Clinical practice guidelines. New-to-practice family physicians' attitudes

OBJECTIVE

To examine the attitudes toward clinical practice guidelines of a group of family physicians who had recently entered practice in Ontario, and to compare them with the attitudes of a group of internists from the United States.

DESIGN

Mailed questionnaire survey of all members of a defined cohort.

SETTING

Ontario family practices.

PARTICIPANTS

Certificants of the College of Family Physicians of Canada who received certification in 1989, 1990, and 1991 and who were practising in Ontario. Of 564-cohort members, 395 (70%) responded. Men (184) and women (211) responded at the same rate.

MAIN OUTCOME MEASURES

Levels of agreement with 10 descriptive statements about practice guidelines and analyses of variance of these responses for several physician characteristics.

RESULTS

Of respondents in independent practice, 80% were in group practice. Women were more likely to have chosen group practice, in which they were more likely to use practice guidelines than men. Generally favourable attitudes toward guidelines were observed. Physician characteristics occasionally influenced agreement with the descriptors. The pattern of agreement was similar to that noted in the study of American internists, but, in general, Ontario physicians were more supportive.

CONCLUSIONS

This group of relatively new-to-practice Ontario family physicians shows little resistance to guidelines and appears to read less threat of external control in them than does the US group.

Medicine and the Canadian state: from the politics of conflict to the politics of accommodation?

This paper analyzes data from three large-scale surveys of Canadian physicians conducted over the past decade to examine the politics of a cohort of recently established family physicians in Ontario, and to assess the extent to which these politics represent a "softening" of professional resistance to government health insurance. Politically, this is an important cohort because the physicians in it have grown up without any firsthand knowledge of the pre-Medicare period, and because they are among the first to establish practices in the wake of the month-long 1986 Ontario physicians' strike, a high point of profession-government conflict. Factors which may have contributed to a moderation of medical politics include the progressive entry of women into medicine. Our data suggest that professional opposition to Medicare is declining and that fewer physicians support a return to voluntary and commercial control of the health system, a shift which could assist in breaking the historical cycle of profession-government conflict and moving to the politics of accommodation. In the conclusions we discuss implications for medical politics in Canada and other countries such as the United States.

Gender differences in practice patterns of Ontario family physicians (McMaster medical graduates)

This study examined the extent to which physician gender influences practice patterns. Data came from the Ontario Hospital Insurance Plan billing profiles of general practitioner and family medicine graduates of McMaster University School of Medicine. The women physicians studied were more likely to be certified in family medicine than the men and a higher proportion of their patients were female. Women were more likely to be working part time, billed during fewer months of the year, earned less, and saw fewer patients. They provided greater numbers of services in psychotherapy and counselling and ordered more laboratory tests; associated with this were higher costs per service and per patient. Women offered a less diverse mix of services than men. They provided fewer hospital, emergency room, and intrapartum services and a lower proportion of women included house calls, after-hours work, hospital, emergency room, surgical or intrapartum services in their service mix. Thus these women appeared more likely to restrict their practices to the office setting and to provide a higher proportion of psychosocial care. The overall impact of these sex differences in practice patterns on the health care system requires further exploration.

Laboratory Tests: Which Physicians Order More?: How women's practices differ from men's

The authors examined OHIP billings for 1986 for 644 primary care physicians who graduated between 1972 and 1983. Women tended to order more laboratory services than men and had a higher mean monthly cost of laboratory service per patient. These differences are correlated with practice features related to physicians, such as proportion of total work done in the office, proportion of patients who are women aged 15 to 49, and proportion of the physician's practice that is psychotherapeutic. The practices of men and women differ in these features.

Female and Male Physicians: Different Practice Profiles: Will increasing numbers of female GPs affect practice patterns of the future?

In a descriptive study using provincial billing profiles, women physicians were found to perform fewer services, see fewer patients, and earn less. Their practices included relatively more female patients and were less likely to include emergency room duty, assists at technical or surgical procedures, visits outside the office, obstetrical care, or after-hours services. Women provided more psychotherapy and counseling, ordered more laboratory tests, and generated higher laboratory costs than the men.

Career interruptions and hours practiced: comparison between young men and women physicians

This study compares current level of workforce participation and number, type and length of career interruptions since entering medical school reported by young men and women physicians. By 10 years from medical school entry, one third of the women studied had taken a maternity/child care leave and 24% had taken time away from their careers for other reasons while only 11% of men had interrupted their careers. The average time taken and reasons given for non-maternity-related career interruption were similar for men and women. Both men and women in the types of medical careers that historically have attracted more women work shorter hours than those in medical career types where women are under-represented. Across career types, women worked shorter hours per week than men and the presence of children further reduced hours of work for women only. Although the women studied are more active professionally than previous generations during their childbearing/rearing years, a considerable gap in the participation level remains.

