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Women's health care has evolved significantly since it was first acknowledged as an integral part of internal medicine training more than two decades ago. To update and clarify core competencies in sex- and gender-based women's health for general internists, the Society of General Internal Medicine (SGIM) Women and Medicine Commission prepared the following Position Paper, approved by the SGIM council in 2023. Competencies were developed using several sources, including the 2021 Accreditation Council for Graduate Medical Education Program Requirements for Internal Medicine and the 2023 American Board of Internal Medicine Certification Examination Blueprint. These competencies are relevant to the care of patients who identify as women, as well as gender-diverse individuals to whom these principles apply. They align with pivotal advances in women's health and acknowledge the changing context of patients' lives, reaffirming the role of general internal medicine physicians in providing comprehensive care to women., (© 2023. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Introduction: Many patients now turn to the internet as a resource for healthcare information and advice. However, patients' use of the internet to manage their health has been positioned as a potential source of strain on the doctor-patient relationship in primary care. The current evidence about what happens when internet-derived health information is introduced during consultations has relied on qualitative data derived from interview or questionnaire studies. The 'Harnessing resources from the internet to maximise outcomes from GP consultations (HaRI)' study combines questionnaire, interview and video-recorded consultation data to address this issue more fully., Methods and Analysis: Three data collection methods are employed: preconsultation patient questionnaires, video-recorded consultations between general practitioners (GP) and patients, and semistructured interviews with GPs and patients. We seek to recruit 10 GPs practising in Southeast England. We aim to collect up to 30 patient questionnaires and video-recorded consultations per GP, yielding up to 300. Up to 30 patients (approximately three per participating GP) will be selected for interviews sampled for a wide range of sociodemographic characteristics, and a variety of ways the use of, or information from, the internet was present or absent during their consultation. We will interview all 10 participating GPs about their views of online health information, reflecting on their own usage of online information during consultations and their patients' references to online health information. Descriptive, conversation and thematic analysis will be used respectively for the patient questionnaires, video-recorded consultations and interviews., Ethics and Dissemination: Ethical approval has been granted by the London-Camden & Kings Cross Research Ethics Committee. Alongside journal publications, dissemination activities include the creation of a toolkit to be shared with patients and doctors, to guide discussions of material from the internet in consultations., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ.)

Background: Much implementation research is focused on full-scale trials with little evidence of preceding modelling work. The Medical Research Council Framework for developing and evaluating complex interventions has argued for more and better theoretical and exploratory work prior to a trial as a means of improving intervention development. Intervention modelling experiments (IMEs) are a way of exploring and refining an intervention before moving to a full-scale trial. They do this by delivering key elements of the intervention in a simulation that approximates clinical practice by, for example, presenting general practitioners (GPs) with a clinical scenario about making a treatment decision., Methods: The current proposal will run a full, web-based IME involving 250 GPs that will advance the methodology of IMEs by directly comparing results with an earlier paper-based IME. Moreover, the web-based IME will evaluate an intervention that can be put into a full-scale trial that aims to reduce antibiotic prescribing for upper respiratory tract infections in primary care. The study will also include a trial of email versus postal invitations to participate., Discussion: More effective behaviour change interventions are needed and this study will develop one such intervention and a system to model and test future interventions. This system will be applicable to any situation in the National Health Service where behaviour needs to be modified, including interventions aimed directly at the public., Trial Registration: ClinicalTrials (NCT): NCT01206738.

Background: Emergency healthcare services are under intense pressure to meet increasing patient demands. Many patients presenting to emergency departments could be managed by general practitioners in general practitioner-emergency department service models., Objectives: To evaluate the effectiveness, safety, patient experience and system implications of the different general practitioner-emergency department models., Design: Mixed-methods realist evaluation., Methods: Phase 1 (2017-8), to understand current practice: rapid realist literature review, national survey and follow-up key informant interviews, national stakeholder event and safety data analysis. Phase 2 (2018-21), to collect and analyse qualitative (observations, interviews) and quantitative data (time series analysis); cost-consequences analysis of routine data; and case site data for 'marker condition' analysis from a purposive sample of 13 case sites in England and Wales. Phase 3 (2021-2), to conduct mixed-methods analysis for programme theory and toolkit development., Results: General practitioners commonly work in emergency departments, but delivery models vary widely in terms of the scope of the general practitioner role and the scale of the general practitioner service. We developed a taxonomy to describe general practitioner-emergency department service models (Integrated with the emergency department service, Parallel within the emergency department, Outside the emergency department on the hospital site) and present a programme theory as principal output of the study to describe how these service models were observed to operate. Routine data were of variable quality, limiting our analysis. Time series analysis demonstrated trends across intervention sites for: increased time spent in the emergency department; increased emergency department attendances and reattendances; and mixed results for hospital admissions. Evidence on patient experience was limited but broadly supportive; we identified department-level processes to optimise the safety of general practitioner-emergency department models., Limitations: The quality, heterogeneity and extent of routine emergency department data collection during the study period limited the conclusions. Recruitment was limited by criteria for case sites (time series requirements) and individual patients (with 'marker conditions'). Pandemic and other pressures limited data collection for marker condition analysis. Data collected and analysed were pre pandemic; new approaches such as 'telephone first' and their relevance to our findings remains unexplored., Conclusion: Findings suggest that general practitioner-emergency department service models do not meet the aim of reducing the overall emergency department waiting times and improving patient flow with limited evidence of cost savings. Qualitative data indicated that general practitioners were often valued as members of the wider emergency department team. We have developed a toolkit, based on our findings, to provide guidance for implementing and delivering general practitioner-emergency department services., Future Work: The emergency care data set has since been introduced across England to help standardise data collection to facilitate further research. We would advocate the systematic capture of patient experience measures and patient-reported outcome measures as part of routine care. More could be done to support the development of the general practitioner in emergency department role, including a core set of competencies and governance structure, to reflect the different general practitioner-emergency department models and to evaluate the effectiveness and cost effectiveness to guide future policy., Study Registration: This study is registered as PROSPERO CRD42017069741., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/145/04) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 10. See the NIHR Funding and Awards website for further award information.

Background: Telemedicine is often promoted as a possible solution to some of the challenges healthcare systems in many countries face, and an increasing number of studies evaluate the clinical effects. So far, the studies show varying results. Less attention has been paid to systemic factors, such as the context, implementation, and mechanisms of these interventions., Methods: This study evaluates the experiences of patients and health personnel enrolled in a pragmatic randomized controlled trial comparing telemedicine-based follow-up of chronic conditions with usual care. Patients in the intervention group received an individual treatment plan together with computer tablets and home telemonitoring devices to report point-of-care measurements, e.g., blood pressure, blood glucose or oxygen saturation, and to respond to health related questions reported to a follow-up service. In response to abnormal measurement results, a follow-up service nurse would contact the patient and consider relevant actions. We conducted 49 interviews with patients and 77 interviews with health personnel and managers at the local centers. The interview data were analyzed using thematic analysis and based on recommendations for conducting process evaluation, considering three core aspects within the process of delivering a complex intervention: (1) context, (2) implementation, and (3) mechanisms of impact., Results: Patients were mainly satisfied with the telemedicine-based service, and experienced increased safety and understanding of their symptoms and illness. Implementation of the service does, however, require dedicated resources over time. Slow adjustment of other healthcare providers may have contributed to the absence of reductions in the use of specialized healthcare and general practitioner (GP) services. An evident advantage of the service is its flexibility, yet this may also challenge cost-efficiency of the intervention., Conclusions: The implementation of a telemedicine-based service in primary healthcare is a complex process that is sensitive to contextual factors and that requires time and dedicated resources to ensure successful implementation., Trial Registration: The trial was registered in www., Clinicaltrials: gov (NCT04142710). Study start: 2019-02-09, Study completion: 2021-06-30, Study type: Interventional, Intervention/treatment: Telemedicine tablet and tools to perform measurements. Informed and documented consent was obtained from all subjects and next of kin participating in the study., (© 2024. The Author(s).)

Background: In Belgium, the Planning Commission for Medical Supply is responsible for monitoring human resources for health (HRH) and ultimately proposing workforce quotas. It is supported by the Planning Unit for the Supply of the Health Professions. This Unit quantifies and forecasts the workforce in the healthcare professions on the basis of a stock and flow model, based on trends observed in the past. In 2019, the Planning Unit asked the KCE (Belgian Health Care Knowledge Centre) to develop additional forecasting scenarios for the midwifery workforce, to complement the standard historical trend approach. The aim of this paper is to present the development of such forecasting scenarios., Methods: The Robust Workforce Planning Framework, developed by the Centre for Workforce Intelligence in the UK was used to develop alternative midwifery workforce scenarios. The framework consists of four steps (Horizon scanning, Scenario generation, Workforce modelling, and Policy analysis), the first two of which were undertaken by KCE, using two online surveys and five workshops with stakeholders., Results: Three alternative scenarios are proposed. The first scenario (close to the current situation) envisages pregnancy and maternity care centred on gynaecologists working either in a hospital or in private practice. The second scenario describes an organisation of midwife-led care in hospitals. In the third scenario, care is primarily organised by primary care practitioners (midwives and general practitioners) in outpatient settings., Conclusions: The Robust Workforce Planning Framework provides an opportunity to adjust the modelling of the health workforce and inform decision-makers about the impact of their future decisions on the health workforce., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Loneliness in older adults is common, particularly in women. In this article, gender differences in the association of loneliness and health care use are investigated in a large sample of community-dwelling older adults., Methods: Data of 2525 persons (ages 55-85 years)-participants of the fourth follow- up (2011-2014) of the ESTHER study- were analyzed. Loneliness and health care use were assessed by study doctors in the course of a home visit. Gender-specific regression models with Gamma-distribution were performed using loneliness as independent variable to predict outpatient health care use, adjusted for demographic variables., Results: In older women, lonely persons were shown to have significantly more visits to general practitioners and mental health care providers in a three-month period compared to less lonely persons (p = .005). The survey found that outpatient health care use was positively associated with loneliness, multimorbidity, and mental illness in older women but not in older men. Older men had significantly more contact with inpatient care in comparison to women (p = .02)., Conclusions: It is important to consider gender when analyzing inpatient and outpatient health care use in older persons. In older women loneliness is associated with increased use of outpatient services., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Aim: To identify key predictors of general practitioner (GP) satisfaction and increase insight into the mechanisms behind ethnic health inequities in New Zealand., Method: Regression analyses were conducted using data from the 2019 New Zealand Attitudes and Values Study (n=38,465)., Results: Initially, Māori and Asian peoples showed lower, and Pasifika peoples showed no significant difference in GP satisfaction level relative to New Zealand (NZ) Europeans. However, after accounting for differences in patient-perceived GP cultural respect and GP ethnic similarity, Māori and Pasifika peoples showed higher and Asian peoples showed no difference in GP satisfaction level relative to NZ Europeans. These effects continued to hold when adjusting for a range of demographic factors. Subsequent regression analyses were conducted to investigate the impact of GP perceptions, GP satisfaction and demographic factors on healthcare access satisfaction and health status across ethnic groups. For all ethnic groups, GP satisfaction was the strongest predictor of satisfaction with access to healthcare. Higher GP satisfaction was also a significant predictor of higher self-rated health and lower psychological distress., Conclusion: Lack of GP cultural respect is a key contributor to lower GP satisfaction among ethnic minorities, which can further exacerbate inequities in healthcare access and health outcomes. Interventions to enhance GPs' provision of culturally respectful and safe healthcare services may help reduce ethnic health inequities and improve population health., Competing Interests: Nil, (© PMA.)

