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Objective To assess the effect of general practitioner testing for C reactive protein (disease approach) and receiving training in enhanced communication skills (illness approach) on antibiotic prescribing for lower respiratory tract infection.Design Pragmatic, 2×2 factorial, cluster randomised controlled trial.Setting 20 general practices in the Netherlands.Participants 40 general practitioners from 20 practices recruited 431 patients with lower respiratory tract infection.Main outcome measures The primary outcome was antibiotic prescribing at the index consultation. Secondary outcomes were antibiotic prescribing during 28 days’ follow-up, reconsultation, clinical recovery, and patients’ satisfaction and enablement.Interventions General practitioners’ use of C reactive protein point of care testing and training in enhanced communication skills separately and combined, and usual care.Results General practitioners in the C reactive protein test group prescribed antibiotics to 31% of patients compared with 53% in the no test group (P=0.02). General practitioners trained in enhanced communication skills prescribed antibiotics to 27% of patients compared with 54% in the no training group (P<0.01). Both interventions showed a statistically significant effect on antibiotic prescribing at any point during the 28 days’ follow-up. Clinicians in the combined intervention group prescribed antibiotics to 23% of patients (interaction term was non-significant). Patients’ recovery and satisfaction were similar in all study groups.Conclusion Both general practitioners’ use of point of care testing for C reactive protein and training in enhanced communication skills significantly reduced antibiotic prescribing for lower respiratory tract infection without compromising patients’ recovery and satisfaction with care. A combination of the illness and disease focused approaches may be necessary to achieve the greatest reduction in antibiotic prescribing for this common condition in primary care.Trial registration Current Controlled Trials ISRCTN85154857.

Introduction Pregnancy and childbirth are stages in a woman’s life that are associated with many different changes. These changes make normal pregnancy stressful and, if not adequately attended to, can have various irreparable effects on the fetus and the mother. Therefore, this study was conducted with the aim of evaluating the effect of an educational self-care intervention on the empowerment of primigravida pregnant women in the GP program in the city of Estahban. Materials and methods The present study was a randomized controlled trial. The sample included 80 pregnant primigravida women with a gestational age of 14–28 weeks. The samples were randomly selected and divided into an intervention group ( n  = 40) and a control group ( n  = 40). The method of sample selection for the generalizability of the study results and the maximum reduction of the socio-economic differences of the samples of the two control and experimental groups were selected from 4 health centers based in a simple random method, 2 centers along with the covered bases were selected as the control group and two other comprehensive health centers along with the covered bases were selected as the experimental group. In the selected databases, the names of eligible people were listed from the SIB system and among the mothers eligible to enter the study, 40 people were randomly considered as the control group and 40 people as the intervention group. Six sessions were held for the intervention group; however, the control group received no training. A posttest was conducted 1 month after the educational intervention for both the intervention and control groups. The data were analyzed via 3 questionnaires (demographic data, Kameda Empowerment of Pregnant Women and Self-Assessed Self-Care Empowerment in Pregnancy (SSAP)) and SPSS version 27 as well as chi-square tests, independent t-tests and paired t-tests. Results One month after the intervention, a significant difference was observed in all the constructs of the Pender health promotion model and empowerment subscales compared to with those of the control group ( p  < 0.001). In the in-group comparison in the intervention group, although no significant differences were observed in the interpersonal influence structure and future image, social support or joy in addition to the family subscales, the mean scores increased. Conclusion Self-care interventions based on Pender’s health promotion model can increase the ability of pregnant primigravida women to address common problems during pregnancy and thus improve pregnancy outcomes. To achieve significant changes in the interpersonal influence structure and future image, social support and the joy of an addition to the family subscales, more educational sessions, together with their trusted supporters, including their husbands, are emphasized. Trial registration Before starting the current research, it was registered in the clinical trial portal with the specifications of the clinical code Trial Id: 73547, IRCT Id: IRCT20131014015015N23, Registration date: 2023–11-10, 1402/08/19 and Membership number: 15015.

