related to CFIR actors and inner and outer settings: high patient volume, too few specialists, time-constraints, physician burnout, lack of robust communication system or referral linkage, paucity of electronic health records, lack of patient counsellors, polypharmacy and lack of sustainable financing schemes for outpatient services. In addition, low health literacy, high cost of treatment, misinformation bias, and difficulty in maintaining lifestyle changes were key barriers from patients’ and caregivers’ perspectives. Potential benefits of the C-QIP strategy emerged, such as standardized treatment protocol to minimize variation in care, reduced medication errors, improved physician-patient relationships, and enhanced self-care management. However, concerns were raised about feasibility, adoption, and implementation of EHR-DSS across heterogenous healthcare settings, including related to interoperability, patient confidentiality and data security, appropriateness across diverse patient groups, and care delivery costs.Conclusions. Our findings reveal context-specific, patient-, provider- and health system factors that will influence C-QIP strategy implementation in India. Strategies to optimize chronic care of CVD need to be low-cost, culturally acceptable, targeted, and integrated into existing systems and care pathways to be successful.

Substance Use Disorders and the Impaired Physician

Patient safety is jeopardized when healthcare services are provided by physicians who suffer from substance use disorders (SUDs). When focusing on the problem of substance abuse and dependence among physicians, certain factors inherent in the medical field, such as long hours, the high-stress nature of the work, and the ease of access to drugs, make physicians more susceptible to abusing or becoming dependent on prescription drugs and alcohol. SUDs may differ in severity. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (Washington, DC: American Psychiatric Association, 2013) provides three severity specifiers: mild, moderate, and severe. Severe SUDs are also known as addictive disorders. To make matters worse, a culture of silence exists among colleagues, who often seek to protect the compromised physician from the legal consequences of abusing drugs. Luckily, the compromised physician can be provided with an intense and individualized treatment regime through physician health programs that aim for rehabilitation over termination of employment.

The Cancer Risk among Physicians in Taiwan, a PopulationBased Propensity Score Matched Cohort Study

Background: The field of physician health is gaining increasing attention; however, most research and interventions have concentrated on factors such as job stress, mental health, and substance abuse. The risks of major cancers in physicians remain unclear. We used a propensity score-matched analysis to investigate the risk of cancer in physicians relative to the general population who had no healthcare-related professional background. Methods: Data were obtained from the National Health Insurance system in Taiwan. The physician cohort contained 29,713 physicians, and each physician was propensity score-matched with a person from the general population. Results: The physicians demonstrated a 0.90-fold lower risk of all-cancers (95% confidence interval [CI] = 0.83 – 0.96) when compared with the general population. Female physicians had a higher risk of cancer than male physicians (adjusted hazard ratio [HR] = 1.59; 95% CI = 1.28 – 1.96). Physicians had higher risks of prostate (HR = 1.26; 95% CI = 1.00 – 1.59) and thyroid cancers (HR = 3.16; 95% CI = 1.69 – 5.90) when compared with the general population. Conclusion: Physicians have lower rates of overall cancer risk than the general population. Female physicians have higher cancer risks than male physicians. Male physicians have higher risks of thyroid and prostate cancer relative to the general population.

A Manuscript Regarding Suicidal Death of Physicians Resulting from Psychological Stress in their Inner World (No. 355)

The author is a 73-year-old medical research scientist who recently read an article regarding physician health and death [1]. Inspired by the story and his own past experiences, he decided to write a special manuscript to be shared with medical doctors. This article has a different writing style compared to his previous 354 math-physical medicine research papers, based on a quantitative method to derive analysis results with high precision, aimed at helping patients