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Lyne Lalonde,1–4 Manon Choinière,3,5 Elisabeth Martin,3 Lise Lévesque,3 Éveline Hudon,2,3,6 Danielle Bélanger,2 Sylvie Perreault,1,7 Anaïs Lacasse,8 Marie-Claude Laliberté1,9 1Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada; 2Équipe de recherche en soins de première ligne, Centre de santé et de services sociaux de Laval, Laval, QC, Canada; 3Centre de recherche, Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada; 4Sanofi Aventis Endowment Chair in Ambulatory Pharmaceutical Care, Faculty of Pharmacy, Université de Montréal and Centre de santé et de services sociaux de Laval, QC, Canada; 5Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; 6Department of Family Medicine and Emergency, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; 7Sanofi Aventis Endowment Chair in Drug Utilization, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada; 8Département des sciences de la santé, Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, QC, Canada; 9AbbVie Corporation, St-Laurent, QC, Canada Purpose: There is evidence that the management of chronic non-cancer pain (CNCP) in primary care is far from being optimal. A 1-day workshop was held to explore the perceptions of key actors regarding the challenges and priority interventions to improve CNCP management in primary care. Methods: Using the Chronic Care Model as a conceptual framework, physicians (n=6), pharmacists (n=6), nurses (n=6), physiotherapists (n=6), psychologists (n=6), pain specialists (n=6), patients (n=3), family members (n=3), decision makers and managers (n=4), and pain researchers (n=7) took part in seven focus groups and five nominal groups. Results: Challenges identified in focus group discussions were related to five dimensions: knowledge gap, “work in silos”, lack of awareness that CNCP represents an important clinical problem, difficulties in access to health professionals and services, and patient empowerment needs. Based on the nominal group discussions, the following priority interventions were identified: interdisciplinary continuing education, interdisciplinary treatment approach, regional expert leadership, creation and definition of care paths, and patient education programs. Conclusion: Barriers to optimal management of CNCP in primary care are numerous. Improving its management cannot be envisioned without considering multifaceted interventions targeting several dimensions of the Chronic Care Model and focusing on both clinicians and patients. Keywords: chronic pain, community-based participatory research, health service accessibility, patient-centered care, primary health care

Ghaya Jouini,1–3 Manon Choinière,3,4 Elisabeth Martin,2,3 Sylvie Perreault,1,5 Djamal Berbiche,2,3 David Lussier,6–8 Eveline Hudon,2,3,9 Lyne Lalonde1–3,101Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada; 2Équipe de recherche en soins de première ligne, Centre de santé et de services sociaux de Laval, Laval, Quebec, Canada; 3Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada; 4Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada; 5Sanofi-Aventis Endowment Research Chair in Optimal Drug Use, Université de Montréal, Montreal, Quebec, Canada; 6Institut universitaire de gériatrie de Montréal, Montreal, Quebec, Canada; 7Division of Geriatric Medicine and Alan-Edwards Center for Research on Pain, McGill University, Montreal, Quebec, Canada; 8Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada; 9Department of Family Medicine and Emergency, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada; 10Sanofi-Aventis Endowment Research Chair in Ambulatory Pharmaceutical Care, Université de Montréal and Centre de santé et de services sociaux de Laval, Quebec, CanadaPurpose: Describe the pharmacotherapeutic management of primary-care patients with chronic noncancer pain, assess their satisfaction with pain treatment, and identify the determinants of their satisfaction.Methods: A cohort study was conducted in Quebec (Canada). Patients reporting chronic noncancer pain with an average pain intensity of at least 4 on a 0–10 scale (10= worst possible pain) and having an active analgesic prescription from a primary-care physician were recruited. They completed a telephone interview and a self-administered questionnaire to document their pain, emotional well-being, satisfaction with treatment, and barriers/beliefs/attitudes about pain and its treatment. Information on pharmacotherapy was based on an administrative provincial database and pharmacies' charts. Determinants of patients' satisfaction were identified using multivariate linear regression models.Results: Four hundred and eighty six patients participated. Their mean age was 58.4 years and they had had pain for a mean of 11.7 years (standard deviation, ±11.1) at an average pain intensity of 6.5 in the past week. Although 90% reported adverse gastrointestinal effects, 36.4% and 54.4% of these patients took no over-the-counter or prescribed medication for constipation or nausea, respectively. On a scale from 0–100, the mean overall satisfaction score was 64.7 (95% confidence interval [CI] =63.5–65.9). Patient satisfaction was low, particularly regarding the “information about pain and its treatment” (mean 50.6; 95% CI =47.6–53.7) and “treatment efficacy” (mean 53.6; 95% CI =51.5–55.6) subscales. The overall treatment satisfaction score decreased with more pain disability, probable depression and anxiety, more barriers to pain treatment, higher incidence of nausea, and use of over-the-counter analgesics.Conclusion: In primary care, patients’ level of satisfaction with their pain treatment is not optimal. This study underlines how the expanded scope of practice of community pharmacists may allow them to play a pivotal role in providing information, discussing barriers to pain treatment, and monitoring pain disability, and by appropriately managing pharmacotherapy to optimize effectiveness while minimizing adverse effects.Keywords: noncancer chronic pain, primary care, pharmacotherapy, analgesic, adverse effects, cohort study

