Le pouvoir médical et le défi de la collaboration interprofessionnelle. Trois cas de figure

Dans la foulée de la loi 90 adoptée au Québec en 2002, l’article analyse l’évolution du statut professionnel des médecins dans le cadre spécifique de leurs relations avec trois groupes de professionnels : les infirmières, les chiropraticiens et les techniciens ambulanciers. Tirées d’entrevues et de sources documentaires, nos données montrent que les médecins n’ont pas renoncé à une part significative de leur pouvoir dans leurs rapports avec ces groupes professionnels : en refusant de déléguer le droit au diagnostic et à la détermination du traitement médical, ils continuent d’exercer un contrôle réel sur les pratiques des autres groupes professionnels.Following the adoption of Bill 90 in Québec in 2002, this paper analyses the changes in the professional status of physicians in the specific context of their relations with three professional groups: nurses, chiropractors and ambulance technicians. Our data, drawn from interviews and from documentary sources, indicate that physicians have not given up a significant portion of their power in their relations with these professional groups: by refusing to delegate the right to perform diagnosis and to prescribe medical treatment, they continue to exercise significant control over the practices of other professional groups

Pouvoir médical et interventions législatives au Québec, 2001-2008

Traditionnellement déduit de la reconnaissance sociale accordée aux médecins et de la nature scientifique de leur savoir, le pouvoir médical semble désormais contesté sur la base de divers facteurs, notamment les connaissances accrues des patients, mais peut-être spécialement la volonté des responsables politiques de rationaliser les pratiques dans le domaine de la santé, en particulier dans la perspective de réduction des coûts. Au-delà de la perception que des médecins ont eux-mêmes de leur pouvoir et de son évolution, nous examinons 28 lois qui, adoptées par l’Assemblée nationale du Québec entre 2001 et 2008, touchent à différents degrés la profession et la pratique médicales. Il ressort de cet exercice que le pouvoir médical est objet à la fois d’une érosion relative et d’une consolidation, selon qu’on porte attention au contrôle des conditions d’exercice de la pratique ou au statut hégémonique de la profession au sein du système de santé.Traditionally derived from the social recognition granted to physicians and from the scientific nature of their knowledge, the power of the medical profession now seems to be challenged on the basis of several factors, including increased knowledge on the part of patients, but perhaps more especially the desire of political leaders to streamline practices in the health care sector, particularly with a view to cost reduction. Above and beyond the perception that physicians themselves have of their own power and its evolution, this paper examines 28 bills adopted by the National Assembly of Québec between 2001 and 2008 that affect the medical profession and medical practice to varying degrees. This exercise tends to indicate that medical power is undergoing both a relative degree of erosion and a consolidation, depending on whether one focuses on the control of conditions of the exercise of practice, or on the hegemonical status of the profession within the health-care sector

Perceived conflict in the couple and chronic illness management: Preliminary analyses from the Quebec Health Survey

BACKGROUND: The quality of the relationship with the spouse/partner appears crucial among patients with multiple chronic conditions where illness management is complex and multifaceted. This study draws on data from the Quebec Health Survey (QHS) to examine, among patients with one or more chronic conditions, the relation between marital status, the perceived conflict with the spouse/partner, and what the patients do to manage their illness as well as how they perceive their health. METHODS: Data from the QHS 1998 were used. The sample included 7547 coupled adults who had one or more chronic health problems lasting more than 6 months. Independent variables included marital status, perceived conflict with the spouse/partner, and the number of chronic conditions. Illness management was defined broadly as a measure of the patient's efforts at self-care and an illness status indicator, including visits to the generalist and the specialist, the use of telephone health line in the last 12 months, self-rated general health, mental health, and a measure of psychological distress. Linkages between the independent variables and illness management were assessed for males and females separately with logistic regressions, while accounting for the survey sampling design and household clustering. RESULTS: Female patients who did not live with their partner and had never been married were more likely to report a negative perception of their general health and a higher psychological distress than those who were married. Perceived conflict with the partner was linked to a negative perception of mental health and a higher psychological distress among both men and women. Compared to patients with only one chronic condition, males who reported more than one chronic condition were more likely to have consulted a generalist prior to the survey and used the telephone health line, whereas females were more likely to have consulted a specialist. Both males and females with more than one chronic condition were more likely to have a negative perception of their general health and mental health. CONCLUSION: The study provides a useful preliminary measure of the importance of living arrangements and the quality of the couple relationship in chronic illness management broadly conceived as a measure of the patient's efforts at self-care and an illness status indicator. Results of this study prod us to examine more closely, within longitudinal designs, the influence of living arrangements and the presence of conflict in the couple on chronic illness management as well as the modifying effect of gender on these associations

