To train to be a general practitioner in the U.K. a doctor must spend two years in hospital training posts and one year in general practice as a general practice registrar (GPR). Concern has been expressed in the literature about both the duration and adequacy of general practice training. A literature review identified that there was limited knowledge of and understanding about the learning experiences of GPRs. The aim of the study was to describe and interpret the learning experiences of GPRs in the South East of Scotland during their year in general practice. The methodology was derived from Denzin's concept of Interpretivism and involved in depth interviews over time with GPRs and thick description to capture and interpret the GPRs learning experiences. Two cohorts of 24 GPRs were recruited, cohort one ran from September 2002 to July 2003 and cohort two from September 2003 to August 2004. The GPRs were interviewed on three occasions during their year. In addition to the interviews six GPR focus groups and six GP trainer focus groups were held over the period December 2002 to September 2003. 21 GPRs in cohort one completed all three interviews and 20 GPRs in cohort two. All the participating GPRs completed at least two interviews. The results were interpreted within the educational concept of the curriculum. Four main curricula were identified during the GPR year: these were the formal, assessment, individual and hidden. Each independently contributed to the GPRs learning and also interacted synergistically at various times during the year. In the last quarter of the year there was a tension between the requirements of the assessment and individual curricula. The individual curriculum which was composed of the GPRs clinical experiences and in particular epiphanies was the main driver of GPR learning. Epiphanies were identified by GPRs as having the most significant impact on their learning. Central to this learning was the contribution of their general practice trainer who supported their learning both through the development of the practice learning environment and the promotion of reflection and self directed learning. GPR learning during the year was an iterative process, which involved a reflective and supported interaction between the GPR, their clinical experiences, epiphanies and their trainer. Through this process the GPRs became self directed and reflective learners and developed individual learning networks which led to changes in the way they practiced medicine. This process also led to the socialisation of their learning and promoted their integration into the culture of working general practice, through which they were exposed to the working realities of life as a general practitioner and these experiences had a critical effect on their future career choice. A number of important policy implications were identified which have implications for the present and future direction of training for general practice. The process of thick description and the longitudinal nature of the study allowed for a new interpretation of the learning experiences of GPRs and added to the knowledge and understanding of how GPRs learn during their training.

Burnout among primary care providers, which include physicians, nurse practitioners, and physician assistants, can negatively impact patients, providers, and organizations. Researchers have reported that up to 37% of primary care physicians experience burnout, yet the prevalence, predictors, and outcomes associated with primary care nurse practitioner burnout remains unknown. Since 69% of nurse practitioners provide primary care to patients, this dissertation investigates the predictors and outcomes associated with primary care nurse practitioner burnout. A history of burnout as well as the importance of investigating burnout among primary care nurse practitioners are discussed in the first chapter. A systematic review of the predictors and outcomes of primary care provider burnout is discussed in the second chapter. The third chapter describes a cross-sectional study conducted among 396 primary care nurse practitioners from New Jersey and Pennsylvania, which investigated whether the practice environment is associated with nurse practitioner burnout. The fourth chapter describes a cross-sectional study investigating whether the use of multifunctional electronic health records is associated with primary care nurse practitioner burnout. The fifth chapter includes another cross-sectional study examining the relationship between primary care nurse practitioner burnout and quality of care, and if the practice environment moderates the relationship between burnout and quality of care. Finally, the sixth concluding chapter summarizes the findings from chapters two to five and provides recommendations for future research, practice, and policy.

This study examined the validity of using physicians’ self‐assessed needs, relevance and motivation to learn about clinical topics as a means for setting objectives and priorities for continuing medical education (CME) programmes. In an initial survey family doctors were asked to rate their need, relevance and motivation to learn about 120 different clinical topics. Eight months later, the same population was sent a second mail survey asking respondents to indicate if they had learned about a set of sixteen topics taken from the initial survey and, if so, in what kind of learning activities. Eight of the sixteen topics were highly rated and eight were low rated in the initial survey. In terms of actual participation of family doctors, self‐assessed motivation to learn exhibited a strong positive relationship with actual participation. Both self‐assessed need and relevance were negative to only moderately positive in their association with actual participation. This evidence contributed to the value of using self‐assessed motivation as an indicator of future participation of family doctors in CME and questioned the value of using self‐assessed need and relevance as indicators of future patterns of participation.

Introduction: Home visits have become increasingly uncommon although evidence suggests they improve healthcare quality and reduce overall expenditures. This thesis identifies the number and proportion of physician delivering home visits at patient’s end of life and describes characteristics of primary care physicians delivering end-of-life home visits and explores associations with delivery. Method: A retrospective cohort design using population-level health administrative data housed at ICES. Results: A total of 9,884 physicians were identified, of which 2,568 (25.7%) delivered at least one end-of-life home visit. Variables associated with increased odds of home visit delivery were older age, international training, capitation models of remuneration, and population size. Conclusions: This research demonstrates primary care physician’s characteristics and home visit practice patterns. This study aims to improve end-of-life primary care at a system and provider level by identifying factors associated with increased service provision. Increasing physician home services could greatly improve the dying experience of Canadians.

This thesis is a pilot analysis of five Afghan physicians who recently evacuated Afghanistan and are hoping to reenter the medical field in the United States. To this investigator’s knowledge, there has not been a study focusing on physicians who were part of the 2021 evacuation from Afghanistan. Through participant interviews, this thesis aims to illuminate the opportunities and challenges facing these physicians. Additionally, a board member of the Afghan Medical Professionals Association of America was interviewed to better understand the resources provided to newly arrived Afghan physicians. We found that socioeconomic status, lack of social support and guidance, United States Medical Licensing Exams, and limited English proficiency were barriers to reentering the medical field for these physicians. Policy recommendations include allotting residency spots for forcibly displaced physicians and enabling opportunities for physicians to work in other positions in the medical field. / Urban Bioethics

During the past decade medical malpractice litigation has created problems and concern within the medical and legal professions, the malpractice insurance industry, and for healthcare patients. The purpose of this dissertation was to analyze and evaluate the ability of the negligence standard of civil liability to facilitate efficient resource allocation between physicians and their patients. The analysis also attempted to determine whether or not the negligence rule of liability is an effective means of ensuring that cost-justified levels of precaution will be undertaken and that the efficient levels of iatrogenic injuries will result. The negligence standard is not the appropriate liability assignment for activities involving direct contact between buyers (patients) and sellers (physicians). Transaction and negotiation costs are not so high as to engender significant negative externalities and to result in inefficient resource allocation. Tort liability is a problematic and costly system of victim compensation. The study concluded that most personal injuries arising from medical treatment should be allocated contractually between physicians and patients. Assigning more liability for adverse outcomes to patients would not likely reduce the quality of health care while allowing the parties involved to assume voluntarily the appropriate level of risks. / Ph. D.

In this study, county level data for three time periods (1970, 1985, and 1989) are examined to determine the factors affecting the distribution of primary care physicians in rural counties of Virginia. Consistent predictors of proportions of physicians to the population were identified: golf holes per capita and the ratio of hospital beds to population were the most consistent predictors. Per capita income and the elderly population were only significant for some of the years. Variables deemed to be controllable by the community (in the short run) were generally more consistent in predicting the proportions of physicians to population. Policy implications are discussed, and several strategies for improving access to health care in rural areas, thus altering the massive imbalance in physician to population ratio in urban and rural areas are suggested. / Master of Science

Thesis (doctoral)--Justus Liebig-Universität Giessen, 2008.

published_or_final_version / Community Medicine / Master / Master of Public Health

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences