Family Practice Vol. 16, No. 6, 596-599
© Oxford University Press 1999
Who in Brazil has a personal doctor?
Conceição Community Health Service, Rua Ramiro Barcelos 1508/302, 90.035-002 Porto Alegre (RS),
a Federal University of Rio Grande do Sul, Brazil and
b London School of Hygiene and Tropical Medicine, Keppel St, London, UK.
Stein AT, Costa M, Busnello ED and Rodrigues LC. Who in Brazil has a personal doctor? Family Practice 1999; 16: 596–599.
Received 4 January 1999; Revised 14 May 1999; Accepted 25 June 1999.
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Abstract |
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Background. Continued medical care (including having a personal doctor) is regarded as an essential aspect of a good health service.
Objectives. The objectives of the present study were to investigate the reasons for not having a personal doctor, and the satisfaction with the care received by patients with and without a personal doctor.
Methods. We conducted a cross-sectional study with data collected during 20 days over 6 months in the Emergency Service of the Conceição Hospital, the busiest emergency service in Porto Alegre. The subjects were 553 patients selected through systematic random sampling. The main outcome measure was having a personal doctor. Patients who reported usually to see the same doctor and remembered their physician's name were regarded as having a personal doctor.
Results. Patients who usually use primary care service represented 23% of the sample, and were four times more likely to have a personal doctor (OR = 3.83, CI 95% = 2.41–6.11). Independent, statistically significant variables associated with having a personal physician were: usually receiving care from a primary health care service (OR = 3.8, CI 95% = 2.39–6.00) and from a physician in the private sector (OR = 2.16, CI 95% = 1.15–4.00). Patients who had a personal doctor reported higher satisfaction with their access to health care. The personal doctors' specialties were: internal medicine (37%), cardiologist (17%), gynaecologist-obstetrician (13%), family physician (8%) and pneumologist (6%).
Conclusions. For patients who attend emergency services in Brazil, primary health care and private medical care provide better access to continuity of patient care. Patients with personal doctors report higher satisfaction with access to consultations.
Keywords. Continued medical care, personal doctor.
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Introduction |
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The benefits of a personalized and continued medical care include: better medical compliance, adequate notes, effective co-ordination between different providers and more effective communication between the patient and the physician. Continuity of care leads to a closer relationship as patients can identify who is their ‘personal doctor’.1,2 However, continued care is difficult to achieve in Brazil, especially in public health services. The disorganization of services, the financial need for physicians to have more than one job and emphasis on curative and episodic care contribute to the lack of continuity of care. It has been suggested that this leads to an overuse of emergency services.3
The objectives of the present study were as follows.
- To investigate the determinants of having a personal doctor:
- utilization of primary health care versus outpatient clinics;
- the specialty of the physician that the patient usually consults for health care;
- utilization of private versus public health care; and
- perceived quality of life compared with another person of the same age.
- utilization of primary health care versus outpatient clinics;
- To evaluate satisfaction with the health services by patients who report having a personal doctor in comparison to those who do not.
Figure 1
describes the proposed web of causation of the determinant factors for having a personal doctor.
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Methods |
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The Emergency Service of the Conceição Hospital was the setting of the study. It is the busiest emergency service in Porto Alegre, with a catchment area of about 2 million inhabitants. Conceição Hospital is a public general hospital with 917 beds, which provides internal medicine, obstetrics and gynaecology, and surgery. The Emergency Service for adults provides care freeof-charge 24 hours, daily. It is staffed by 33 internists, 10 surgeons, 5 gynaecologists and other auxiliary personnel, providing care for an average of 17 000 patients a month. The Community Health Service of Conceição Hospital has 13 health posts in the north area of Porto Alegre, which provide primary care by family physicians, nurses, social workers, psychologists and auxiliary personnel and is referred to in this paper as the ‘community health service’.
The subjects were included in a systematic random sample of patients attending the Hospital Conceição Emergency Service during 20 chosen days between January 6 and June 25 1996, during two periods every week: Saturday 12.00 p.m. to Sunday 12.00 p.m. and from Monday 12.00 p.m. to Tuesday 12.00 p.m. Five-hundred and fifty-three patients were selected and the response rate was 88%.
This was a cross-sectional study. The sample size was calculated to test with a confidence interval of 95% and 80% statistical power the hypothesis that patients who consult at a primary care service were twice as likely to have a personal doctor; 438 patients were required.
The main outcome measure was whether the patient had a personal doctor. In order to assess this we used the following question: "Do you usually see the same physician when you have a problem, and yes, what is her/his name?". Patients who did not remember their physician's name were regarded as not having a personal doctor.
Fourteen medical students and two general practice registrars participated as interviewers. They were blind to the hypothesis of the study. Data entry and analysis were performed using the software Epi-info, Egret and SPSS.4–6 The analysis included descriptive statistics, univariate analysis and logistic regression.7 Informed consent was sought from all who participated in this study. The ethical Committee of Conceição Hospital approved the research project.
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Results |
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The health service that the patients in this study seek most frequently when they have a health problem is the Conceição Emergency Service (30%); after this come the outpatient department of the same hospital (29%) and primary health care services (23%). The majority of patients (63%) reported that they had chosen an institution with 24-hour provision of care. Only 16% of the patients were seen by a private physician, 20% reported to earn less than the minimum wage and on average they reported 5 years of formal education. Therefore, the majority of patients who were seen at the Emergency Service were from low-income families.
Only 35% (194) reported that they usually consult with the same doctor, but 26 did not remember the doctor's name and were classified by the study as not having a personal doctor. The most frequent specialties of these personal doctors were: internal medicine (37%), cardiologist (17%), gynaecologist-obstetrician (13%), family physician (8%) and pneumologist (6%). In Table 1 it is shown that 52% of the patients who usually received care within primary care and 22% of those patients who usually had care at the hospital reported to have a personal doctor (P < 0.00001).