Purpose: This study aims to describe emotional distress and quality of life (QoL) of patients at different phases of their lung cancer and the association with their family physician (FP) involvement.Methods: A prospective study on patients with lung cancer was conducted in three regions of Quebec, Canada. Patients completed, at baseline, several validated questionnaires regarding their psychosocial characteristics and their perceived level of FP involvement. Emotional distress [profile of mood states (POMS)] and QoL [European Organization for Research and Treatment of Cancer Quality of Life Core 30 (EORTC QLQ-C30)] were reassessed every 3-6 months, whether patients had metastasis or not, up to 18 months. Results were regrouped according to cancer phase. Mixed models with repeated measurements were performed to identify variation in distress and QoL.Results: In this cohort of 395 patients, distress was low at diagnosis (0.79 ± 0.7 on a 0-4 scale), raising to 1.36 ± 0.8 at the advance phase (p < 0.0001). Patient's global QoL scores significantly decreased from the diagnosis to the advance phase (from 66 to 45 on a 0-100 scale; p < 0.0001). At all phases of cancer, FP involvement was significantly associated with patients' distress (p = 0.0004) and their global perception of QoL (p = 0.0080). These associations remained statistically significant even after controlling for age, gender, and presence of metastases.Conclusions: This study provides new knowledge on patients' emotional distress and QoL with cancer evolution and, particularly, their association with FP involvement. Other studies should be conducted to further explore FP role in cancer supportive care. [ABSTRACT FROM AUTHOR]

