Primary Care

Primary Care

  • Rejina Kamrul added an answer:
    What are the most reliable measures (indicators) of treatment adherence in metabolic syndrome?
    We are looking at predicting adherence to medical and behavioral health care recommendations among individuals with metabolic syndrome. I'm curious if anyone might be able to provide personal insight into specific indicators (behavioral or otherwise) that have been effective/reliable in quantifying the construct of treatment adherence?
    Rejina Kamrul · University of Saskatchewan

    Successful management requires identification and addressing both root cause, barrier. Patient vary considerably in their readiness and capacity. Success can be defied as better quality of life. greater self esteem. higher energy level etc. There is an approach for obesity management from Canadian obesity network: www.obesitynetwork.ca

  • Jennifer Giddens added an answer:
    According to the American Association of Suicidology, a person commits suicide every 13.7 minutes. How can we reduce these statistics?

    Hi everyone! My name is Mandy. At the moment, I'm currently involved with a research study at UCSF, where we're doing a survey on how we can reduce suicide rates in primary care settings. According to the CDC, suicide rates in America are steadily increasing, becoming even higher than the rates of homicide. In fact, suicide is now the 10th leading cause of death, surpassing chronic liver disease.

    If you are a physician, nurse practitioner, or a physician assistant in the United States, it'll be great if you can help us fill out this 5-10 min survey! We already have about 120 responses for this study, but we're hoping to get more participants for a more extensive study. Here is the link! http://www.surveygizmo.com/s3/1607736/PCP-Perceptions-in-Clinical-Care

    Jennifer Giddens · Tampa Center for Research on Suicidality, Tampa FL

    I believe the best way to reduce the statistics of completed suicide (and even suicide attempts) is to completely revolutionize the way we understand suicidality.  The current models being followed are largely based on the works of Durkheim and Shneidman.  I do not believe these these models are correct for all of the cases of suicidality.  We need to start looking at suicidality in the same way we look at other disorders - based on phenomenology.  Doing so may lead to creating a classification system for suicidality disorders which may allow specific anti-suicidality treatments (not just anti-depressants or other treatments like CBT or DBT) to be found to help the people experiencing suicidality.  Without a classification system for different types of suicidality the results of any research will be muddled (just as the results would be muddled if you tested a treatment on a group of people with 'mood disorders' without specifically targeting those with Major Depressive Disorder).  Until then, researchers are kind of stuck because the likelihood of one treatment being effective for all types of suicidality is not very high (just as one treatment isn't effective for all mood disorders).

  • How Do I Validate Yale Food Addiction Scale (YFAS) In Another Language?

    In validating the YFAS in another language (Malay), I am curious to know if I would need to run factor analysis to see if the questions match the 8 domains (withdrawal, tolerance etc.) seen in the English version of YFAS? Or should I just run a Cronbach's alpha and determine the internal consistency of each domain and assume that it fits the model? If this is done, I would like to determine the validity through the test-retest method. Does this sound correct?

    Yogarabindranath Swarna Nantha · Ministry of Health Malaysia

    Hi Evelyne,

     Thanks for your feedback and it is never too late for any form of suggestion. In fact your advice came in at the right time. We are about to perform another round of pilot testing. I will consider running a confirmatory factor analysis once this is done. Take care and a tout a l'heure.

    Rabin

  • Is there a way of specifically testing the intrinsic motivation of physicians in primary care/tertiary care using a psychological framework?

    Intrinsic and extrinsic motivation are almost inseparable. At times they work dynamically. However, there are many examples of testing out the intrinsic motivation component in other fields, less so in healthcare. So is it possible to specifically isolate factors to measure intrinsic motivation amongst physicians?

    Yogarabindranath Swarna Nantha · Ministry of Health Malaysia

    Thanks for your feedback Eswaran. Unfortunately, there are not fixed or validated questionnaire for 'intrinsic' motivation. There are lots of those for general motivation assessments.

    I have already designed one and I am on the verge of testing it out but need to confirm if it is sound more a psychological point of view.

  • Carl Alexander Sorensen added an answer:
    Should we routinely screen for depression?

    Depression is a mood disorder that affects the way a person feels, thinks or behaves, which may impair social or occupational functioning, also depression is common in primary care and hospital settings, but it is often not recognised by healthcare professionals. Because depression is potentially treatable, there has been interest in screening patients who present to primary care settings. This has led to calls for screening programmes to aid detection and management.
    Multiple recommendations for clinicians for screening for depression in adults have been published. But the existing evidence on depression screening recommendations are far from unanimously accepted.