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.

Men and women choose different careers in medicine: causes and consequences

WOMEN MEDICAL GRADUATES OF MCMASTER UNIVERSITY WERE DIVIDED INTO TWO GROUPS: those in the fields traditionally chosen by women (primary care, general internal medicine, pediatrics, psychiatry, and anesthesia), and those in nontraditional fields (surgery, subspecialties of medicine, and academic medicine). The careers of the two groups of women were then compared with matched groups of men physicians. More women choosing traditional careers worked in another field, frequently health-related, before deciding to enter medicine than women entering nontraditional careers. Fewer of the former had a university education in the natural sciences, and more of them were married at the start of post-graduate training. Both groups of women worked shorter hours than the comparison groups of men. More women in traditional careers had selected group practice than had the corresponding men. Influences on career choices showed more sex similarities than career-type similarities, with women influenced more by factors related to family responsibilities. Few in any group reported that their choices are not their preferences. The results suggest that complete convergence of the medical careers of men and women in the near future is unlikely.

Career choices of McMaster University medical graduates and contemporary Canadian medical graduates

The MD program at McMaster University, Hamilton, Ont., differs from that at most other Canadian universities in the profile of students admitted and in its teaching methods. To investigate influences of selection policy outcomes and the education program, the career choices of 408 McMaster graduates were compared with those of 1620 graduates of other Canadian English-language schools by analysis of data from the CMA's Physician Manpower Data Bank. Compared with graduates of other schools, McMaster graduates were more likely to have chosen internal medicine, less likely to have chosen surgery and equally likely to have chosen primary care as their medical field. Of those in primary care, a higher proportion of McMaster graduates than other graduates held certification in family medicine. This was largely responsible for the overall higher rate of certification in the McMaster group. While the nature of practice and time spent on patient care did not differ between the two groups, several variables, including time spent on professional activities other than patient care, proportion involved in research and classroom teaching, and proportion of salaried physicians employed by universities, indicated a higher than average level of interest in academic medicine among the McMaster graduates. This could be partially explained by differences in the student profile if students who are interested in education are more likely to choose an educationally innovative medical school.

Specific binding of [3H]oxytocin in the female rat brain

Because of demonstrated effects of oxytocin on some limbic system mediated behaviours, the specific binding of [3H]oxytocin to a plasma membrane containing fraction of rat limbic tissue has been studied. The binding of the microsomal fraction of estrogenized, female rat tissue was time dependent and saturable, with a Bmax of 2.5 X 10(-13) moles per milligram of protein and an apparent KD of 3.53 X 10(-8)M, and appeared to show positive cooperativity. The pH optimum of the binding was 6.0, close to the pH optimum for oxytocin-neurophysin binding; however, other results show the two types of binding to be different. The microsomal fraction did not appreciably degrade oxytocin under the conditions used for [3H]oxytocin binding. The distribution in limbic tissue of oxytocin-degrading activity and of individual enzymes capable of degrading oxytocin has been examined and an interplay of enzymes concentrated in different cell types is proposed.

Does premedical academic background influence medical graduates' perceptions of their medical school or their subsequent career paths and decisions?

A survey of McMaster University's first six medical classes (1972-1977) has shown that neither completion of the science courses that are usually required for admission to other medical schools nor achievement of high grades in premedical studies has an important impact on graduates' perceptions of the medical curriculum or on their evaluation of their preparation for the first year of postgraduate training in comparison to other trainees. No influence of either premedical science background or grade point average was detected on career choices in relation to field of medicine entered, level of specialization, location and type of practice, or on factors influencing these choices.

The content of the medical curriculum at McMaster University: graduates' evaluation of their preparation for postgraduate training

This paper describes McMaster University medical graduates' perceptions of how well their medical curriculum prepared them for postgraduate training. The graduates view their overall preparation for postgraduate work as sound. These perceptions were compared with independent assessments by internship supervisors for one graduated class. The graduates suggest their preparation for postgraduate work differs somewhat from fellow interns. Graduates reported feeling very well prepared compared to fellow postgraduate trainees in independent learning, self-evaluation and problem solving skills. They also judge their preparation in data gathering skills, behavioural science knowledge, ability to deal with social and emotional problems of patients, medical record keeping skills, preventive, follow-up and in-patient care as very good compared to peers. They identified two content areas, pharmacology and the basic medical sciences, as requiring more attention in the curriculum. These findings are discussed and related to the approach to medical education at McMaster University.