Apport de l'humour dans les interventions d'agents pour soutenir le télé-apprentissage

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal

Alternative avenues in the assessment of driving capacities in older drivers and implications for training

The population aging, combined with the overrepresentation of older drivers in car crashes, engendered a whole body of research destined at finding simple and efficient assessment methods of driving capacities. However, this quest is little more than a utopian dream, given that car crashes and unsafe driving behaviours can result from a plethora of interacting factors. This review highlights the main problems of the current assessment methods and training programs, and presents theoretical and empirical arguments justifying the need of reorienting the research focus. Our discussion is elaborated in light of the fundamental principle of specificity in learning and practice. We also identify overlooked variables that are deterministic when assessing, and training, a complex ability like driving. We especially focus on the role of the sensorimotor transformation process. Finally, we propose alternative methods that are in-line with the recent trends in educational programs that use virtual reality and simulation technologies

Comorbidity and glycemia control among patients with type 2 diabetes in primary care

Reports on the relationship between comorbidity and glycemia control in diabetic patients are conflicting and the method of measuring comorbidity varies widely among studies. The aim of the present study was to evaluate the relationship between diabetes control and comorbidity, taking into account all comorbidities and their severity, in a primary care setting. We performed a retrospective descriptive study based on chart review of 96 randomly selected type 2 diabetic patients. Comorbidity was measured with the cumulative illness rating scale (CIRS), an exhaustive comorbidity index. Diabetes was considered as controlled if the mean value of two measurements of glycosylated hemoglobin A (HbA1c) was less than 7%. Taking diabetes control as the dependent variable, its relationship with the CIRS score, age, sex, diabetes duration, and diabetes-related complications was explored. Diabetes control was not significantly related with the CIRS score, age, sex or diabetes severity. Diabetes duration was the only variable significantly related to diabetes control. Our study suggests that comorbidity measured with the CIRS in patients with type 2 diabetes is not a factor that prevents the achievement of a good glycemia control

Older adults with mild cognitive impairments show less driving errors after a multiple sessions simulator training program but do not exhibit long term retention

The driving performance of individuals with mild cognitive impairment (MCI) is suboptimal when compared to healthy older adults. It is expected that the driving will worsen with the progression of the cognitive decline and thus, whether or not these individuals should continue to drive is a matter of debate. The aim of the study was to provide support to the claim that individuals with MCI can benefit from a training program and improve their overall driving performance in a driving simulator. Fifteen older drivers with MCI participated in five training sessions in a simulator (over a 21-day period) and in a 6-month recall session. During training, they received automated auditory feedback on their performance when an error was noted about various maneuvers known to be suboptimal in MCI individuals (for instance, weaving, omitting to indicate a lane change, to verify a blind spot, or to engage in a visual search before crossing an intersection). The number of errors was compiled for eight different maneuvers for all sessions. For the initial five sessions, a gradual and significant decrease in the number of errors was observed, indicating learning and safer driving. The level of performance, however, was not maintained at the 6-month recall session. Nevertheless, the initial learning observed opens up possibilities to undertake more regular interventions to maintain driving skills and safe driving in MCI individuals

Comparative assessment of three different indices of multimorbidity for studies on health-related quality of life