Background Health literacy plays a vital role in effective patient-physician communication. Over the past decades, health literacy efforts have strengthened public empowerment by improving access to health information and its effective use. Despite this progress, there are still insufficient digitalized teaching materials in medical schools, especially in the post-pandemic era. To address this gap, this study developed an interactive e-book as a supplementary e-learning tool for fifth-year medical students during their family medicine clerkship. The e-book integrates game-based learning, multimedia content, and scenario-based simulations to enhance students’ knowledge, attitudes, and skills in health literacy. Methods A true experimental design was employed, involving 216 medical students randomly assigned to experimental ( n  = 110) and control ( n  = 106) groups. Students in the experimental group utilized the e-book alongside standard clerkship training, while the control group participated in standard training alone. Pre- and post-intervention assessments measured health literacy knowledge, attitudes, and skills using a validated questionnaire. Results Results showed the experiment group ( n  = 110) who read the e-book demonstrated greater improvements in health literacy knowledge, attitude, and skills than the control group ( n  = 106). Knowledge scores increased by 0.117 points, attitudes by 0.175 points, and skills by 0.162 points ( p  < 0.05). Students reported high satisfaction with the e-book’s engaging and interactive format, highlighting its potential for enhancing learning outcomes. Conclusions This study demonstrates the effectiveness of incorporating interactive digital tools into medical education to foster health literacy competencies, which should be expected in medical education and clinical pratical settings.

Background An important barrier to smoking-cessation counseling for physicians is a lack of education at the undergraduate level. Interactive methods such as peer role-play (RP) or modules utilizing standardized patients (SPs) may be effective for medical students to enhance their performance on tobacco cessation counseling. This study compared the effectiveness of a module using SPs to that of a RP module for undergraduate medical students on tobacco cessation counseling. Methods This study was conducted over a single week of the family medicine clerkship. One hundred and thirteen fourth-year medical students were randomized into either the SP group or the RP group. A RP module involved a ten-minute encounter between the student doctor and the student patient followed by five minutes of feedback from the observer student using a group developed checklist. In a SP module, each student was asked to interview a SP portraying a smoker with willingness to quit. After the encounter, the SP provided five minutes of direct oral feedback to the student. In both modules, the total intervention lasted three-and-half hours and was supervised by faculty staff. Students’ objective structured clinical examination (OSCE) scores were evaluated to determine their tobacco cessation counseling skills. Four evaluation periods were conducted at baseline, postintervention, post-clerkship, and before receiving the Korean medical licensing examination (KMLE). Students’ smoking knowledge test scores and counseling self-confidence levels at pre- and post-intervention were also compared. Results In both groups, post-intervention OSCE scores increased significantly compared to baseline (Cohen’s d 0.87, p  < 0.001 in SP group; d 0.77, p  < 0.001 in RP group). However, there were no differences between the two groups. Students achieved the highest OSCE score for smoking-cessation counseling before the KMLE. After training, student self-confidence and smoking-knowledge test scores increased significantly, regardless of the type of module. Self-confidence was higher in the SP group compared with the RP group ( d 0.37, p  = 0.01). Conclusions Peer role-play may be equivalent to the SP method with regard to knowledge and skills reported during smoking-cessation counseling and SP method may be better in self-confidence. Cost and student self-confidence may be important factors when choosing among the teaching methods for smoking-cessation counseling.