Objective: To review short- and long-term complications associated with intraoperative rupture of benign ovarian cysts., Data Sources: The Cochrane Central Register of Controlled Trials, BIOSIS, Medline (Ovid), Web of Science, ClinicalTrials.gov, and Google Scholar were searched using the following terms and their combinations: "spillage," "rupture," "leakage," "ovarian cyst," "teratoma," "dermoid," "operative," "surgery," "outcome.", Methods of Study Selection: Randomized controlled and observational studies evaluating the operative outcomes of surgical treatment of ovarian cysts with intraoperative spillage compared with those of surgical treatment of ovarian cysts without spillage were included. A systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed., Tabulation, Integration, and Results: A total of 28 studies were included in the qualitative analysis and 12 in the quantitative analysis. Ovarian cyst diameter was not found to be associated with the risk for spillage (relative risk [RR] 0.75; 95% confidence interval [CI], -0.33 to 1.82). Intraoperative benign ovarian cyst rupture was not associated with adverse short- and long-term outcomes such as reoperation (RR 1.16; 95% CI, 0.39-3.48), infertility (RR 0.73; 95% CI, 0.15-3.63), transient fever (RR 3.22; 95% CI, 0.83-12.51), and readmission (RR 1.00; 95% CI, 0.33-2.98). However, intraoperative spillage was found to be associated with increased risk for benign recurrence (RR 3.1; 95% CI, 1.05-9.14). A subgroup analysis of the studies that included only dermoid cysts showed an association between intraoperative cyst rupture and postoperative chemical peritonitis (RR 9.36; 95% CI, 1.20-73.28)., Conclusion: Intraoperative ovarian cyst spillage of a benign cyst is associated with limited adverse clinical outcomes. Although the surgical approach (minimally invasive vs open) should not be affected by the concern regarding an intraoperative cyst rupture, maximal efforts should be made to prevent intra-abdominal spillage., (Crown Copyright © 2020. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this work is to evaluate the place of new treatments in the management of endometriosis outside the context of infertility., Methods: A review of the literature was conducted by consulting Medline data until July 2017., Results: Dienogest is effective compared to placebo in short term (NP2) and long term (NP4) for the treatment of painful endometriosis. In comparison with GnRH agonists, dienogest is also effective in terms of decreased pain and improved quality of life in non-operated patients (NP2) as well as for recurrence of lesions and symptomatology postoperatively (NP2). Data on GnRH antagonists, selective progesterone receptor modulators as well as selective inhibitors (anti-TNF-α, matrix metalloprotease inhibitors, angiogenesis growth factor inhibitors) are insufficient to provide evidence of interest in clinical practice for the management of painful endometriosis (NP3)., Conclusion: Dienogest is recommended as second-line therapy for the management of painful endometriosis (Grade B). Because of lack of evidence, aromatase inhibitors, elagolix, SERM, SPRM and anti-TNF-α are not recommended for the management of painful endometriosis (Grade C)., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Objective: To assess a selection of psychometric properties of the TRANSIT indicators., Design: Using medical records, indicators were documented retrospectively during the 14 months preceding the end of the TRANSIT study., Setting: Primary care in Quebec, Canada., Participants: Indicators were documented in a random subsample (n = 123 patients) of the TRANSIT study population (n = 759)., Interventions: For every patient, the mean compliance to all indicators of a category (subscale score) and to the complete set of indicators (overall scale score) were established. To evaluate test-retest and inter-rater reliabilities, indicators were applied twice, two months apart, by the same evaluator and independently by different evaluators, respectively. To evaluate convergent validity, correlations between TRANSIT indicators, Burge et al. indicators and Institut national d'excellence en santé et en services sociaux (INESSS) indicators were examined., Main Outcome Measures: Test-retest reliability, inter-rater reliability, and convergent validity., Results: Test-retest reliability, as measured by intraclass correlation coefficients (ICCs) was equal to 0.99 (0.99-0.99) for the overall scale score while inter-rater reliability was equal to 0.95 (0.93-0.97) for the overall scale score. Convergent validity, as measured by Pearson's correlation coefficients, was equal to 0.77 (P < 0.001) for the overall scale score when the TRANSIT indicators were compared to Burge et al. indicators and to 0.82 (P < 0.001) for the overall scale score when the TRANSIT indicators were compared to INESSS indicators., Conclusions: Reliability was excellent except for eleven indicators while convergent validity was strong except for domains related to the management of CVD risk factors., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: Facilitation is a powerful approach to support practice change. The purpose of this study is to better understand the facilitation roles exercised by both external facilitators and interprofessional facilitation teams to foster the implementation of change. Building on Dogherty et al.'s taxonomy of facilitation activities, this study uses an organizational development lens to identify and analyze facilitation roles. It includes a concise definition of what interprofessional facilitation teams actually do, thus expanding our limited knowledge of teams that act as change agents. We also investigate the facilitation dynamics between change actors., Methods: We carried out a qualitative analysis of a 1-year process of practice change implementation. We studied four family medicine groups, in which we constituted interprofessional facilitation teams. Each team was supported by one external facilitator and included at least one family physician, one case manager nurse, and health professionals located on or off the family medicine group's site (one pharmacist, plus at least one nutritionist, kinesiologist, or psychologist). We collected our data through focus group interviews with the four teams, individual interviews with the two external facilitators, and case audit documentation. We analyzed both predetermined (as per Dogherty et al., 2012) and emerging facilitation roles, as well as facilitation dynamics., Results: A non-linear framework of facilitation roles emerged from our data, based on four fields of expertise: change management, project management, meeting management, and group/interpersonal dynamics. We identified 72 facilitation roles, grouped into two categories: "implementation-oriented" and "support-oriented." Each category was subdivided into themes (n = 6; n = 5) for clearer understanding (e.g., legitimation of change/project, management of effective meetings). Finally, an examination of facilitation dynamics revealed eight relational ties occurring within and/or between groups of actors., Conclusions: Facilitation is an approach used by appointed individuals, which teams can also foster, to build capacity and support practice change. Increased understanding of facilitation roles constitutes an asset in training practitioners such as organizational development experts, consultants, facilitators, and facilitation teams. It also helps decision makers become aware of the multiple roles and dynamics involved and the key competencies needed to recruit facilitators and members of interprofessional facilitation teams.