Since Internal Medicine (IM) is the most frequent setting of hospitalization for both patients with advanced liver disease and those with comorbidities and risk factors for infection, through this position paper FADOI aims to promote and disseminates its vision regarding the current and potential role of IM in managing hepatitis C virus (HCV) infection (screening, diagnosis, linkage-to-care, treatment). The Internist plays an important role in identifying new cases, in selecting the appropriate diagnostic work-up for liver disease staging and prognosis, and in initiating antiviral therapy, coordinating care and communication with other specialists, the Hepatology outpatient clinic and General Practitioners. Since the Internist is naturally accustomed to the management of multiple comorbidities, he has a fundamental role in the identification of extrahepatic diseases associated with HCV infection and in the diagnosis of comorbidities, some of which are potential factors of liver disease progression. Moreover, in the prescription of the antiviral therapy, it is important to consider the possible drug interactions, and this ideally fits the role of the Internist who can weigh the risk/benefit ratio of possible alternatives, by considering the patient's clinical situation, especially in case of multiple comorbidities. Moreover, it seems appropriate that the ability to prescribe antiviral therapy is guaranteed to all IM hepatology clinics, favoring a spread of awareness as well as an increase in national coverage and therefore patient access to therapies. The network of IM can also contribute to homogenizing the management policies of HCV treatment, which sometimes differ between Italian Regions. [ABSTRACT FROM AUTHOR]

Urgent care practice (UCP) is a novel concept for India. Urgent care primarily deals with injuries or illnesses requiring immediate care. Medical emergency and urgency can happen anywhere unannounced. Research has shown that 90% of the morbidities can be resolved within the community by primary care physicians lead teams. Given the changing professional demands, non-specialists tend to refer away far too many cases to specialists, undermining generalist medical care, particularly in Indian settings. The spillover of the patient load from the primary care setting to the tertiary care centers is enormous leading to resource mismatch. Family physicians and other primary care providers are best positioned to develop practices and provide good quality urgent care to society. Family physicians, general practitioners, and medical officers are already functioning as the frontline care providers for any emergency or medical urgency arising within communities. Urgent care is essentially ambulatory care or outpatient care outside of a traditional hospital emergency room. "UCP aims to provide timely support, which is easily accessible with a focus on good clinical outcomes, e.g. survival, recovery, lack of adverse events, and complications. Core interventions of urgent care are centered on the 4Rs - Rescue, Resuscitate, Relate, and Refer. At present, there are no available, established training model for future faculty, residents, and medical students on "UCP" in India. [ABSTRACT FROM AUTHOR]

Background: Privately-owned cannabis clinics have sprung up in many jurisdictions where medicinal cannabis has been legalised and provide an alternative pathway for patients who are unable or unwilling to access a prescription for cannabis-based medicinal products from their usual healthcare providers., Aims: This study aimed to explore physicians' views on cannabis clinics, including their perceptions of the role cannabis clinics play in the wider health system., Methods: A qualitative study using in-depth, semi-structured interviews with thirty-one physicians affiliated with private and community clinics in New Zealand (including cannabis clinicians, GPs, and specialist doctors). The interviews were conducted from July to December 2021. Data were transcribed and analysed using inductive thematic analysis., Results: Cannabis clinicians positioned themselves as (1) "service providers", facilitating consumer access to cannabis prescriptions and products, and (2) "educators", providing advice to patients and the wider physician community. While general practitioners and specialists recognised the benefits of specialised cannabis clinics (i.e., knowledge of products and a non-judgmental environment), they questioned the limited evidence of clinical efficacy for cannabis, potential financial conflicts of interests of cannabis clinicians that may blur their clinical judgement, and the risk of compartmentalising patients' healthcare., Conclusions: Our paper raises a number of challenges with attempting to integrate cannabis clinics into the wider health system., (© 2023. The Author(s).)