Background Musculoskeletal (MSK) complaints often present initially to primary care physicians; however, physicians may lack appropriate instruction in MSK procedures. Diagnostic and therapeutic injections are useful orthopedic tools, but inaccuracy leads to unnecessary costs and inadequate treatment. The authors hypothesized that trainees afforded the opportunity to practice on a cadaver versus those receiving visual-aided instruction on subacromial injections (SAI) will demonstrate differences in accuracy and technique. Methods During Spring of the year 2022, 24 Internal Medicine and Family Medicine residents were randomly divided into control and intervention groups to participate in this interventional randomized cadaveric study. Each group received SAI instruction via lecture and video; the intervention group practiced on cadavers under mentored guidance. Subjects underwent a simulated patient encounter culminating in injection of latex dye into a cadaveric shoulder. Participants were evaluated based on a technique rubric, and accuracy of injections was assessed via cadaver dissection. Results Twenty-three of twenty-four participants had performed at least one MSK injection in practice, while only 2 (8.3%) of participants had performed more than 10 SAIs. There was no difference in technique between control 18.4 ± 3.65 and intervention 19.2 ± 2.33 ( p  = 0.54). Dissections revealed 3 (25.0%) of control versus 8 (66.7%) of intervention injections were within the subacromial space. Chi-Square Analysis revealed that the intervention affected the number of injections that were within the subacromial space, in the tissues bordering the subacromial space, and completely outside the subacromial space and bordering tissues ( p  = 0.03). The intervention group had higher self-confidence in their injection as opposed to controls ( p  = 0.04). Previous SAI experience did not affect accuracy ( p  = 0.76). Conclusions Although primary care physicians and surgeons develop experience with MSK procedures in practice, this study demonstrates a role for early integrated instruction and simulation to improve accuracy and confidence. The goal of improving accuracy in MSK procedures amongst all primary care physicians may decrease costs and avoid unnecessary referrals, diagnostic tests, and earlier than desired surgical intervention.

The CellScope Oto® is a smartphone otoscope attachment allowing physicians to share diagnostic-quality images of the ears. Our primary objective was to evaluate the residents' accuracy in diagnosing acute otitis media in children using the CellScope Oto® attachment compared to traditional otoscope. A randomized crossover controlled trial was performed at a single, tertiary care, pediatric emergency department. Participants were a convenience sample of preschool children, consulting for fever and respiratory symptoms. All children were evaluated by two residents randomized to use the CellScope Oto® smartphone device or a traditional otoscope. The primary outcome was the diagnostic accuracy of residents in ear evaluation compared to pediatric otolaryngologist's using binocular microscopy. Secondary outcomes included the need for a second ear exam by the treating physician and parental preference. Between August 2015 and June 2016, 90 residents examined 100 patients. Six patients were excluded, leaving 94 children evaluated twice. Diagnostic accuracies were 0.69 (95% CI: 0.52 to 0.75) for the residents using a traditional otoscope and 0.74 (95% CI: 0.68 to 0.80) for those using the CellScope Oto® for an absolute difference of 0.06 (95% CI: −0.03 to 0.15). The emergency physicians reported no need for a control exam in 49/91 (54%) situations. Finally, 44 (47%) families preferred the CellScope Oto®, 26 (28%) the traditional otoscope and 23 (25%) had no preference. Residents using the CellScope Oto® had accuracies as good as those using the traditional otoscope to evaluate the ears of young children at risk of acute otitis media. www.clinicaltrials.gov: Identifier NCT02521597.

We reanalyzed the data from a cluster-randomized controlled trial (C-RCT) of a quality improvement intervention for prescribing antihypertensive medication. Our objective was to estimate the effectiveness of the intervention using both interrupted time-series (ITS) and RCT methods, and to compare the findings. We first conducted an ITS analysis using data only from the intervention arm of the trial because our main objective was to compare the findings from an ITS analysis with the findings from the C-RCT. We used segmented regression methods to estimate changes in level or slope coincident with the intervention, controlling for baseline trend. We analyzed the C-RCT data using generalized estimating equations. Last, we estimated the intervention effect by including data from both study groups and by conducting a controlled ITS analysis of the difference between the slope and level changes in the intervention and control groups. The estimates of absolute change resulting from the intervention were ITS analysis, 11.5% (95% confidence interval [CI]: 9.5, 13.5); C-RCT, 9.0% (95% CI: 4.9, 13.1); and the controlled ITS analysis, 14.0% (95% CI: 8.6, 19.4). ITS analysis can provide an effect estimate that is concordant with the results of a cluster-randomized trial. A broader range of comparisons from other RCTs would help to determine whether these are generalizable results.