    Carl Alexander Sorensen · University of South Carolina

    In my opinion, depression is almost like a cough: it accompanies many medical conditions (both traditionally conceived and psychological) and depression screens could thus be an important initial screening tool. Additionally, many of the well-established tools have been adapted to, and tested in, numerous languages.

  • Dharma N Bhatta added an answer:
    Is there any evidence of link between banned cosmetics use and maternal mortality?
    The world is struggling with MDG 5. In developing countries like Tanzania, a comprehensive strategy has been put in place during the last 20 years involving many aspects such as family planning, education to prevent teenage pregnancies, focused antenatal care (where up to 95% of pregnant mothers attend antenatal care), increasing skilled labour attendance (over 51% of all deliveries now attended by trained midwife), addressing PPH (use of misoprostol) and even training on post abortion care. Despite the efforts, the reduction in maternal mortality does not seem to match achievements in the implementation of these interventions and overall improvement on the services. Furthermore, in urban settings, we still see a number of unexplainable maternal mortalities despite readily availability of the services provides through these national interventions. Thre is political will and even our President is now tasking Regional and District Administrative Officers to investigate the maternal deaths. Obviously, it is time to think beyond the box. Is there any evidence that exposure to dangerous chemicals such as mercury compunds, triclosan, lead acetate, phthalates, oxybenzene, etc via persistent use of banned prodiucts e.g. food, cosmetics etc contribute to maternal mortality? Would a survey to attempt to establish the relationship (if it exists) be useful?
    Dharma N Bhatta · PS University

    Concern is interesting but this can be the confounding factor for maternal mortality and other moralities also. ANC coverage can help to aware and educate the risk of mortality. ANC neither predict nor prevent the maternal mortality at all in rural and poor settings. You did not mention about BEOC and CEOC serivices, increment of these services can help to reduce MMR. If the exposure of those chemical is in higher level, it could be the possible risk factors.

  • Jenni Moore added an answer:
    What should integrated care look like in the General Practice?

    We're looking at mapping out processes of care in the primary care setting. What should integrated care look like in General Practice? And how can we measure the extent of integration?

    Jenni Moore · Northland District Health Board

    Interesting discussion and aligned with my work. In searching for measures of integration i have come across a paper form NZ by Sue Pullon et al: Developing Indicators of Service Integration for child health: Perception of service providers and families of young children in an area of high need in New Zealand, published in the Journal of Child Health care 12 august 2013. http://chc.sagepub.com/content/early/2013/08/02/1367493513496673

  • Michael F Weaver added an answer:
    What are the best indicators to use when assessing safe opioid prescribing in a primary care chart review?

    I would like to start some research on whether primary care opioid prescribing for chronic non-cancer pain meets current guidelines, especially for patient safety. There are too many recommendations in our guidelines to use all of them, some are more/less important, and some are difficult to operationalize for a chart review or ongoing quality improvement.  I have seen some initial work on quality/safety indicators for opioid prescribing by others in unpublished and grey literature.  Does anyone know which would be the best to use, and where/how this is being measured?

    Michael F Weaver · University of Texas Health Science Center at Houston

    In terms of identifying indicators to help determine more safe versus less safe opioid prescribing practices for quality improvement (and potential research), I recommend to look at frequency of certain physician behaviors that can be verified through more than one source during chart review.  Frequency of office visits, frequency of urine drug testing (that takes into account the frequency of office visits), frequency of prescription refill requests without an office visit, documentation of use of risk assessment tools (such as the ORT mentioned by Vahid Mohabbati), use of a pain medication agreement, documentation of at least one discrete and specific pain diagnosis, and co-prescription of riskier medications such as benzodiazepines (as mentioned by Yacov Fogelman).  These can be identified in the chart and verified by cross-referencing with lab results, pharmacy records, charges billed, etc. For some general examples of how this has been done, you may want to see the following articles:

    Yanni LM, Weaver MF, Johnson BA, et al: Management of chronic nonmalignant pain: A needs assessment in an Internal Medicine Resident Continuity Clinic. J Opioid Manage 2008;4:201-211.

    Chelminski PR, Ives TJ, Felix KM, et al: A primary care, multi-disciplinary disease management program for opioid treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Serv Res. 2005;5:3.