Purpose: The purpose of this study was to evaluate a computerized touch-screen version of the asthma-specffic quality-of-life (cA-QOL) questionnaire against the conventional paper-and-pencil version (pA-QOL) for equivalence, time for completion, user preference, and ease of use. Methods: A total of 261 patients were recruited. A randomized cross-over design was used. Patients in group A completed the cA-QOL first while waiting to see a physician, and completed the pA- QOL version after seeing the physician. Patients allocated in group B completed these questionnaires in the reverse order. The patients were asked questions about user preference and ease of use of the cA-QOL. The time taken to complete both versions of the questionnaire was measured. Results: Weighted kappa coefficients of all items showed almost per- fect agreement. The time required to complete the pA-QOL is faster than the time for cA-QOL. The patients who preferred the cA-QOL were 37.5%, while those who preferred the pA-QOL were 29.9%. Most patients reported that the cA-QOL was "easy" or "very easy" to complete. Conclusion: The cA-QOL is the computerized equivalent of the pA-QOL. The findings herein demonstrate that the cA-QOL can be helpful to nurses in busy practices for assessing, collecting, and evaluating their patients' health related quality of life. [ABSTRACT FROM AUTHOR]

Our professional organizations have prepared this paper as part of an integrated, multidisciplinary plan to ensure the availability of well-trained practitioner teams to sustain safe, effective and high-quality rural surgical and operative delivery services. Without these robust local (or nearby) surgical services, sustaining rural maternity care is much more difficult. This paper describes the "network model" as a health human resources solution to meet the surgical needs, including operative delivery, of rural residents; outlines necessary policy directions for achieving this solution; and poses a series of enabling recommendations. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization recommends vaccination rates of 75% against seasonal influenza for patients over 65 years old. In the 2013/2014 season, the German vaccination rates ranged between 14 and 65%. This study aimed to compare the attitudes, personal characteristics and vaccination behaviours of general practitioners (GPs) in regions with high and low vaccination rates in Germany., Methods: In May 2016, a questionnaire was sent to 1594 GPs practising in 16 districts with the highest and the lowest vaccination rates in Western and Eastern Germany as described by the Central Research Institute of Ambulatory Health Care in Germany for the 2013/2014 season. Descriptive statistics and multiple regression analyses were computed to identify potential factors associated with high vaccination rates., Results: A total response rate of 32% (515/1594 participants) was observed in the study. GPs reported their attitudes towards vaccination in general and vaccination against influenza as mostly 'very positive' (80%, n = 352 and 65%, n = 288, respectively). GPs practising in regions with low vaccination rates reported their attitudes towards vaccinations in general (p = 0.004) and towards influenza vaccination (p = 0.001) more negatively than their colleagues from regions with high vaccination rates. Multiple logistic regression identified an increasing influence of year-dependent changing efficiency on GPs' influenza rates as the strongest factor for predicting GPs from highly vaccinating regions (OR = 4.31 [1.12-16.60]), followed by the patient's vaccination refusal despite GP advice due to already receiving a vaccination from another physician (OR = 3.20 [1.89-5.43]) and vaccination information gathering through medical colleagues (OR = 2.26 [1.19-4.29])., Conclusions: The results of this study suggest a correlation between GPs' attitudes and regional vaccination rates. Beneath GPs' individual attitudes, the regional attitude patterns of patients, colleagues and medical assistants surrounding those GPs seem decisive and should be integrated into future campaigns to increase vaccination rates at a regional level.

Summary: Objectives: In Austria, the general practitioner (GP) is the first point of contact for persons with health problems. Depending on the severity of the person''s medical condition, a GP may refer her or him to a secondary care hospital consultant, who reports findings back to the GP in form of a paper-based discharge letter. Researchers report that paper-based communication of medical documents between different health care providers is insufficient in quality, error prone and too slow in many cases. Our aim was to develop and to realise a strategy for a stepwise replacement of the paper-based transmission of medical documents with a distributed, shared medical record. Methods: In the first step of a three-steps strategy for development of a consistent, comprehensive and secure regional health care network, an electronic communication of discharge letters and diagnostic results between existing information systems of different health care providers in Tyrol, Austria, has been established: in the form of cryptographically signed S/MIME e-mail messages and, additionally, via a secure web portal system. In two further steps, an extension of the system by a bi-directional communication and by improvements of the web portal system is planned, leading to a comprehensive electronic patient record for shared care. Results: After realisation of step 1, in October 2004, about 3500 electronic discharge letters were sent out from the Innsbruck University Hospital (IUH), which represents about 8% of the total number of discharge letters of the IUH. In addition, a lot of feedback was received and legal, organisational, financial and methodical difficulties were overcome. Discussion: The stepwise approach to replace paper-based with electronic communication in the first step was helpful, since knowledge has been gained and cooperations were formed. For the realisation of a distributed, shared medical record (steps 2 and 3), it will not be sufficient only to replace paper-based transmission of medical documents with electronic communication technologies, but in the further steps, organisational changes will become necessary. As well, legal ambiguities must be resolved before a distributed medical record for cooperative care, used by several institutions as well as by patients, could be established. [Copyright &y& Elsevier]