BACKGROUND: Measures of multimorbidity are often applied to source data, populations or outcomes outside the scope of their original developmental work. As the development of a multimorbidity measure is influenced by the population and outcome used, these influences should be taken into account when selecting a multimorbidity index. The aim of this study was to compare the strength of the association of health-related quality of life (HRQOL) with three multimorbidity indices: the Cumulative Illness Rating Scale (CIRS), the Charlson index (Charlson) and the Functional Comorbidity Index (FCI). The first two indices were not developed in light of HRQOL. METHODS: We used data on chronic diseases and on the SF-36 questionnaire assessing HRQOL of 238 adult primary care patients who participated in a previous study. We extracted all the diagnoses for every patient from chart review to score the CIRS, the FCI and the Charlson. Data for potential confounders (age, sex, self-perceived economic status and self-perceived social support) were also collected. We calculated the Pearson correlation coefficients (r) of the SF-36 scores with the three measures of multimorbidity, as well as the coefficient of determination, R(2), while controlling for confounders. RESULTS: The r values for the CIRS (range: -0.55 to -0.18) were always higher than those for the FCI (-0.47 to -0.10) and Charlson (-0.31 to -0.04) indices. The CIRS explained the highest percent of variation in all scores of the SF-36, except for the Mental Component Summary Score where the variation was not significant. Variations explained by the FCI were significant in all scores of SF-36 measuring physical health and in two scales evaluating mental health. Variations explained by the Charlson were significant in only three scores measuring physical health. CONCLUSION: The CIRS is a better choice as a measure of multimorbidity than the FCI and the Charlson when HRQOL is the outcome of interest. However, the FCI may provide a good option to evaluate the physical aspect of HRQOL for the ease in its administration and scoring. The Charlson index may not be recommended as a measure of multimorbidity in studies related to either physical or mental aspects of HRQOL

Prevalence estimates of multimorbidity: a comparative study of two sources

<p>Abstract</p> <p>Background</p> <p>Published prevalence studies on multimorbidity present diverse data collection methods, sources of data, targeted age groups, diagnoses considered and study populations, making the comparability of prevalence estimates questionable. The objective of this study was to compare prevalence estimates of multimorbidity derived from two sources and to examine the impact of the number of diagnoses considered in the measurement of multimorbidity.</p> <p>Methods</p> <p>Prevalence of multimorbidity was estimated in adults over 25 years of age from two separate Canadian studies: a 2005 survey of 26,000 respondents randomly selected from the general population and a 2003 study of 980 patients from 21 family practices. We estimated the prevalence of multimorbidity based on the co-occurrence of ≥ 2 and ≥ 3 diseases of the seven diseases listed in the general population survey. For primary care patients, we also estimated multimorbidity prevalence using an open list of chronic diseases.</p> <p>Results</p> <p>Prevalence estimates were considerably higher for each age group in the primary care sample than in the general population. For primary care patients, the number of chronic diseases considered for estimates resulted in large differences, especially in younger age groups. The prevalence of multimorbidity increased with age in both study populations.</p> <p>Conclusions</p> <p>The prevalence of multimorbidity was substantially lower when estimated in a general population than in a family practice-based sample and was higher when the number of conditions considered increased.</p

Validation of a French-language version of the health education impact Questionnaire (heiQ) among chronic disease patients seen in primary care : a cross-sectional study

Background The Health Education Impact Questionnaire (heiQ) allows for the evaluation of the effects of education interventions provided to patients with chronic diseases. This study describes the process for the cross-cultural adaptation and validation of the heiQ into French (heiQ-Fv). Methods We undertook a systematic translation process followed by a validation study based on the secondary analysis of cross-sectional data from a longitudinal study. Participants in the validation study were adult patients from primary care clinics in Quebec, Canada, with one or more of the following diseases: diabetes, asthma, chronic obstructive pulmonary disease, cardiovascular disease; or one or more risk factors for these diseases. Main outcomes of the study were the French version of the heiQ-Fv and the validation analyses that included internal consistency, test-retest reliability, confirmatory factor analysis (CFA) and concomitant validity. Results The validation analysis was conducted on results from 332 participants. Cronbach’s alphas (internal consistency) for seven domains of the heiQ-Fv varied from 0.80 to 0.89; one domain scored 0.69. The test-retest analysis (n = 50) yielded intra-class correlation coefficients from 0.66 to 0.86. The CFA of the eight heiQ domains with the hypothesis of no correlation between the domains yielded a model that did not exhibit acceptable fit values. A model with the hypothesis of all domains correlated exhibited acceptable fit values (scaled chi-square = 1210.15, degrees of freedom = 712, p < 0.001; CFI = 0.98; RMSEA = 0.06; SRMR = 0.065). Results show a moderate correlation (concomitant validity) between five domains of the heiQ-Fv and the Self-Efficacy for Managing Chronic Diseases. We also found a moderate to strong correlation between the Emotional Wellbeing domain of the heiQ and the Kessler Psychological Distress Scale (K6) (r = 0.61; 95 % CI: 0.52 –0.69, p < 0.01). Conclusions The heiQ was translated into French using a rigorous translation process; the French-language version showed good psychometric properties. Health professionals and researchers in primary care settings may use the heiQ-FV to evaluate the impact of educational programs on patients with chronic diseases