We examined social and physical violence experienced by American Indian/Alaska Native (AI/AN) women in prostitution and their impacts on the mental and physical health of 105 women (81% Anishinaabe, mean age = 35 years) recruited through service agencies in three Minnesota cities. In childhood, abuse, foster care, arrests, and prostitution were typical. Homelessness, rape, assault, racism, and pimping were common. The women's most prevalent physical symptoms included muscle pain, impaired memory or concentration, and headaches. Symptoms of post-traumatic stress disorder and dissociation were common, with more severe psychological symptoms associated with worse health. Most of the women wanted to leave prostitution and they most often identified counseling and peer support as necessary to accomplish this. Most saw colonization and prostitution of AI/AN women as connected.

Implementing interprofessional collaborative practices in primary care is challenging, and research about its facilitating factors remains scarce. The goal of this participatory action research study was to better understand the driving forces during the early stage of the implementation process of a community-driven and patient-focused program in primary care titled "TRANSforming InTerprofessional cardiovascular disease prevention in primary care" (TRANSIT). Eight primary care clinics in Quebec, Canada, agreed to participate by creating and implementing an interprofessional facilitation team (IFT). Sixty-three participants volunteered to be part of an IFT, and 759 patients agreed to participate. We randomized six clinics into a supported facilitation ("supported") group, with an external facilitator (EF) and financial incentives for participants. We assigned two clinics to an unsupported facilitation ("unsupported") group, with no EF or financial incentives. After 3 months, we held one interview for the two EFs. After 6 months, we held eight focus groups with IFT members and another interview with each EF. The analyses revealed three key forces: (1) opportunity for dialogue through the IFT, (2) active role of the EF, and (3) change implementation budgets. Decision-makers designing implementation plans for interprofessional programs should ensure that these driving forces are activated. Further research should examine how these forces affect interprofessional practices and patient outcomes.

Objective: To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care., Design: Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices., Setting: Three regions of Quebec., Participants: Health care professionals and staff of 5 PC practices., Methods: Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed., Main Findings: The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters., Conclusion: Irrespective of their models, PC practices' pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care., (Copyright© the College of Family Physicians of Canada.)

Objective: To evaluate the link between the quantity and quality of continuing professional development (CPD) activities completed by family physicians in Quebec and the quality of their practice., Design: Retrospective analysis of data collected during professional inspection visits (PIVs)., Setting: Quebec., Participants: Three groups were created from among Quebec family physicians who had been subject to PIVs (peer evaluation) by the Collège des médecins du Québec between 1998 and 2005. Group 1 was composed of physicians who were members of the College of Family Physicians of Canada, which requires participation in 250 hours of CPD in every 5-year cycle. Group 2 was composed of family physicians who were not members of the College of Family Physicians of Canada but who had declared at least 50 hours a year of CPD on their Collège des médecins du Québec annual notice of assessment for the same period. Group 3 was composed of family physicians who had declared fewer than 10 hours of CPD a year., Main Outcome Measures: During the PIV, the following characteristics were examined: record keeping, quality and number of hours of CPD activities, and quality of professional practice based on 3 components- clinical investigation, accuracy of diagnosis, and appropriateness of treatment plan and follow-up., Results: The factors associated with a high quality of practice were privileges in a hospital or local community health centre (institution) and a substantial number of accredited CPD hours (Mainpro-M1, Credit I, or Mainpro-C). The factors associated with a poor quality of practice were advanced age of the physician, absence of privileges in an institution (hospital or local community health centre), and participation in CPD activities that were more informal, such as reading and non-accredited activities (Mainpro-M2)., Conclusion: This study supports earlier research showing that CPD activities of sufficient quality and quantity are correlated with a high quality of professional practice by family physicians.

Background: In Canada, many health authorities recommend that primary care physicians (PCP) stay involved throughout their patients' cancer journey to increase continuity of care. Few studies have focused on patient and physician expectations regarding PCP involvement in cancer care., Objective: To compare lung cancer patient, PCP and specialist expectations regarding PCP involvement in coordination of care, emotional support, information transmission and symptom relief at the different phases of cancer., Design: Canadian survey of lung cancer patients, PCPs and cancer specialists, Participants: A total of 395 patients completed questionnaires on their expectations regarding their PCP participation in several aspects of care, at different phases of their cancer. Also, 45 specialists and 232 community-based PCP involved in these patients' care responded to a mail survey on the same aspects of cancer care., Results: Most specialists did not expect participation of the PCP in coordination of care in the diagnosis and treatment phases (65% and 78% respectively), in contrast with patients (83% and 85%) and PCPs (80% and 59%) (p < 0.0001). At these same phases, the best agreement among the 3 groups was around PCP role in emotional support: 84% and more of all groups had this expectation. PCP participation in symptom relief was another shared expectation, but more unanimously at the treatment phase (p = 0.85). In the advanced phase, most specialists expect a major role of PCP in all aspects of care (from 81% to 97%). Patients and PCP agree with them mainly for emotional support and information transmission., Conclusion: Lung cancer patient, PCP and specialist expectations regarding PCP role differ with the phase of cancer and the specific aspect of cancer care. There is a need to reach a better agreement among them and to better define PCP role, in order to achieve more collaborative and integrated cancer care.

Background: Collaborative practices allow physicians and pharmacists to comanage pharmacotherapy to maximize the benefits of medication regimens. The Trial to Evaluate an Ambulatory primary care Management program for patients with dyslipidemia (TEAM) study compared the efficacy of a physician-pharmacist collaborative primary care (PPCC) intervention, where pharmacists requested laboratory tests and adjusted medication dosage, to the usual care (UC) for patients under treatment with lipid-lowering medication., Objective: In a qualitative study nested within the TEAM study, the perceptions of physicians, pharmacists, and patients regarding the PPCC model, interprofessional collaboration, and the clinicians' willingness to implement the model in their practice were explored., Methods: In the area of Montreal (Quebec, Canada), TEAM study participants assigned to the PPCC group were invited to participate. Individual semistructured interviews with physicians (n=7) and 2 six-member focus groups with pharmacists (n=12) and patients (n=12) were analyzed using a phenomenological approach., Results: The vast majority of participants reported PPCC was more structured and systematic than the UC they had received previously, wherein physicians prescribe and adjust pharmacotherapy and pharmacists provide the counseling and dispense medications. Many patients felt they received better follow-up and reported being reassured and well informed, making them more inclined to care for themselves better. These feelings were attributed largely to the pharmacists' accessibility and ability to communicate with them easily. Given the physician shortage, physicians perceived interprofessional collaboration as almost inevitable. They considered PPCC to be safe and effective. However, obstacles were also identified. Physicians were concerned that it might alter their special relationship with patients and threaten their overall medical follow-up. Pharmacists felt enthusiastic about their new role, but found PPCC time consuming and thought it might not be applicable to all the patients., Conclusions: PPCC model was highly appreciated by patients, and clinicians saw it as beneficial to patients. However, several obstacles still have to be overcome before the model can be implemented in the current health care context., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Few studies have reported the efficacy of collaborative care involving family physicians and community pharmacists for patients with dyslipidemia., Methods: We randomly assigned clusters consisting of at least two physicians and at least four pharmacists to provide collaborative care or usual care. Under the collaborative care model, pharmacists counselled patients about their medications, requested laboratory tests, monitored the effectiveness and safety of medications and patients' adherence to therapy, and adjusted medication dosages. After 12 months of follow-up, we assessed changes in low-density lipoprotein (LDL) cholesterol (the primary outcome), the proportion of patients reaching their target lipid levels and changes in other risk factors., Results: Fifteen clusters representing a total of 77 physicians and 108 pharmacists were initially recruited, and a total of 51 physicians and 49 pharmacists were included in the final analyses. The collaborative care teams followed a total of 108 patients, and the usual care teams followed a total of 117 patients. At baseline, mean LDL cholesterol level was higher in the collaborative care group (3.5 v. 3.2 mmol/L, p = 0.05). During the study, patients in the collaborative care group were less likely to receive high-potency statins (11% v. 40%), had more visits with health care professionals and more laboratory tests, were more likely to have their lipid-lowering treatment changed and were more likely to report lifestyle changes. At 12 months, the crude incremental mean reduction in LDL cholesterol in the collaborative care group was -0.2 mmol/L (95% confidence interval [CI] -0.3 to -0.1), and the adjusted reduction was -0.05 (95% CI -0.3 to 0.2). The crude relative risk of achieving lipid targets for patients in the collaborative care group was 1.10 (95% CI 0.95 to 1.26), and the adjusted relative risk was 1.16 (95% CI 1.01 to 1.34)., Interpretation: Collaborative care involving physicians and pharmacists had no significant clinical impact on lipid control in patients with dyslipidemia. International Standard Randomized Controlled Trial register no. ISRCTN66345533.

Introduction: In a physician-pharmacist collaborative-care (PPCC) intervention, community pharmacists were responsible for initiating lipid-lowering pharmacotherapy and adjusting the medication dosage. They attended a 1-day interactive workshop supported by a treatment protocol and clinical and communication tools. Afterwards, changes in pharmacists' knowledge, their skills, and their satisfaction with the workshop were evaluated., Methods: In a descriptive study nested in a clinical trial, pharmacists assigned to the PPCC intervention (n = 58) completed a knowledge questionnaire before and after the workshop. Their theoretical skills were evaluated with the use of a vignette approach (n = 58) after the workshop and their practical skills were assessed by direct observation with study patients (n = 28)., Results: The mean (SD) overall knowledge score was 45.8% (12.1%) before the workshop; it increased significantly to 89.3% (8.3%) afterwards (mean difference: 43.5%; 95% CI: 40.3%-46.7%). All the pharmacists had an overall theoretical-skill score of at least 80%, the minimum required to apply the PPCC in the trial. From 92.9% to 100% of the pharmacists' interventions with study patients complied with the treatment protocol., Discussion: In primary care, a short continuing-education program based on a specific treatment protocol and clinical tools is necessary and probably sufficient to prepare pharmacists to provide advanced pharmaceutical care.

The purpose of the study was to analyze the development of nursing practice in family medicine groups (FMGs). The two-year case study consisted of 73 semi-directed interviews ofnurses, physicians and managers in five FMGs. The findings led to three main observations: nursing practice varies considerably from one FMG to another, the development of nurses' practice seems to be associated with the development of a collaborative relationship, and the satisfaction of the professionals in the FMG, nurses in particular, depends on the type of practice. It is important to implement measures to encourage the optimal use ofnurses' skills in a FMG.

Objective: To explore terminally ill patients' perceptions of their own suffering in order to describe, from these patients' perspective, some elements of health care providers' response to suffering., Design: Qualitative study using content analysis methods suited to a grounded theory approach., Setting: Teaching and nonteaching hospital oncology clinics, palliative care services (both ambulatory and in-unit), and family practices., Participants: Twenty-six patients diagnosed with terminal cancer., Methods: Interviews were audiotaped and transcribed verbatim. Data from each interview were coded and categorized to identify and define themes. Themes were discussed and refined until those rating them agreed on them. Data were collected until saturation of emerging issues was reached., Main Findings: In our health care system, patients are caught in a pervasive pattern of suffering avoidance, which in turn contributes to increased suffering. Health care services are perceived as a battlefield where physicians and patients are engaged in a losing struggle to ward off illness and death. Both physicians and patients engage in avoiding skepticism and muffling distress. The unavoidable avowal of powerlessness in the face of terminal disease is perceived as capitulation and therapeutic abandonment. Budgetary restraints and understaffing, along with a pervasive culture that implicitly denies death, produce an environment conducive to the avoidance of suffering. To counter this, health care practices that foster increased overlap and continuity between the spheres of oncology, palliative care, and family medicine seem worth developing., Conclusion: The suffering of gravely ill patients might be hard to alleviate in the context of modern health care organizations. In some cases, health care delivery directly contributes to increased suffering. Providing support while also helping patients and their families to face upcoming harsh realities is a delicate balancing act that needs to be further explored.