    Adams NJ, Plane MB, Fleming MF, et al: Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage. 2001;22:791-796.

  • Sukhmeet Singh Panesar added an answer:
    What are the barriers and facilitators to reporting errors in primary care?

    Patient safety reporting systems despite their limitations are great source of deriving insights into the delivery of safer care. Over the last 10 years, the national reporting and learning system has accrued over 10 million reports of patient safety incidents in England and Wales; most are from hospitals. Why does primary care especially in general practice lag behind?

    Sukhmeet Singh Panesar · Imperial College London

    Thanks for your response Clare (and all),

    Really impressive work going on in Scotland. In fact Paul and Neil will be sharing some of their lessons in the upcoming WHO Roadmap for Safer Primary Care. 

    SEAs do not routinely make it into the National Reporting and Learning System (NRLS) in England and Wales and so there is very little opportunity to aggregate the findings of all SEAs (likely 2 per GP, so about 70,000 in England and Wales per annum at the very least). Keen to explore what the levers and barriers would be for GPs to report more to the NRLS.

    Janet: thanks for your very valid point on TQM.

    Wj: Perhaps we need to rethink what patient safety means in primary care? You are right, most efforts and hence mechanisms of reporting were aimed at acute settings. Most GP practices have limited capabilities, for example there is no patient safety officer, risk manager, etc.

    Emilia: rating might be one option 

    Nathan - time constraint is such a problem and there is limited time, if any to do anything else other than seeing patients.

    Sudarshan: the box idea seems popular. An alternative might be for GP computer systems and hence electronic patient records to have some sort of ehealth intervention to highlight cases where unsafe care may have occurred and then discuss them monthly, perhaps?

    Eric: Great point on differences between LMICs and high-income countries.

  • Chai Eng Tan added an answer:
    How does nursing home care to elderly patients living in their own homes work?
    I´m a spanish primary care nurse and I'm interested in how nursing home care to elderly patients living in their own homes works in different countries.
    I appreciate your information.
    Chai Eng Tan · Hospital Universiti Kebangsaan Malaysia (HUKM)

    For the first question:

    The plan for domiciliary care under the Ministry of Health Malaysia is to be executed by the primary care team (currently being piloted in several states before nationwide implementation).  Postnatal home visits have been long established by the maternal and child health section of the public primary care clinics.  I am also a family medicine specialist who happens to have an interest in home care, and thus, am working together with the nurses to develop the service further.  In Singapore, it is also run by the Family Medicine / primary care unit. 

     

    For the second question:

    For the home care service offered by the teaching hospital I'm working in, patients referred to us are patients who have reasonable logistic difficulty to come to the hospital / clinic for nursing procedures, staying within the catchment area, and agreeable to the terms of service.  These include stroke patients, patients with spinal cord injuries, cerebral palsy, diabetic foot ulcers, post-amputation etc. 

     

    For the third question:

    Services offered are nursing procedures such as changing Ryle's tube, changing urinary catheters and suprapubic catheters, wound dressing, caregiver education and monitoring of blood pressure and capillary blood glucose.  We are working to extend our services and now we include doctors doing house calls for complex cases, and in future may coordinate with rehabilitation or dietetic services.  However, due to logistics, it is still very challenging to coordinate services from various other departments.  Our services are partially subsidized as our teaching hospital is under the purvey of the Ministry of Education, whereas clinics under teh Ministry of Health offer their services at an even more highly subsidized rates.  We don't have the facility for telemonitoring at the moment.  So I do envy the Australians as described by Ms Franks above. 

  • William R Hazzard added an answer:
    Who should treat elderly patients in a community? Their primary care physician or a specialist in geriatrics?
    Geriatric medicine is a distinct medical specialty with vast specific knowledge accumulated over the last 30 years. On the other side most present primary care community physicians have not been exposed to systematic geriatric education. How could this gap be bridged?
    William R Hazzard · Wake Forest School of Medicine

    To Jenice in particular (but all who may read this): Thanks for your efforts within the hard-working, futuristic (but currently much maligned) VA, where I worked as director of Geriatrics & Extended Care ar VA Puget Sound from 2000-2010): I could not agree more. I would only suggest substitution of  "gerontologize" for "geriatricize". Gerontologize rolls off the tongue more easliy, plus it encompasses all we do and know as a scientific discipline that studies and values life from conception through death as well as caring for those nearing the end of their lives. Good luck! Bill

  • Terry Richmond added an answer:
    Do you have any information on successful implementations of fall-prevention strategies in your country?
    We will be looking at the implementation of the fall-prevention strategies in the acute sector, primary care and nursing homes.
    Terry Richmond · Kingston General Hospital

    Daily mobility assessments and falls risk assessments by nursing staff .Identification of falls risk patients with use of falling star logos.Daily walking program by 2 personal care assistants on all patients over 65yrs admitted to medicine program that come from home,retirement home or rehab.Frequent audits.Daily discussuins of mobility status and falls risk at board rounds. 