Objective To assess the effects of a multifaceted educational intervention in Norwegian general practice aiming to reduce antibiotic prescription rates for acute respiratory tract infections and to reduce the use of broad spectrum antibiotics.Design Cluster randomised controlled study.Setting Existing continuing medical education groups were recruited and randomised to intervention or control.Participants 79 groups, comprising 382 general practitioners, completed the interventions and data extractions.Interventions The intervention groups had two visits by peer academic detailers, the first presenting the national clinical guidelines for antibiotic use and recent research evidence on acute respiratory tract infections, the second based on feedback reports on each general practitioner’s antibiotic prescribing profile from the preceding year. Regional one day seminars were arranged as a supplement. The control arm received a different intervention targeting prescribing practice for older patients.Main outcome measures Prescription rates and proportion of non-penicillin V antibiotics prescribed at the group level before and after the intervention, compared with corresponding data from the controls.Results In an adjusted, multilevel model, the effect of the intervention on the 39 intervention groups (183 general practitioners) was a reduction (odds ratio 0.72, 95% confidence interval 0.61 to 0.84) in prescribing of antibiotics for acute respiratory tract infections compared with the controls (40 continuing medical education groups with 199 general practitioners). A corresponding reduction was seen in the odds (0.64, 0.49 to 0.82) for prescribing a non-penicillin V antibiotic when an antibiotic was issued. Prescriptions per 1000 listed patients increased from 80.3 to 84.6 in the intervention arm and from 80.9 to 89.0 in the control arm, but this reflects a greater incidence of infections (particularly pneumonia) that needed treating in the intervention arm.Conclusions The intervention led to improved antibiotic prescribing for respiratory tract infections in a representative sample of Norwegian general practitioners, and the courses were feasible to the general practitioners.Trial registration Clinical trials NCT00272155.

Introduction: There is a trend towards GPs diversifying their role by working in health areas beyond general practice. However, little is known about whether this trend is apparent among early-career GPs once they make the transition from training to independent practice.Aim: To describe the prevalence of and characteristics associated with early-career GPs providing other medical work.Methods: A cross-sectional questionnaire-based study of GPs (‘alumni’) who had fellowed within the past 2 years from three of Australia’s nine regional training programs. The outcome factor was provision of medical work in addition to clinical general practice. Associations of independent variables (encompassing alumni demographics, current practice characteristics and vocational training experience) with the outcome were estimated using univariate and multivariable logistic regression.Results: Of 339 responding alumni, 111 (33%) undertook other regular medical work. Sixty-five (59%) of these were in medical education. In multivariable analysis, factors associated with providing other medical work were having a spouse/partner not in the workforce (odds ratio (OR) 5.13), having done any training part-time (OR 2.67), providing two or more of home visits, nursing home visits and after-hours care (OR 2.20), working fewer sessions per week (OR 0.74), and currently working in an area of lower socio-economic status (OR 0.84). Having dependent children (OR 0.27), and being female (OR 0.43) were associated with not providing other medical work.Discussion: In this study, many early-career GPs are providing other medical work, particularly medical education. Acknowledging this is important to general practice workforce planning and education policy.

AbstractObjective To test the effectiveness of educational interventions in improving detection rates and management of dementia in primary care.Design Unblinded, cluster randomised, before and after controlled study.Setting General practices in the United Kingdom (central Scotland and London) between 1999 and 2002.Interventions Three educational interventions: an electronic tutorial carried on a CD Rom; decision support software built into the electronic medical record; and practice based workshops.Participants 36 practices participated in the study. Eight practices were randomly assigned to the electronic tutorial; eight to decision support software; 10 to practice based workshops; and 10 to control. Electronic and manual searches yielded 450 valid and usable medical records.Main outcome measures Rates of detection of dementia and the extent to which medical records showed evidence of improved concordance with guidelines regarding diagnosis and management.Results Decision support software (P = 0.01) and practice based workshops (P = 0.01) both significantly improved rates of detection compared with control. There were no significant differences by intervention in the measures of concordance with guidelines.Conclusions Decision support systems and practice based workshops are effective educational approaches in improving detection rates in dementia.