The essential mandate of medicine is the relief of suffering. However, the quest for an integrated model towards a conceptualization of suffering is still ongoing and empirical studies are few. Qualitative inquiry using 31 in-depth interviews and content analysis was carried out between 1999 and 2001 in 26 patients diagnosed with terminal cancer. The suffering experience was described through a multiplicity of heterogenous elements from the physical, psychological, and social spheres. Systematic synthesis of interview material yielded three apparently irreducible core dimensions. Respondents defined their suffering in terms of 1) being subjected to violence, 2) being deprived and/or overwhelmed, and 3) living in apprehension. Cassell wrote, in 1991, that to know the suffering of others demands an exhaustive understanding of what makes them the individuals they are (1). Our model can be of use in structuring and eliciting this necessary information. Understanding how a particular patient feels harmed, deprived or overburdened, and overtaken by fear, provides a lever for action tailored to the specifics of that person's experience.

Objective: To determine the nature of inaccuracies likely to occur when standardized patients (SPs) are used to measure physician behaviour and to evaluate the potential impact of these inaccuracies on estimates of physician performance., Design: Secondary analysis from a randomized controlled trial., Setting: Family physicians' offices., Study Participants: Eighteen individuals, each portraying one of two patient scenarios, made a total of 179 visits to 92 family physicians who were participating in a separate randomized controlled trial to evaluate the impact of an educational workshop on implementation of preventive guidelines., Main Outcome Measures: Accuracy of SPs' portrayal of the assigned scenarios and accuracy of their coding of physician performance, determined on the basis of audiotapes of the visits and correlated with indicators of physicians' preventive practices., Results: Accuracy of portrayal of the patient scenario was 84.8% for the male SPs and 93.5% for the female SPs. Inaccuracies in portrayal had no impact on physician performance scores. Accuracy of coding of physician performance was 90.5% for the female SPs (kappa = 0.66) and 90.1% for the male SPs (kappa = 0.68). Coding inaccuracies occurred most frequently for assessment of alcohol consumption and advice against smoking., Conclusion: SPs can provide valid information about physicians' professional performance. However, standardization of their activities must not be taken for granted. It may be more difficult to obtain standardized coding for counselling activities, an aspect of physician visits for which SPs are particularly appropriate.

Background: Educational interventions that support the implementation of complex clinical practice guidelines (CPGs) require substantial time commitments from participants. We conducted a comparative study to evaluate if a 90-minute workshop would increase compliance with the recommendations of the Canadian Task Force on Preventive Health Care as well as decrease the ordering of tests not the subject of specific recommendations., Methods: Eighty-seven family physicians from Quebec participated in the study. Group assignment was initially randomized, but, owing to logistic problems, randomization was not maintained. After unannounced visits, 2 standardized patients coded the physicians' performance of 23 items recommended for inclusion in the periodic health examination (10 for men and 13 for women) and 8 items recommended for exclusion (4 for both men and women). The "exposed" physicians were visited within 4 to 6 months after the workshop. The "nonexposed" physicians were visited within 4 to 6 months after consent was obtained but before they attended the workshop. We used linear regression analysis to determine if exposure to the workshop resulted in improved performance., Results: Exposure to the workshop was not associated with a difference in the adjusted mean score for items recommended for inclusion (12.07 for exposed physicians v. 12.35 for those not exposed; maximal and ideal score 23; r = -0.28; 95% confidence interval [CI] = -1.63 to 1.08). However, workshop exposure was associated with lower adjusted mean scores for items recommended for exclusion (1.55 v. 3.17; maximal score 8, ideal score 0; r = -1.63; 95% CI = -2.50 to -0.75) and for other tests (3.59 v. 6.53; r = -2.95; 95% CI = -5.10 to -0.79)., Interpretation: A short workshop can decrease the ordering of unnecessary screening tests by family physicians. Given its low cost and its potential for general application, such an intervention can support the implementation of prevention CPGs.

Background: Clinical practice guidelines, such as those of the Canadian Task Force on Preventive Health Care, although based on sound evidence, may conflict with the perceived needs and expectations of patients and physicians. This may jeopardize the implementation of such guidelines. This study was undertaken to explore patients' and family physicians' acceptance of the task force's recommendations and the values and criteria upon which the opinions of these 2 groups are based., Methods: Focus groups were used to collect study data. In total, 35 physicians (in 7 groups) and 75 patient representatives (in 9 groups) participated in the focus groups. An inductive approach was used to develop coding grids and to generate themes from the transcripts of the interviews., Results: Physicians expressed resistance to discontinuing the annual check-up, which they viewed as an organizational strategy to counteract the many barriers to preventive care that they encounter. They reported difficulties in explaining to their patients the recommendations of the Canadian Task Force on Preventive Health Care, which they found complex and inconsistent with popular wisdom. Both patients and physicians attributed high value to the detection of insidious diseases, even in the absence of proof of the effectiveness of such activity., Interpretation: The patients and family physicians who participated in this study shared many opinions on the value of preventive activities that depart from the values used by "prevention experts" such as the Canadian Task Force on Preventive Health Care in establishing their recommendations. A better understanding of the values of patients and physicians would help guideline developers to create better targeted communication strategies to take these discrepancies into account.

A sensitive and specific radioimmunoassay for a novel luteinizing-hormone-releasing-hormone (LHRH) agonist, [2-Me-D-Trp6, DesGly10]LHRH ethylamide (meterelin), was developed for documenting the pharmacokinetic parameters of this peptide following its intravenous (iv) and subcutaneous (sc) administration in dogs. The assay was also used for monitoring meterelin in plasma following its release from d,l-lactide-glycolide implants in the same species. Rabbit antisera generated against [DespyroGlu1] meterelin and conjugated to bovine serum albumin with glutaraldehyde showed high specificity, whereas crossreactivity to LHRH and its fragments and to analogs with substitutions at residues 6 and 10 was found insignificant. The assay was validated in terms of accuracy (recovery range, 94.0-105.4%), in terms of precision (intra- and interassay variations of 10.0-12.4% and 8.6-11.3%, respectively), and in terms of sensitivity (minimum detectable dose of 2.7 pg/assay). Following iv acute administration, a biexponential decline of plasma meterelin levels was observed, with distribution and elimination half-lives of 5.9 +/- 2.5 and 106 +/- 22 min, respectively. After sc acute administration, the elimination half-life was in the range of 103 to 173 min. The systemic clearance (CLT) ranged from 1.6 to 2.6 mL/min/kg, and the volume of distribution at steady state (Vdss) varied from 285 to 438 mL/kg. The elimination half-life (T1/2 beta), Vdss, and ClT were not significantly different after both routes of administration over the 1-100-microgram/kg dose range of peptide studied. Castrate levels of testosterone were attained 10 days after sc administration of the implant, lasted for up to 247 days, and were well correlated with plasma levels of meterelin.

The results of a population-based survey of 170 children's vaccination records were used to calculate the cumulative distributions of the ages (in months) at which each dose of vaccine had been received. Considerable delays in the administration of measles-mumps-rubella (MMR) vaccine and of the fourth dose of diphtheria-pertussis-tetanus vaccine were observed, particularly in children vaccinated by private physicians rather than at public health clinics. The delay before MMR vaccination causes concern because of the frequency of measles in children aged 1 to 2 years, particularly those attending day-care centres, and the fragility of the herd immunity against this disease. Physicians should follow up patients who have missed appointments for MMR vaccination if a voluntary measles control program is to succeed.