Anatomy of the elephant in Quebec family practice

Background Whole person care has been a foundation of the modern practice of family medicine, and therefore one might expect that such an approach by family practitioners   would evolve and mature over time. Some of these clinicians, however, currently question their ability to provide such holistic care because of external factors they perceive as negative, and over which they have little or no control. Objectives This presentation will explore perceived inhibiting factors affecting family doctors ability to provide whole person care within the publicly-funded health care system of the Canadian province of Quebec. Method The presenter, an academic and clinician scientist with forty-four years of   experience practicing family medicine, will present personal perspectives, along with those gathered informally from a broad cadre of colleagues working in different settings. Using the idiom of “elephant in the room” to identify problems or obstacles that may not be voiced, this talk will start with consideration of elephant anatomy as being comprised of thirteen distinct anatomical parts that contribute to a functional whole. An analogy will be developed in which thirteen distinct factors are presented as likely impeding or discouraging whole person care by family physicians. Conclusion Some agendas and policies of health care planners and administrators, either alone or collectively, and intentionally or unintentionally, may decrease opportunity or ability of family physicians to provide whole person care

The impact of virtual care on relationship centered care: Observations of a family physician

The COVID-19 pandemic propelled many physicians and their patients into an unfamiliar world of virtual care. This presentation is based on the perceptions of a family physician/ teacher/ researcher with 43 years of interest in, and promotion of, a strong doctor-patient relationship. It will describe a protocol that governed how tele-medicine and video-conferencing took place over nearly 18 months in his practice. It will then describe observed positive and negative impacts for the patients, their family members, the physician, and members of the family medicine health care team. Interpretation will be made about what such observations mean for the doctor-patient relationship. &nbsp

A novel source of patients' and families' written words to identify what they value in the doctor-patient encounter

Context:  The value and desirability of a positive doctor-patient relationship has traditionally been described using case histories and narratives, and less often with formal literature, art, movies, and theatre. To the detriment of this relationship some family physicians are facing pressure to engage in volume medicine, at the possible expense of personalized care. What patients appreciate in their care is at risk of being ignored. Objective: To understand what adult patients value in the clinical encounters with their family physicians.  Design: In this research, still in progress, we have adopted an interpretive hermeneutics approach to examine a collection of over 140 cards and letters received by an academic family doctor in practice for 39 years.  Participants:  The patients or their family members who sent the aforementioned notes. Findings: Preliminary analysis suggests that correspondence is not spontaneous, but initiated at holidays (Christmas, New Years, Chanukah); life cycle events (birth, recovery from illness, death); and transitions (leaving the practice because of geographical re-location). Notes are commonly  personalized through hand-written text written on behalf of oneself and/or ones family. Showing a wide variety of word selection they expresses appreciation for family physician care of oneself or a family member that was perceived as knowledgeable bio-medically, and experienced as available, authentic, supportive, professional, compassionate, offering hope, and sensitive to suffering. Conclusions: The writing of notes to ones doctors may serve many functions: catharsis, closure, and bearing witness to patients’ appreciation of care in which Hippocratic and Asclepian traditions overlap and complement each other

Instabilities of Electroweak Strings

We investigate the instabilities of low winding number electroweak strings using standard numerical techniques of linear algebra. For strings of unit winding we are able to confirm and extend existing calculations of the unstable region in the ($m_H/m_W,\sin^2\theta_W$) plane. For strings of higher winding number we map the unstable regions for the various decay modes.Comment: Latex, 11 pages, 1 uuencoded figur

The Use of Senior Volunteers in the Care of Discharged Geriatric Patients

This article reports on a project that utilized senior volunteers in the role of health advocates for geriatric patients discharged from a hospital. The project was evaluated to determine if healthy and active seniors could make a contribution to the health and social welfare of such discharged elderly persons. The study was conducted in Montreal, Canada and funded by a federal grant from Health Canada. The research collaborators came from a 414-bed secondary care university-affiliated community hospital, a community social service agency with a mandate to respond to the needs of its frail elderly constituents, and a university-based research centr

Development of a Comprehensive Hospital-Based Elder Abuse Intervention: An Initial Systematic Scoping Review

Introduction Elder abuse, a universal human rights problem, is associated with many negative consequences. In most jurisdictions, however, there are no comprehensive hospital-based interventions for elder abuse that address the totality of needs of abused older adults: psychological, physical, legal, and social. As the first step towards the development of such an intervention, we undertook a systematic scoping review. Objectives Our primary objective was to systematically extract and synthesize actionable and applicable recommendations for components of a multidisciplinary intersectoral hospital-based elder abuse intervention. A secondary objective was to summarize the characteristics of the responses reviewed, including methods of development and validation. Methods The grey and scholarly literatures were systematically searched, with two independent reviewers conducting the title, abstract and full text screening. Documents were considered eligible for inclusion if they: 1) addressed a response (e.g., an intervention) to elder abuse, 2) contained recommendations for responding to abused older adults with potential relevance to a multidisciplinary and intersectoral hospital-based elder abuse intervention; and 3) were available in English. Analysis The extracted recommendations for care were collated, coded, categorized into themes, and further reviewed for relevancy to a comprehensive hospital-based response. Characteristics of the responses were summarized using descriptive statistics. Results 649 recommendations were extracted from 68 distinct elder abuse responses, 149 of which were deemed relevant and were categorized into 5 themes: Initial contact; Capacity and consent; Interview with older adult, caregiver, collateral contacts, and/or suspected abuser; Assessment: physical/forensic, mental, psychosocial, and environmental/functional; and care plan. Only 6 responses had been evaluated, suggesting a significant gap between development and implementation of recommendations. Discussion To address the lack of evidence to support the recommendations extracted in this review, in a future study, a group of experts will formally evaluate each recommendation for its inclusion in a comprehensive hospital-based response

The Hagedorn/Deconfinement Phase Transition in Weakly Coupled Large N Gauge Theories

We demonstrate that weakly coupled, large N, d-dimensional SU(N) gauge theories on a class of compact spatial manifolds (including S^{d-1} \times time) undergo deconfinement phase transitions at temperatures proportional to the inverse length scale of the manifold in question. The low temperature phase has a free energy of order one, and is characterized by a stringy (Hagedorn) growth in its density of states. The high temperature phase has a free energy of order N^2. These phases are separated either by a single first order transition that generically occurs below the Hagedorn temperature or by two continuous phase transitions, the first of which occurs at the Hagedorn temperature. These phase transitions could perhaps be continuously connected to the usual flat space deconfinement transition in the case of confining gauge theories, and to the Hawking-Page nucleation of AdS_5 black holes in the case of the N=4 supersymmetric Yang-Mills theory. We suggest that deconfinement transitions may generally be interpreted in terms of black hole formation in a dual string theory. Our analysis proceeds by first reducing the Yang-Mills partition function to a (0+0)-dimensional integral over a unitary matrix U, which is the holonomy (Wilson loop) of the gauge field around the thermal time circle in Euclidean space; deconfinement transitions are large N transitions in this matrix integral.Comment: harvmac, 90 pages, 14 figures, 67 footnotes. V3: added references and minor clarifications. v4: added reference, minor changes. v5: corrected figure captions. v6: small corrections and added footnot

Improving the Management of Late-Life Depression in Primary Care: Barriers and Facilitators

The objectives of this study were to elicit Canadian health professionals' views on the barriers to identifying and treating late-life depression in primary care settings and on the solutions felt to be most important and feasible to implement. A consensus development process was used to generate, rank, and discuss solutions. Twenty-three health professionals participated in the consensus process. Results were analysed using quantitative and qualitative methods. Participants generated 12 solutions. One solution, developing mechanisms to increase family physicians' awareness of resources, was highly ranked for importance and feasibility by most participants. Another solution, providing family physicians with direct mental health support, was highly ranked as important but not as feasible by most participants. Deliberations emphasized the importance of case specific, as needed support based on the principles of shared care. The results suggest that practitioners highly value collaborative care but question the feasibility of implementing these principles in current Canadian primary care contexts

When one is sick and two need help: Caregivers’ perspectives on the negative consequences of caring

Informal or family caregivers contribute significantly to individual care, and to the Canadian healthcare system, yet receive limited support from governments, institutions, and healthcare professionals in recognition of their role, or in response to their health and social care needs – often due to the negative consequences of caregiving. Learning about the diversity of others’ experiences can positively influence personal decision-making, reduce feelings of isolation, as well as promote adjustment to a personal situation. For caregivers, however, few resources exist that provide reliable information on others’ experiences. We collected the narratives of caregivers’ experiences of caring for someone with a chronic physical illness and produced an evidence-based web resource. Through purposive variation sampling, 42 caregivers were recruited across Canada for interviews in their homes or alternate location using video/audio recording. Qualitative data analysis followed a constant comparison approach. 29 thematic pages were developed for the web site (www.healthexperiences.ca) featuring the diversity of lived experiences, and presenting topics important to the caregivers with illustrative video/audio clips, along with other sources of information. Key themes related to caregivers’ perspectives on the negative consequences of caregiving included: the impact upon personal health; challenging interactions with professionals; inconsistent information, limited support from family and friends, and unhelpful societal views. These results contribute to existing evidence of caregiver burden, but uniquely in the voices of caregivers themselves – with constructive insights for understanding the causes of ill health related to caregiving burden and for informing policy and practice

Sex Differences in the Association Between Cumulative Use of Cannabis and Cognitive Function in Middle Age: The Coronary Artery Risk Development in Young Adults Study.

Background: Cannabis use may impair cognitive function (CF) differently in men and women, due to sex-specific differences in neurobiological mechanisms and environmental risk factors. Objective: Assess sex differences in the association between cumulative exposure to cannabis and cognitive performance in middle age. Methods: We studied participants from the Coronary Artery Risk Development in Young Adults (CARDIA) Study, including Black and White men and women 18-30 years old at baseline followed over 30 years. Our cross-sectional analysis of CF scores at year 30 was stratified by sex. We computed categories of cumulative exposure in "cannabis-years" (1 cannabis-year=365 days of use) from self-reported use every 2 to 5 years over 30 years. At years 25 and 30, we assessed CF with the Rey Auditory Verbal Learning Test (verbal memory), the Digit Symbol Substitution Test (processing speed), and the Stroop Interference Test (executive function). At year 30, additional measures included Category and Letter Fluency Test (verbal ability) and the Montreal Cognitive Assessment (global cognition). We computed standardized scores for each cognitive test and applied multivariable adjusted linear regression models for self-reported cumulative cannabis use, excluding participants who used cannabis within 24 h. In a secondary analysis, we examined the association between changes in current cannabis use and changes in CF between years 25 and 30. Results: By year 30, 1,352 men and 1,793 women had measures of CF; 87% (N=1,171) men and 84% (N=1,502) women reported ever cannabis use. Men had a mean cumulative use of 2.57 cannabis-years and women 1.29 cannabis-years. Self-reported cumulative cannabis use was associated with worse verbal memory in men (e.g., -0.49 standardized units [SU] for ≥5 cannabis-years of exposure; 95% CI=-0.76 to -0.23), but not in women (SU=0.02; 95% CI=-0.26 to 0.29). Other measures of CF were not associated with cannabis. Changes in current cannabis use between years 25 and 30 were not associated with CF in men or women. Conclusions: Self-reported cumulative cannabis exposure was associated with worse verbal memory in men but not in women. Researchers should consider stratified analyses by sex when testing the association between cannabis and cognition