As the first point of contact for patients, General Practitioners (GPs) play a crucial role in the National Health Service (NHS). An accurate primary diagnosis from the GP can alleviate the burden on specialists and reduce the time needed to re-confirm the patient's condition, allowing for more efficient further examinations. However, GPs have broad but less specialized knowledge, which limits the accuracy of their diagnosis. Therefore, it is imperative to introduce an intelligent system to assist GPs in making decisions. This paper introduces two data augmentation methods, the Complaint Symptoms Integration Method and Symptom Dot Separating Method, to integrate essential information into the Integration dataset. Additionally, it proposes a hybrid architecture that fuses the features of words from different representation spaces. Experiments demonstrate that, compared to commonly used pre-trained attention-based models, our hybrid architecture delivers the best classification performance for four common neurological diseases on the enhanced Integration dataset. For example, the classification accuracy of the BERT+CNN hybrid architecture is 0.897, which is a 5.1% improvement over both BERT and CNN with 0.846. Finally, this paper develops an AI diagnosis assistant web application that leverages the superior performance of this architecture to help GPs complete primary diagnosis efficiently and accurately. [ABSTRACT FROM AUTHOR]

The article discusses the ethical issues associated with capital punishment. It describes the position of the World Medical Association (WMA) on the role of physicians in capital punishment. The concepts of liberty, equality, utilitarianism, virtue and racial disparities, in relation to capital punishment are described. The article also explains the legal arguments on deterrence and retribution in criminal law.

The article discusses the aspirations and potential of the Academic Department of Family Medicine that was established in 2010. It says that the department aims to provide an undergraduate and postgraduate training programme to produce appropriately skilled general practitioners who can lead the primary care in transforming access and quality of health care. It also mentions that the curriculum was based on the regional distinctness of Family Medicine in African context which is formulated in the 2010 Statement of Consensus on Family Medicine in Africa.

This article seeks to establish an interactive dialogue with clinicians regarding the diagnosis and treatment of mental depression patients in practice. The goal is, over time, to create an in-clinic application of the American Psychiatric Association's guidelines, which directs physicians to select antidepressant therapy based on side effect profiles, since all agents are equal in their efficacy. Patient typing presupposes a determination of depression as a diagnosis and then seeks to highlight characteristics of the presentation, which would serve to stratify the specific antidepressant therapy most likely to provide the best outcome for the patient. Seven patient types are presented which may form the beginnings of a new construct, which will be useful in choosing the most effective treatment for a patient's specific symptoms.

The author comments on the discussion paper "Thoughts on the state of Family Medicine in South Africa" presented at 16th National Family Practitioners Conference in Cape Town. He discusses the role of family physicians in the provision of quality private medical services, clinical governance and all teaching levels within the district health system (DHS). Particular focus is given to family medicine training programme to ensure high-standard care in state health services.

Background: Gallbladder polyps are increasingly being identified due to the widespread use of abdominal ultrasound imaging. They are concerning lesions due to their potential malignant risk. It is hoped that managing them correctly will play a role in improving poor survival rates of gallbladder cancer. Awareness of these lesions is lacking. Management continues to be guided by expert opinion and observational studies and a number of consensus statements exist. Objective: This paper reviews and summarises the current literature and provides an approach for general practitioners based on the available guidance. Discussion: Although minor variation exists between consensus statements, the risk of malignancy for gallbladder polyps is still largely dictated by size, with those ≤5 mm generally considered to pose little risk and not requiring follow-up, whereas those ≥10 mm considered at greater risk and requiring referral for cholecystectomy. [ABSTRACT FROM AUTHOR]

The article discusses the significance of Electronic Health Record System over paper charts, in allowing the physician or other provider to have in hand at the time of the visit all of information known about a patient--lab results, imaging reports, correspondence from consultants, medications lists, refill histories and all the chart notes. The focus of the visit can then be on rendering a medical opinion, not on collecting missing data. In a paper-based office, crucial information is often lacking.

Despite their low cost, the use of email invitations to distribute surveys to medical practitioners have been associated with lower response rates. This research compares the difference in response rates from using email approach plus online completion rather than a mailed invitation letter plus a choice of online or paper completion. A parallel randomised controlled trial was conducted during the 11th annual wave of the nationally representative Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal survey of doctors. The control group was invited using a mailed paper letter (including a paper survey plus instructions to complete online) and three mailed paper reminders. The intervention group was approached in the same way apart from the second reminder when they were approached by email only. The primary outcome is the response rate and the statistical analysis was blinded. 18,247 doctors were randomly allocated to the control (9,125) or intervention group (9,127), with 9,108 and 9,107 included in the analysis. Using intention to treat analysis, the response rate in the intervention group was 35.92% compared to 37.59% in the control group, a difference of -1.66 percentage points (95% CI: -3.06 to -0.26). The difference was larger for General Practitioners (-2.76 percentage points, 95% CI: -4.65 to -0.87) compared to other specialists (-0.47 percentage points, 95% CI: -2.53 to 1.60). For those who supplied an email address, the average treatment effect on the treated was higher at -2.63 percentage points (95% CI: -4.50 to -0.75) for all physicians, -3.17 percentage points (95% CI: -5.83 to -0.53) for General Practitioners, and -2.1 percentage points (95% CI: -4.75 to 0.56) for other specialists. For qualified physicians, using email to invite participants to complete a survey leads to lower response rates compared to a mailed letter. Lower response rates need to be traded off with the lower costs of using email rather than mailed letters. [ABSTRACT FROM AUTHOR]

Objective: Observational studies using electronic health record (EHR) databases often face challenges due to unspecific clinical codes that can obscure detailed medical information, hindering precise data analysis. In this study, we aimed to assess the feasibility of refining these unspecific condition codes into more specific codes in a Dutch general practitioner (GP) EHR database by leveraging the available clinical free text., Methods: We utilized three approaches for text classification-search queries, semi-supervised learning, and supervised learning-to improve the specificity of ten unspecific International Classification of Primary Care (ICPC-1) codes. Two text representations and three machine learning algorithms were evaluated for the (semi-)supervised models. Additionally, we measured the improvement achieved by the refinement process on all code occurrences in the database., Results: The classification models performed well for most codes. In general, no single classification approach consistently outperformed the others. However, there were variations in the relative performance of the classification approaches within each code and in the use of different text representations and machine learning algorithms. Class imbalance and limited training data affected the performance of the (semi-)supervised models, yet the simple search queries remained particularly effective. Ultimately, the developed models improved the specificity of over half of all the unspecific code occurrences in the database., Conclusions: Our findings show the feasibility of using information from clinical text to improve the specificity of unspecific condition codes in observational healthcare databases, even with a limited range of machine-learning techniques and modest annotated training sets. Future work could investigate transfer learning, integration of structured data, alternative semi-supervised methods, and validation of models across healthcare settings. The improved level of detail enriches the interpretation of medical information and can benefit observational research and patient care., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Primary care is an essential pillar of health systems. Many countries have implemented different policies to improve access to primary care. However, persistent challenges remain. This paper offers a critical analysis of the evolution of primary care coverage in Portugal, focusing on the number of patients without an assigned general practitioner (GP)., Methods: We collected and analyzed publicly available data from 2009 to 2023 to decompose primary care coverage in three components: the number of patients enrolled in primary care units (demand-side effect), the number of GPs measured in full-time equivalent (supply-side effect), and the average number of patients on each GP's list (patient-to-GP ratio, capturing a productivity effect). We provide national and local level estimates for these three components., Results: Between 2009 and 2023, there was an overall decline in the number of patients enrolled in primary health care units. Concurrently, there was also a net decrease of GPs measured in full-time equivalent. Additionally, there was a progressive reduction in the average number of patients on each GP's list. The rise in the number of patients without an assigned GP is attributed not only to a reduction in the number of physicians, but also to a decrease in the patient load per doctor., Conclusions: Hiring additional GPs may not suffice to enhance coverage. Achieving higher coverage may imply revisiting patient load per doctor or considering alternative care models. Understanding the challenges related to GP coverage is critical for improving the efficiency of primary care., (© 2024. The Author(s).)

Background: There is a lack of understanding regarding the impact of telehealth on clinical delivery and the feasibility of sustained implementation by health services. The COVID-19 pandemic provided an ideal opportunity to identify factors related to the implementation of telehealth. This study assessed factors that influenced telehealth implementation during COVID-19 in the Western region of Victoria, Australia, from the perspectives of practice managers and general practitioners (GPs)., Methods: Employing a qualitative approach, we conducted semi-structured interviews with 14 GPs and 11 practice managers across metropolitan and rural settings in the Western region of Victoria, Australia. Interviews were conducted between December 2021 to June 2022, which included periods during and beyond the peak of the COVID-19 pandemic. Themes were synthesised using the Consolidated Framework for Implementation Research, which comprised five domains: innovation, inner setting, outer setting, individuals and implementation process. An additional domain related to billing and finances was added., Results: The innovation domain revealed that telehealth was identified by both stakeholder groups as a critical tool for improving healthcare access for vulnerable patients. GPs highlighted the role of telehealth in follow-up care and the need for extended telephone consultation services. For the implementation process, both stakeholder groups identified a shift in attitudes among GPs from reluctance to acceptance of telehealth. In terms of outer setting, constant changes in regulations posed challenges to administrative staff. Practice managers faced difficulties in acquiring information on changes, but those with robust professional networks were well supported. Initial loss of incentive funding and government-imposed billing methods posed hurdles for clinics. Both stakeholder groups highlighted the need for education around videoconference and a standardised telehealth platform., Conclusion: Evolving telehealth regulations during the emergence of COVID-19 posed financial, operational and administrative challenges to primary care clinics. To ensure sustainability, policymakers should improve stakeholder communication, set interoperability standards, and ensure sustainable funding for telehealth., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

