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BACKGROUND: The College of Physicians and Surgeons of Ontario has conducted a Peer Assessment Program since 1980. All physicians who turn 70 years of age in a given year are automatically selected for assessment, and the program assesses a random selection of physicians within specific practice and specialty areas. Each assessor--a physician who practices in the same area of medicine as the physician undergoing assessment--reviews the physical facilities, the system of record keeping and the content of approximately 20-30 medical records, and the quality of care provided, as determined by the medical record content and discussions with the physician. The assessed physician is then assigned a grade. In 1998, program records for 109 nonspecialist physicians who had undergone two assessments more than 10 years apart (first assessment, 1981 to 1987; second, 1991 to 1997) were examined to determine possible changes in performance. RESULTS: The mean time between assessments was 12.2 years. Seventy (64.2%) of the 109 physicians showed a decline in grade, whereas 35 (32.1%) received the same grade, and only 4 (3.7%) had an improvement in grade. CONCLUSIONS: This report is consistent with previous observations that performance changes with age. In contrast to previous studies, this report is based on longitudinal rather than cross-sectional data.

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OBJECTIVE: This study examines the differences in frequency and distress caused by menopausal symptoms experienced by Canadian and Chinese women. DESIGN: Cross-sectional surveys were conducted in Canada and China. SETTING: The Canadian studies were conducted in Toronto. The Chinese data were collected in Guangzhou City. PARTICIPANTS: Women, 47-62 years old, 2-7 years after a natural menopause, were recruited. METHODS: Two hundred and eighty-two Canadians were recruited for two menopause studies. Data from 297 Chinese were obtained through a household survey. From a 105-item symptom questionnaire, women indicated the frequency and distress caused by symptoms in the previous month. MAIN OUTCOME MEASURES: Frequency and mean distress score of problems were ranked and compared. Using the importance score method, a Chinese questionnaire was constructed and compared with the Menopause-Specific Quality of Life questionnaire. RESULTS: The frequency of symptoms and distress experienced by Canadian and Chinese women differed markedly. Fourteen of the 29 items differed between the Chinese questionnaire and the Menopause-Specific Quality of Life questionnaire. CONCLUSIONS: There are striking differences between Chinese and Canadian women in the frequency and distress caused by menopausal symptoms. The Canadian questionnaire may not be relevant for Chinese women.

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BACKGROUND: The College of Physicians and Surgeons of Ontario has assessed randomly selected physician office practices since 1972. Each assessment consists of a tour of the premises and a review of a random selection of 20 to 30 medical records to evaluate the system of record keeping and the content of the records and to thereby indicate the quality of the physician's examinations, history taking, diagnosis and management plan. About 12% of nonspecialist physicians who need help to improve their records and/or the care they provide are identified annually, and following an interview with peers and simple educational interventions, more than 75% are successful in improving. METHODS: A follow-up was conducted to assess physician practices an average of six years after the first intervention. The reviewers were blinded as to whether the physician being reviewed had been reviewed previously. Each revisited physician was matched to three others undergoing their initial assessments in the same year. The matching variables were age, sex, school of graduation (Canadian versus other), rural versus urban practice location, and affiliation status with the College of Family Physicians of Canada. The assessed performance of the two groups was compared. RESULTS: The performance of the revisit group was significantly better than that of the matched group (p = 0.05). CONCLUSIONS: The assessment, interview, and educational interventions undertaken by the licensing authority produced an improvement in practice in the short term in the bottom 10%-15% of all physicians reviewed, which was sustained for more than six years.

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OBJECTIVE: To describe the relationship between the quality of care provided by family and general practitioners in Ontario and the demographics of the practitioners. DESIGN: Descriptive study using univariate and multivariate analysis to relate physician demographics to quality of care. SETTING: Ambulatory family and general practices in Ontario. PARTICIPANTS: Each year from 1990 to 1994, all non-specialist physicians in Ontario reaching 70 years of age and a random sample of physicians younger than 70 who had been in practice more than 5 years were selected for assessment. After exclusion criteria were applied, the sample size was 922 physicians. MAIN OUTCOME MEASURES: Grades assigned by the College of Physicians and Surgeons of Ontario's Peer Assessment Committee. RESULTS: Practices were assessed and graded by the Peer Assessment Committee. Grades were related to many variables, but many variables were correlated. Four variables remained significant at the P < .05 level. Younger physicians, female physicians, certificates of the College of Family Physicians of Canada, and urban physicians had, on average, higher grades. CONCLUSION: Grades reflecting quality of care and record keeping were significantly associated with age, sex, certification status, and practice location. These findings should be examined and, for the benefit of patients, methods for improving care should be developed and explored.

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OBJECTIVE: To provide clinical guidelines for primary care physicians who are dealing with domestic abuse and who have both the abused woman and her partner as patients. PARTICIPANTS: A 15-member expert panel with members having experience in family practice, gynecology, emergency medicine, medical ethics, nursing, psychology, law, and social work; an 11-member consulting group with members representing medicine, consumers, police, psychology, social work, and nursing; and participants from focus groups including 48 previously abused women and 10 previously abusive men. Members of the expert panel and the consulting group were recruited by the research team. Focus group members were recruited through the agencies from which they were receiving services. EVIDENCE: Available research information, and opinions of the expert panel, the consulting group, and the focus group participants. CONSENSUS PROCESS: Scoring of 144 clinical scenarios was performed by the expert panel using a modified Delphi technique involving 4 iterations. Scenarios were rated in terms of best practice for primary care physicians dealing with suspected and confirmed cases of physical abuse. Consulting group members and focus group participants then commented on the panel's results. Final guidelines were approved by the panel and the consulting group, with comments reserved in the guidelines for information from focus group participants. CONCLUSIONS: It is not a conflict of interest for the physician to deal with abuse of the female partner when both partners are patients. Both patients have a right to autonomy, confidentiality, honesty, and quality care. Patients should be dealt with independently, thereby facilitating assessment of the magnitude and severity of the victim's injuries. Physicians should not discuss the possibility of domestic abuse with the male partner without the prior consent of the abused female partner. Joint counseling is generally inadvisable and should be attempted only when the violence has ended, provided both partners give independent consent and the physician has adequate training and skills to deal with the situation without escalating the violence. If the physician feels unable to deal effectively with either patient because of the dual relationship, referral to another qualified physician is preferred.

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Dissemination of new information to caregivers in ways that enhance the care they deliver is central to quality improvement in health care. This article describes several strategies that have been employed in one long-term care setting and discusses evidence of their success.

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PROBLEM BEING ADDRESSED: With the increasing emphasis on quality improvement, we need programs for improving office practice. OBJECTIVE OF PROGRAM: To demonstrate a simple and inexpensive program that resulted in improvement in the quality of Papanicolaou smears in a family practice teaching clinic. The performance measure was the proportion of smears containing endocervical components. MAIN COMPONENTS OF PROGRAM: The program involved annual feedback on the performance of the physicians in the clinic. Feedback was given to physicians at a regular group meeting; brief discussion of the findings also occurred at that time. There were no other interventions. CONCLUSIONS: A program involving straightforward feedback and discussion for less than 1 hour contributed to a 7% improvement in the proportion of Pap smears with endocervical components. This "low tech" approach should be tested in other settings and with other procedures and treatments.

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OBJECTIVE: To develop a condition-specific quality of life questionnaire for the menopause with documented psychometric properties, based on women's experience. SUBJECTS: Women 2-7 years post-menopause with a uterus and not currently on hormone replacement therapy. Questionnaire development: A list of 106 menopause symptoms was reduced using the importance score method. Replies to the item-reduction questionnaire from 88 women resulted in a 30-item questionnaire with four domains, vasomotor, physical, psychosocial and sexual, and a global quality of life question. Psychometric properties: A separate sample of 20 women was used to determine face validity, and a panel of experts was used to confirm content validity. Reliability, responsiveness and construct validity were determined within the context of a randomized controlled trial. Construct validation involved comparison with the Neugarten and Kraines'Somatic, Psychosomatic and Psychologic subscales, the reported intensity of hot flushes, the General Well-Being Schedule, Channon and Ballinger's Vaginal Symptoms Score and Libido Index, and the Life Satisfaction Index. RESULTS: The face validity score was 4.7 out of a possible 5. Content validity was confirmed. Test-retest reliability measures, using intraclass correlation coefficients were 0.81, 0.79, 0.70 and 0.55 for the physical, psychosocial, sexual domains and the quality of life question. The intraclass correlation coefficient for the vasomotor domain was 0.37 but there is evidence of systematic change. Discriminative construct validity showed correlation coefficients of 0.69 for the physical domain, 0.66 and 0.40 for the vasomotor domain, 0.65 and -0.71 for the psychosocial domain, 0.48 and 0.38 for the sexual domain, and 0.57 for the quality of life question. Evaluative construct validity showed correlation coefficients of 0.60 for the physical domain, 0.28 for the vasomotor domain, 0.55 and -0.54 for the psychosocial domain, 0.54 and 0.32 for the sexual domain, and 0.12 for the quality of life question. Responsiveness scores ranged from 0.78 to 1.34. CONCLUSIONS: The MENQOL (Menopause-Specific Quality of Life) questionnaire is a self-administered instrument which functions well in differentiating between women according to their quality of life and in measuring changes in their quality of life.

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A consortium of eight long-term care facilities in Ontario devised a new instrument to measure patient satisfaction in long-term care settings. A standardized protocol for administration was developed that included a program to train volunteers to conduct in-person interviews. Nine facilities have carried out the survey using the standardized protocol.

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This is the second of four articles describing the construction and use of an instrument to evaluate resident and family satisfaction with care provided in long-term care settings. It addresses operational issues that arose in the application of the instrument.

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As the demographics of practising physicians change, especially as the number of women doctors in an area increases, it is important that those planning for the provision of medical care in the future understand the relationships between the demographics and changes in practice patterns.

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Little is known about the physician's appearance and its effect on patients' confidence and trust. This study reports on the attitudes of family physicians and their patients toward physicians' dress, sex, and age. The data suggest that while age and style of dress are important considerations in a patient's ability to trust a physician, sex of the physician is much less important. The majority of patients stated a preference for their doctors to be between 30 and 50 years old. It appears patients strongly prefer a male physician to dress in the traditional "professional" manner with a white coat, tie, shirt, and dress pants. The desirable "uniform" for the female physician was less clear, with variables of patient age, sex, education, and geographic location causing significant differences in patients' preferences regarding dress for female physicians.

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An evaluation tool for measuring the experiences of family practice residents as they rotate through various services was developed and tested. The tool is described and the effect on the program is discussed. The ease of administration has led to acceptance in not only the family practice program but also in other departments.

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The authors describe the resident-project component of the Family Practice Residency program at the University of Toronto. The goals of the project are to allow the residents an experience of critical appraisal, writing for a medical forum, and presenting in a style acceptable to the medical community. Over 305 projects have been completed, and 100% of the residents complete projects at this time. An analysis of the types of projects, the topics covered, and the effect on the residency program is presented. An appendix lists projects that have been published.

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The increasing financial restraints on the use of health care resources make it important to examine the appropriateness of present usage patterns. The authors studied referral patterns for a group of academic family physicians practising in a health service organization in Ontario. They found that for all consultant encounters, the family physician directly controlled 65% of these consultations, whereas 13% were continuing consultations with the specialist without direct family physician referral. The remainder were either unknown or referred from other sources, for example, emergency room or specialist-to-specialist referrals. The family physician made the exact same diagnosis as the consultant in 73.4% of cases for which data were available, and the patient was referred to an inappropriate specialist in only 2.7% of cases.

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Analysis of laboratory use and referrals within a family practice teaching group showed large differences in physicians' behavior. There were three- to four-fold differences between physicians, both for the number and the costs of laboratory use and X-ray services. There were equally large variations in the types of referrals (to medical, dermatologic, obstetric and gynecologic, surgical, ophthalmological and psychological services). There was no consistent pattern for any physician: that is, if a physician used laboratory investigations often, that physician might seldom use X-ray services or might refer fewer patients to specialists. These results have major implications for teachers and for teaching cost containment.

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Using a crossover design, it is shown that an individual criteria setting followed by immediate feedback of previous performance produced a sustained and continuing improvement in recording for two common conditions (cystitis and vaginitis). The intervention, which is simple and could easily be applied in other settings, produced improvements significant at the P = .001 level. The study controlled for overall improvement in record keeping. Further testing of this method of influencing physician performance is warranted.

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The frequency and cost of referrals to specialists in March 1984 for 8980 rostered patients attending a family practice clinic located in a teaching hospital were analysed. The patients made 1891 visits to specialists. In all age groups and for all specialties female patients were more likely to be seen. The total direct provider costs were higher for female patients than for male patients. However, costs per patient seen were higher for male patients, except for psychiatry and medicine. Visits to surgeons had the highest total cost, while visits to psychiatrists had the highest cost per patient seen. Of the direct provider costs 61% was for specialist services. The family physician, in the "gatekeeper" role, has an opportunity to control some of the costs of the health care system by ensuring that the best and most efficient use is made of the referral network.

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