  • Are there any review articles on integration of sleep medicine in a primary care setting?
    There are several studies on integrating mental health services in primary care. I am interested in integrating sleep medicine services in a primary care setting.
    Pandi-Perumal Seithikurippu Ratnas · Somnogen Canada Inc
    Here is the first edition of Primary Care Sleep Medicine:

    http://link.springer.com/book/10.1007%2F978-1-59745-421-6

    Second edition will be released in few months!
  • Aoife Lawton added an answer:
    What are the visual, clinical and verbal barriers and facilitators to disclosure of domestic violence in a primary care setting?
    I'm looking for research around patient engagement in primary care - GP setting. Specifically around domestic violence discovery and disclosure.
    Aoife Lawton · Health Service Executive
    Dear Daniel and Jeanettte, the author has now published her Thesis.
    I thought you might be interested in it. It is openly accessible in our repository, available at http://www.lenus.ie/hse/handle/10147/316150
  • Tim Noonan added an answer:
    Are you familiar with the notion of complementary and alternative medicine more than conventional primary care?
    Conventional medicine prides itself on being science-based, and shuns alternative medicine for being "unproven," however, many of the non-communicable diseases have been taken care of successfully by alternative medicine. Conventional medicine is still behind and it will send your health into a downward spiral.
    Tim Noonan · STAT Medical Transport
    "Eg desferrioxamine has been around for about 48 years as an iron chelator, I would consider that safe and effective (not withstanding, as with all drugs there can be side effects)."

    That is not evidence of safety or efficacy.

    Please provide some valid evidence.

    The macrolide antibiotics have been around for decades, which would be evidence of safety and efficacy according to your earlier mentioned standard.

    I have been critical of the rampant use of antibiotics, but they remain popular. The side effects are not really new.

    This is why we need to have high standards for evidence. Too many treatments are used without good evidence that the treatment is better than a similar drug with a better safety profile.

    Again, we need to raise our standards, not lower them.

    "I could go on, but I think it is incumbent upon all of us to be open minded and not follow slavishly."

    Why should we open our minds - if that means endangering our patients with treatments that are not safe and do not work?

    "We need to use what works, and saying a treatment does not work because it is a CAM is not an accurate statement."

    Here is what I wrote. If you want to quote me, go ahead, but do not make up statements that I did not make.

    "I include everything that does not have evidence of safety and efficacy - efficacy of improved outcomes that matter, not just surrogate endpoint outcomes.

    I hold alternative medicine to the same standard, but there does not appear to be anything of benefit to patients from alternative medicine."

    CAM is not useless because it is CAM, it is useless because there is no evidence that it works. Provide valid evidence and I will change my mind about any particular treatment that has valid evidence that it improves outcomes.

    If we cannot have an honest discussion among ourselves, how can our patients expect us to be honest with them?