This paper draws on qualitative research using focus groups involving 38 general practitioners (GPs). It explores their attitudes and feelings about (over-)medicalisation. Our main findings were that GPs had a complex representation of (over-)medicalisation, composed of many professional, social, technological, economic and relational issues. This representation led GPs to feel uncomfortable. They felt pressure from all sides, which led them to question their social roles and responsibilities. We identified four main GP-driven proposals to deal with (over-)medicalisation: (1) focusing on the communication in doctor-patient relationships; (2) grounding practices in evidence-based medicine; (3) relying on clinical skills, experience and intuition; and (4) promoting training, leadership bodies and social movements. Drawing on these proposals, we identify and discuss five paradigms that underpin GPs' attitudes toward (over-)medicalisation: underlying social factors, preventing medicalisation, managing uncertainties, sharing medical decision-making and thinking about care as a rationale. We suggest that these paradigms constitute a defensive posture against GPs' uncomfortable feelings. All five defensive paradigms were identified in our focus groups, echoing contemporary political debates on public health. This non-exhaustive framework forms the outline of what we call ordinary defensive medicine. GPs' uncomfortable feelings are the origin of their defensive solutions and the manifestation of their vulnerability. This professional vulnerability can be shared with the patient's vulnerability. In our view, this creates an opportunity to rediscover patient-doctor relationships and examine patients' and doctors' vulnerabilities together."There are many cases in which-though the signs of a confusion of tongues between the patient and his doctor are painfully present-there is apparently no open controversy. Some of these cases demonstrate the working of two other, often interlinked, factors. One is the patient's increasing anxiety and despair, resulting in more and more fervently clamouring demands for help. Often the doctor's response is guilt feelings and despair that his most conscientious, most carefully devised examinations do not seem to throw real light on the patient's "illness", that his most erudite, most modern, most circumspect therapy does not bring real relief." (Balint M. The Doctor, His Patient and the Illness. New York: International Universities; 2005. [1957].)"Theories about care put an unprecedented emphasis on vulnerability-taking up that challenge to transform what really counts in today's hospitals implies letting colleagues inside previously closely guarded professional boundaries" (2, our translation)., (© 2024. The Author(s).)

INTRODUCTION: There are important changes in the health care needs of women presenting to general practice in New Zealand, which prompted an evaluation of postgraduate training needs of general practitioners (GPs) who care for women in the community. AIM: To evaluate the perceived relevance of the curriculum of Otago University postgraduate programmes in women's health to GPs' work profile to identify any need for curricular change. This study was also performed to investigate the need for refresher courses or a Master's degree in obstetrics, gynaecology and women's health. METHODS: In total, 426 GPs and GP trainees who had completed the postgraduate Certificate and Diploma programmes in women's health were invited to complete an online survey. The survey consisted of multiple-choice questions with five-point Likert scale ratings to rate the relevance of papers to general practice, and options for free-text comments. RESULTS: There were 86 responses (20.2% response rate) and we analysed 73 (17.1%). Curriculum modules related to gynaecological care were rated as more relevant than obstetric and newborn care. GPs suggested more training in contraception and management of infertility, abnormal uterine bleeding and pelvic pain including procedural skills such as insertion of long-acting reversible contraceptives, implants and intrauterine devices. An interest in a refresher course was indicated by 76.6% of GPs. DISCUSSION: GPs recognised the need for enhanced training in women's gynaecological care. Revision of the postgraduate women's health curriculum and development of new refresher courses will enable GPs, trainees and prospective GPs to improve their care for women in the community. [ABSTRACT FROM AUTHOR]