Career development of McMaster University medical graduates and its implications for Canadian medical manpower

A study was undertaken of the career paths and decisions, and the factors influencing the decisions, of the first six graduating classes of McMaster University's medical school. Climate and geography, preference for urban or rural living and influence of spouse were the factors that most influenced the location of practice, although the graduates who moved to the United States considered economic factors important too. Nearly one third of the specialists were practising in the United States. Personal challenge and positive clinical experience in the field were the major influences on choice of medical field. Graduates entering a specialty were more likely than those entering primary care to consider encouragement of others, a positive example set by medical school faculty members, working hours and research experience in the field as important influences on their choice of medical field. Data are needed on the career decisions, and the factors affecting them, of the graduates of all Canadian medical schools if Canadian medical manpower planning is to be realistic.

Influence of oxytocin on human memory processes: validation by a control study

An earlier report (1) of an adverse effect of high doses of oxytocin on human memory included results of studies on women receiving oxytocin as part of the treatment to induce 2nd trimester therapeutic abortion. These women served as their own controls. We have now been able to study a group of women who have been treated in all ways like the original group, with the exception that they did not receive oxytocin. The results from this external control corroborate the finding that oxytocin affected memory.

Career choices, work patterns and perceptions of undergraduate education of McMaster medical graduates: comparison between men and women

A survey of the first six classes to graduate from McMaster University's medical school was carried out 5 years after graduation for the classes of 1972 to 1974 and 2 years after graduation for the classes of 1975 to 1977. Although the men and women entered similar fields of medicine the women were more likely to have taken time away from work and to be working fewer hours, and more women than men were influenced by their spouses in their career choices. More women than men expressed some dissatisfaction with the 3-year undergraduate program, and more women identified the "anxiety level created" as a weakness of the program. The women compared their preparation for the first year of postgraduate training with that of other trainees somewhat less favourably than did the men.

Perspectives of graduates two or five years after graduation from a three-year medical school

The 1970s have been described as an era of the rise and fall of three-year medical school programs. The present paper describes how graduates of one of the few North American medical schools that has retained its three-year curriculum view the problem-based curriculum and its length. On the whole the graduates of McMaster University School of Medicine were very positive about their undergraduate medical education. Many more of its features were endorsed as strengths than deficiencies. Eighty-two percent of McMaster graduates reported they would enroll in a three-year curriculum if they were entering medical school again, and they said that the advantages of a three-year curriculum outweight its disadvantages. The majority of graduates would return to a problem-based medical curriculum: 58 percent to an unaltered curriculum, 3 percent to one altered slightly, and 8 percent to one spread over four years. Of those that would not return, most chose a somewhat more structured curriculum, while very few chose traditional curricula.

Action of oxytocin on mammary gland: influence of hypotonicity

The enhancement of the response of an isolated strip of lactating mouse mammary gland to oxytocin, resulting from dilution of the Tyrode solution in which oxytocin is administered, is due to the effects of hypotonicity per se and not to changes in concentration of any of the ions in the bathing solution. Inhibition of membrane ATPase also causes an enhancement, which is probably due to activation of a secondary facilitating mechanism, rather than to enhancement of the entire train of oxytocin-induced reactions. A variety of conditions which alter the response to oxytocin have the same effect on the response to acetylcholine. Hypotonicity can therefore increase the sensitivity of this bioassay for oxytocin, but not its selectivity.

Glutathione-insulin transhydrogenase activity in pregnant mouse mammary gland: hormonal influences studied in tissue culture

Glutathione-insulin trandhydrogenase (GIT) activity has been shown to be stimulated in culture of explants of pregnant mouse mammary gland by a mixture of insulin, cortisol, and prolactin. Since this hormone mixture stimulates lactogenesis in vitro it is possible that the increase in GIT activity is functionally related to one of the processes of milk secretion or ejection. Oxytocin is degraded by GIT and the interaction of this hormone with its mammary gland receptors may be influenced by the change in enzyme activity. The increase in GIT activity caused by insulin, cortisol, and prolactin in vitro can be prevented by the addition of progesterone or oxytocin to the culture medium.

Synthesis and some pharmacological properties of (2-tryptophan)-oxytocin

Previous studies have suggested that an aromatic amino acid residue at position 2 in oxytocin facilitates the expression of the hormone's biolgocial activities. [2-Tryptophan]-oxytocin, in which a residue of tryptophan has replaced that of tyrosine in oxytocin, has been synthesized by the method of azide coupling of the N-terminal dipeptide and C-terminal heptapeptide amide. It was found to have approximately 0.1% of the potency of oxytocin in milk ejection and uterotonic biological activities.