    :-)
  • Closed account added an answer:
    How are EHRs influencing the safety of ambulatory care?
    Positively? Negatively? What is the evidence? What works? What doesn't? What is inspirational? What is a hazard? How do we know and what evidence do we have? If we don't have the evidence, how should we get it?
    I found your question intriguing. I was an EPIC software trainer and Go Live support consultant for an implementation in Connecticut in 2012. I found the experience exhausting, but I learned so much about the impact of data on patient management. One role I had was enforcer for the medication & problem list (meaningful use criteria) for admission, transfer to a new unit, and discharge. This required cooperation between the patient/family, ER, resident, nursing, and the physician of record's office. Our physician offices were the first to adopt EPIC. Once the whole suite of modules went live, it required rethinking the CPOE screens and workflow of patient care. Much of this occurred in real-time. You could not discharge a patient from the system without medication review and sign-off. Since that was a new practice, it led to many instances where my diplomatic skills were put to the test. But to the credit of the organization, we had an abundance of experienced support personnel 24/7 for the first 2 months to decrease any impact on patient safety. If you want to do a study, the EPIC trainers would be a good group for a qualitative interview. Many of them have been part of the training and implementation for several healthcare systems. You can find them on LinkedIn...a great source for a purposeful sample. For the large hospital systems with affiliate physician practices, the data you seek for a patient safety study can be de-identified and made available. Our medical center at UCONN has already started putting some data into RedCap (web based research database) and R2D2 (research registry and d-identified database).
  • Marsha Green added an answer:
    Does anyone know of good papers regarding implementation of clinical decision support systems in primary care?
    Looking at good (and bad!) examples of successful CDSS implementation in primary care/general practice
    Marsha Green · College of St. Scholastica
    Take a look at the Institute for Clinical Systems Improvement (ICSI) website - this is a collaborative program which conducts process improvement/standardization/protocols focused on delivering guidelines for multiple clinical topics that are related to primary care.
  • Rodney P Jones added an answer:
    Does a long time series of deaths in Scotland shed light on what is happening in urgent care?
    Analysis of a time series of monthly deaths in Scotland from 1990 to 2012 shows evidence for a series of infectious like events which also appear to be linked to increases in ED attendance, medical admissions and a wobble in the gender ratio.

    http://www.bmijournal.org/index.php/bmi/article/viewFile/167/117

    Is this the missing piece of information explaining what is happening in urgent health care?

    Your comments and thoughts would be welcome.
    Rodney P Jones · Healthcare Analysis & Forecasting, Camberley, UK
    Have submitted some more work which suggests that the transmission of the agent reaches a minimum in the summer suggesting Vitamin D is of vital importance. This is somewhat timely given the explosion of studies demonstrating the beneficial effects of vitamin D against mortality and morbidity. So until we can all come up with a better solution (immunization or low cost anti-viral) vitamin D for the elderly seems a sensible first step.
  • Fernando A. Alonso López added an answer:
    Can someone tell me how or if they are incorporating Spirometry in their primary care offices?
    HEDIS guidelines require us to do Spirometry to gauge the severity of COPD, preferably when the patient is not suffering an acute exacerbation. Would someone share with me how they are addressing that guideline?
    Fernando A. Alonso López · Servicio Cántabro de Salud
    We have 2 nurses with skills about spirometry to make all our health center need. Using an spirometer and calibration bubble all the weeks
  • Aziz Sheikh added an answer:
    How can we improve patient's safety in the Middle East Region?
    The incidence of preventable adverse events, errors and near misses is relatively high in developing countries. Can you share some successful programs to improve patient's safety by improving systems?
    Aziz Sheikh · The University of Edinburgh
    You may find it useful to take a look at this recent paper on global safety priorities for primary care: http://www.ncbi.nlm.nih.gov/pubmed/24260028
  • Joanne Pike added an answer:
    Are you aware of exemplar models of community based primary health care and/or integrated models of care for older adults with multimorbidities?
    I'm particularly interested in models that span multiple health and/or social care sectors.
    Joanne Pike · Glyndwr University
    Here in Wales we have a case management approach, whereby District Nurses and Case managers (nurses with an advanced practice qualification - at Masters level) work within an intergrated team. But there are many variations of this still, and it is an evolving service. The services are targeted at those living at home with multiple morbidities. The model is a development of the 'Evercare' or Kaiser Permenante model. Try this address for the strategic approach being taken. I know it's dated, but there have been progress reports published on the net.
    http://www.wales.nhs.uk/documents/serviceplane.pdf
  • James Harris added an answer:
    Can someone send me the the beck anxiety inventory for primary care 7 item self report instrument?
    Typically a 7 item self-report instrument
    James Harris · University of Phoenix
    David,

    Many Thanks! Have a good weekend; best, James
  • George Dowswell added an answer:
    Sexual dysfunction following cancer and cancer treatment: European perspectives on primary care service provision?
    I suspect that there's lots of good practice across Europe but that it is not being translated between settings and healthcare systems. Is anyone working on improving primary care diagnosis and treatment of sexual dysfunction? There are networks for primary care, cancer, sexual dysfunction but what about a network for primary care identification and treatment of sexual dysfunction following cancer?