Background: The adoption and use of health information technology (IT) continues to grow around the globe. In Switzerland, the government nor professional associations have to this day provided incentives for health IT adoption.Objective: We aim to assess the proportion of physicians who are routinely working with electronic health data and describe to what extent physicians exchange electronic health data with peers and other health care providers. Additionally, we aim to estimate the effect of physicians' attitude towards health IT on the adoption of electronic workflows.Methods: Between May and July 2013, we conducted a cross-sectional survey of 1200 practice based physicians in Switzerland. Respondents were asked to report on their technical means and where applicable their paper-based workarounds to process laboratory data, examination results, referral letters and physician's letters. Physicians' view of barriers and facilitators towards health IT use was determined by a composite score.Results: A response rate of 57.1% (n=685) was reached. The sample was considered to be representative for physicians in Swiss ambulatory care. 35.2% of the respondents documented patients' health status with the help of a longitudinal semi-structured electronic text record generated by one or more encounters in the practice. Depending on the task within a workflow, around 11-46% of the respondents stated to rely on electronic workflow practices to process laboratory and examination data and dispatch referral notes and physician's letters. The permanent use of electronic workflow processes was infrequent. Instead, respondents reported paper-based workarounds affecting specific tasks within a workflow. Physicians' attitude towards health IT was significantly associated with the adoption of electronic workflows (OR 1.04-1.31, p<0.05), but the effect sizes of factors related to the working environment (e.g., regional factors, medical specialty, type of practice) were larger.Conclusion: At present, only a few physicians in Swiss ambulatory care routinely work with electronic health data. Until more of their peers participate in electronic exchange of structured clinical information, most physicians will continue to stay in paper-based systems and workarounds. The survey found that physicians with a positive attitude towards health IT were more likely to adopt electronic workflows, but the impact is minor. It will likely be necessary to introduce financial incentives and develop national standards in order to promote the adoption by a critical mass of practicing clinicians. [ABSTRACT FROM AUTHOR]

Background: Exploring factors that may influence general practitioners (GPs)' intentions to remain in rural area is necessary to inform the training and placement of future medical workforce in rural area. However, little is known about how GPs' perception towards the National Compulsory Service Programme (NCSP) and job satisfaction impact their turnover intention. This paper explores GPs' intentions to remain in rural China and how their policy perception and job satisfaction predict the intentions., Methods: We conducted a cross-sectional, online survey from December 2021 to February 2022 to investigate GPs' perception towards NCSP, job satisfaction, and intentions to remain in rural area. Eligible participants were GPs who were required to provide health services as part of NCSP at township health centres of 9 provinces which could represent all NCSP GPs in China. Multinomial logistic regression analyses were performed to explore the associations between policy perceptions, job satisfaction, and intentions to remain., Results: Of 3615 GPs included in the analysis, 442 (12.2%) would like to remain in rural area and 1266 (35.0%) were unsure. Results of the multinomial logistic regression analyses showed that compared with GPs who would leave, GPs with higher perception scores for the restriction on taking postgraduate exam (RRR: 1.93, 95% CI 1.72, 2.16) and the commitment to work for six years (RRR: 1.53, 95% CI 1.31, 1.78) were more likely to remain. In contrast, GPs who had higher perception scores for completing standardised residency training (RRR: 0.75, 95% CI 0.64, 0.88) and passing National Medical Licensing Examinations (RRR: 0.74, 95% CI 0.62, 0.87) were more likely to leave. GPs who were satisfied with the freedom of choosing work methods (RRR: 1.52, 95% CI 1.25, 1.84) and chances of promotion (RRR: 1.60, 95% CI 1.32, 1.94) were more likely to remain., Conclusions: This study highlights the significance of policy perception and job satisfaction on GPs' intentions to remain in rural area. Factors such as career advancement and the empowerment of GPs to build on and use their skills and abilities should be taken into account when designing rural placement programmes., (© 2024. The Author(s).)

Introduction: In England, primary care networks (PCNs) offer opportunities to improve access to and sustainability of general practice through collaboration between groups of practices to provide care with a broader range of practitioner roles. However, there are concerns that these changes may undermine continuity of care. Our study investigates what the organisational shift to PCNs means for continuity of care., Methods: The paper uses thematic analysis of qualitative data from interviews with general practitioners and other healthcare professionals (HCPs, n = 33) in 19 practices in five PCNs, and their patients (n = 35). Three patient cohorts within each participating practice were recruited, based on anticipated higher or lower needs for continuity of care: patients over 65 years with polypharmacy, patients with anxiety or depression and 'working age' adults aged between 18 and 45 years., Findings: Patients and clinicians perceived changes to continuity in PCNs in our study. Larger-scale care provision in PCNs required better care coordination and information-sharing processes, aimed at improving care for 'vulnerable' patients in target groups. However, new working arrangements and ways of delivering care in PCNs undermine HCPs' ability to maintain continuity through ongoing relationships with patients. Patients experience this in terms of reduced availability of their preferred clinician, inefficiencies in care and unfamiliarity of new staff, roles and processes., Conclusions: New practitioners need to be effectively integrated to support effective team-based care. However, for patients, especially those not deemed 'vulnerable', this may not be sufficient to counter the loss of relationship with their practice. Therefore, caution is required in relation to designating patients as in need of, or not in need of continuity. Rather, continuity for all patients could be maintained through a dynamic understanding of the need for it as fluctuating and situational and by supporting clinicians to provide follow-up care., Patient and Public Involvement (ppi): A PPI group was recruited and consulted during the study for feedback on the study design, recruitment materials and interpretation of findings., (© 2024 The Authors. Health Expectations published by John Wiley & Sons Ltd.)