The synthesis and some pharmacological properties of (2-L-DOPA)-oxytocin

The first reported synthetic analogue of a naturally occurring peptide with a residue of L-3,4-dihydroxyphenylalanine (L-DOPA) was prepared by coupling N-carbobenzoxy-S-benzylcysteinyl-L-DOPA azide with isoleucylglutaminylasparaginyl-S-benzylcysteinylprolylleuclglycinamide. The protecting groups were removed from the resultant nonapeptide derivative by sodium in liquid ammonia and the peptide analogue was formed by short term oxidation of the dithiol-containing compound. It was isolated by sequential partition chromatography and exclusion chromatography on Sephadex G-25. It was unstable at neutral or alkaline pH. [2-L-DOPA]-oxytocin was found to possess a minimum milk-ejection-like activity of 54 +/- 9 U/mg and uterotonic activity of 26 +/- 4 U/mg. These potencies are approximately 12% and 5% of the corresponding potencies of oxytocin.

Synthesis and some biological properties of 1-deamino-4-glu-oxytocin (1-beta-mercaptopropionic acid-4-glutamic acid-oxytocin) and its use in preparing a hormone-agarose complex

1-Deamino-4-glu-oxytocin (1-beta-mercaptopropionic acid-4-glutamic acid - oxytocin) was synthesized by sequential reduction by sodium in liquid ammonia and oxidation by hydrogen peroxide of the octapeptide derivative, S-benzyl-beta-mercaptopropionyl-tyrosyl-isoleucyl-gamma-O-benzyl-glutamyl-asparaginyl-S-benzyl-cysteinyl-prolyl-leucyl-glycinamide. The oxidation analogue was isolated and purified by partition chromatography in two different solvent systems followed by exclusion chromatography on Sephadex G-25. It was found to possess approximately 13 I.U. of uterotonic activity, 34 I.U. of milk ejection activity, and 83 I.U. of milk ejection-like activity per milligram, measured on an isolated strip of lactating mouse mammary gland. 1-Deamino-4-Glu-oxytocin was coupled to AH-Sepharose 4B by the way of the free gamma-carboxyl group of its residue of glutamic acid. The water soluble 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide hydrochloride caused the coupling with approximately 70% effectiveness. The resultant peptide-agarose complex had low biological potency in the assay of milk ejection-like activity.

Plasma oxytocinase: the synthesis and biological properties of the first product of the degradation of oxytocin by this enzyme

Oxytocin is hydrolytically cleaved in the presence of plasma oxytocinase to give an acyclic peptide, tyrosyl-isoleucyl-glutaminyl-asparaginyl-S-(S-cysteine)-cysteinyl-prolyl-leucyl-glycinamide (1,2-acyclic oxytocin). The synthesis of this peptide is described. It is shown to be of very low potency in milk-ejection-like activity and uterotonic activity. It does not inhibit the expression of these activities by oxytocin, suggesting that it does not interfere with the hormone's binding to target tissues. The presence of 1,2-acyclic oxytocin slightly inhibits the rate of degradation of oxytocin by plasma from pregnant women, in contrast to the marked inhibition of the degradation of cystine di-β-naphthylamide. The Km for the degradation of oxytocin is 30 times smaller than that of the degradation of cystine di-β-naphthylamide, which is of the same order as the Ki for the inhibition of the degradation of cystine di-β-naphthylamide by 1,2-acyclic oxytocin. These results, together with information on the substrate specificity of plasma oxytocinase with respect to the N-terminal amino acid residue, suggest that there are molecular features of oxytocin other than its N-terminal residue that facilitate its interaction with plasma oxytocinase.

Thiol-protein disulfide oxidoreductase activity in lactating and non-lactating mouse mammary gland

Glutathione–protein disulfide oxidoreductase activity has been demonstrated in mouse mammary gland, with both insulin and oxytocin serving as disulfide-containing substrates. The activity does not change markedly in pregnancy but shows a marked increase when lactation is established, reaching a maximum about the 10th day of lactation.

Thiol-protein disulfide oxidoreductase activity in human placental tissue homogenates

Thiol–protein disulfide oxidoreductase activity was detected in the soluble cell fraction of human placental tissue homogenized in sucrose. This activity was demonstrated in the rapid reduction of oxytocin and the somewhat less rapid reduction of insulin by reduced glutathione. The apparent pH optimum of the enzymic activity for the reduction of oxytocin and insulin was found to be near pH 8.

Deamino-oxytocin: inactivation plasma of women in labor

Incubation of deamino-oxytocin with plasma obtained from women in labor reduced the potency of this analog of oxytocin when assayed on an isolated strip of mammary gland taken from a lactating rat. Plasmas of nonpregnant women had no detectable effect on this activity of deamino-oxytocin, and the effect of plasmas from women just previous to the beginning of labor was not significant. The original. activities of the incubated deamino-oxytocin solutions could be restored by treatment with hydrogen peroxide. The inactivation may be caused by reductive cleavage of the disulfide bridge of deamino-oxytocin, this bridge being reformed by oxidation.