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Four hundred and ninety-six patients were included in a logistic regression where the outcome was having a personal doctor. The following variables remained statistically significant at the 5% level: usually receiving care from a primary health care service (OR = 3.8, CI 95% = 2.39–6.00) and from a physician in the private sector (OR = 2.16, CI 95% = 1.15–4.00). No statistically significant association was found with reported quality of life (comparing with people of the same age). The results were adjusted by social class and education.
In total, 42.5% of those patients who reported that the number of consultations they had was sufficient to keep them in good health had a personal doctor, compared with those who did not have a personal doctor, among whom only 28% reported that the number of consultations was sufficient. This was a statistically significant difference (P = 0.0005).
The main reasons reported by patients for not having a personal doctor was "not having an important disease", "physicians were not always present" and "only seek care when there is an emergency reason" (Fig. 2).
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Over 75% of frequent users of community health service, private practice and health maintenance organizations had a personal doctor (Table 2
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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Patients who usually use primary care service (consultation at the health post) represented 23% of the sample, and were four times more likely to have a personal doctor (OR = 3.83, IC 95% = 2.41–6.11). Independent determinants of having a personal doctor were usually seeking a primary health care service (OR = 3.8, CI 95% = 2.39–6.00) and receiving care from a private physician (OR = 2.16, CI 95% = 1.15–4.00). Patients who had a personal doctor were happier with the number of consultations they had. Most personal doctors were not family practitioners.
The sample of the present study represented the patients who attended the emergency service and could answer the interview. The response rate was high and responders and non-responders had similar social-demographic characteristics. It is unlikely that determinants of having a personal doctor vary among patients in emergency services or other people, but the services they use may do so.
Continuity of care is hard to measure. The definition of "having a personal doctor" we used is based on the nature and quality of contacts rather than their number,8 and it assumes that empathy and personal responsibility would increase the chances of the patient remembering the doctor's name.
Research among elderly men has shown that continuity of care provided by a personal doctor promotes positive attitudes by patients and its lack could have led to an increase of the duration of hospitalized days and low satisfaction.9 Haigh Smith found that continuity of care was a patient's third priority after a doctor who listens and a doctor who sorts out problems.10
Not all continued care was provided by primary care services in our study. There are some successful experimental services which describe specific primary care provision, including continuity of care, in accident and emergency (A&E) departments.8
The main determinants of having a personal doctor were usages of primary care services and private health services. The most common specialty of the personal doctor was the family physician or internist, but 55% reported a specialist as his or her personal doctor. In Brazil, there is an insufficient number of physicians trained in the general practice, and the population does not have universal access to physicians who work in a public environment that provides a comprehensive, personalized care and preventive approach as a priority.3
The higher satisfaction among patients with a personal doctor was not surprising. Studies have demonstrated consistently that access to a personal doctor who works at a primary health care is associated with better access of health services in general.11–13 Several publications have also shown that patients who have a regular source of health care use the emergency services more appropriately.14
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Conclusions |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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Among patients who attend emergency services in Brazil, primary health care and private medical care provide better access to continuity care. Patients with personal doctors report higher satisfaction with access to consultations.
Recommendations
There is a need to expand provision of primary care services with continuity of care and to explore further the role presently played by personal doctors outside the primary health setting as well as within it.
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Acknowledgments |
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We would like to express our gratitude to Andy Haines, who provided valuable input.
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References |
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1 Society for Academic Emergency Medicine. Ethics of emergency department triage: SAEM position statement. Acad Emerg Med 1995; 2: 990–995.[Medline]
2 Ettlinger PRA, Freeman GK. General practice compliance study: is it worth being a personal doctor? Br Med J 1981; 282: 1192–1194.
3 Machado MH. Perfil dos médicos no Brasil: análise preliminar. Rio de Janeiro: FIOCRUZ/CFM-MS/PNUD, 1996.
4 Dean AG, Dean JA, Coulombier D et al. Epi Info, Version 6: a word processing, database, and statistics program for epidemiology on microcomputers. Center for Disease Control and Prevention, Atlanta, Georgia, USA, 1994.
5 EGRET. Statistics and Epidemiology. Research Corporation and Cytel Sofware Corporation, 1991.
6 Norusis M. Statistical Package for Social Science—SPSS. Chicago, 1986.
7 Kirkwood BR. Essentials of Medical Statistics. Oxford: Blackwell Scientific Publications, 1988.
8 Freeman GK, Meakin RP, Lawrenson RA, Leydon GM, Craig G. Primary care units in A&E departments in North Thames in the 1990s: initial experience and future implications. Br J Gen Pract 1999, 49: 107–110.[Medline]
9
Wasson JH, Sauvigne AE, Mogielnicki P et al. Continuity of outpatient medical care in elderly men. A randomized trial. JAMA 1984; 252: 2413–2417.
10 Haigh-Smith C, Armstrong D. Comparison of criteria derived by government and patients for evaluating general practitioner services. Br Med J 1989; 299: 494–496.
11 Dietrich AJ, Marton KL. Does continuous care from a physician make a difference? J Fam Pract 1982; 15: 929–931.[Web of Science][Medline]
12 Starfield B. Primary Care: Concept, Evaluation, and Policy. New York, NY: Oxford University Press, 1992.
13 Alpert JJ, Kosa J, Haggerty RJ et al. Attitudes and satisfactions of low-income families receiving comprehensive pediatric care. Am J Pub Health 1970; 60: 499.
14
Robertson-Steel IRS. Providing primary care in the accident and emergency department: the end of the inappropriate attender. (Editorial.) Br Med J 1998; 316: 409–410.
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