    Such a network could engage clinicians from primary, secondary and tertiary care, not only with an interest in cancer, academics from a range of disciplines, patients and patient groups, policy makers.
    George Dowswell · University of Birmingham
    Thank you - Yesterday someone mentioned to me that HTA had funded a study at UCL so I really appreciate your helpful message - I was going to chase this up when I had found out a little more. You've made it easy now. George
  • Rahul Alam added an answer:
    How can I obtain GP/PALS/PCT/CCG complaints data?
    Has anyone had any experience in trying to obtain patient level complaints data from any of the above organisations?
    Rahul Alam · The University of Manchester
    Hi,

    That's really helpful - thank you. I'll pursue both these avenues.
    Many thanks again.
    Rahul Alam
  • Ezequiel R. Rodriguez Rey added an answer:
    How widespread is the trend to higher emergency department attendances?
    There has been recent alarm in the UK regarding a rapid increase in ED attendances which I suspect is far wider than just the UK. Any observations from elsewhere in the world?
  • Helena Britt added an answer:
    What are your thoughts on using computer aided diagnosis/differential diagnosis generators (DDx) - Patient net or SkyNet?
    Do clinicians routinely use differential diagnosis generators in primary/secondary care? We are undertaking a systematic literature review of their utility and trying to ascertain their feasability in UK General practice. Are they likely to be helpful or be a hindrance?
    Helena Britt · University of Sydney
    Dobn;t use them in Aus. Select a term from an interface terminology, whihc may be differential. Proivding a list of terms used by GPs is more frutiful thatn generating differential diagnoses in my view.
  • Juan M Mendive asked a question:
    Primary prevention of depression - can anyone help?
    Primary care environment to prevent depression from opportunistic approach. What is the quality of life implication of that?
  • Mark Laslett added an answer:
    In your opinon: Is healthcare a right or privilege? (Thank you for your replys)
    Health Care
    Mark Laslett · New Zealand Physiotherapy Board, Wellington, New Zealand
    @Marika. We are now getting to refined usage of words, and the issue of free will is entirely a separate discussion. However I will say this: when someone says "I must do this.." or "I have to.." does not mean that choice is excluded. Quite the opposite usually, since the individual has chosen one path from among others available. This is choice. The evidence that choices are free, however hard sometimes, is that people make them all the time. Sometimes people freely choose disastrous paths, sometimes beneficial ones. Often we don't know how we will respond to difficult choices until we are faced with the options or are in circumstances where choices must be made. While the unique circumstances of everyone's background (culture, geography etc) certainly shape many aspects of our behaviour, the freedom to act exists, and the proof is that people do, all the time, often entirely in contrast to what their culture, society and background would encourage or demand. None of these accidents of birth imply determinism. The issue of free will / determinism is an epistemological discussion, not a political one such as the question of rights i.e. freedom to act in a social context.

    The concept of voluntarism however is difficult to argue against, whether or not you are a determinist or advocate of free will. I don't, but one could argue that our genes, society or God determines our behaviour, but advocating voluntary interaction with others simply means not forcing others to your will. It is polite, it gives dissenters the opportunity to withdraw, and ensures that the concerted action of groups of individuals are not held together by anger and fear. It also requires groups with different viewpoints to acknowledge that other individuals and groups may differ in opinion, and that interactions with them should be polite, respectful and non-violent. Again there are mountains of evidence that such respect and politeness can exist among individuals and groups of diametrically opposed views. Most multicultural societies on Earth actually are rather peaceful, or at least relatively non-violent - and there are many. I live in one, and so do you I think. It is easy to be distracted by the criminals and small proportion of sociopaths who rape, murder and pillage innocent people, but most live their lives, interact with different folk of widely disparate beliefs and opinions. You might be surprised how many of your own friends disagree with you on very fundamental issues. I know I have many such friends. Friendships, social and business relationships are based on values held in common, and mostly we set aside the differences in favour of the benefits and pleasures and interactions resulting from the common values. Many long lasting and loving marriages are between individuals with vastly different philosophies and world views.

    Of course it is easier to support voluntarism if you accept the principle that individuals have free will and the individual rights to their own life, liberty and pursuit of happiness. This places others, regardless of their different or opposing views as one's equals with regards to the freedom to act - or not.

    If we differ on the the issue of free will, perhaps we can agree that the principle of voluntarism is a sound principle with which to interact with others? If so, then my points about the right to seek healthcare is a right, but the right to the services of healthcare providers needs to be questioned. As stated in earlier posts my belief is that the involuntary coercion of health care workers to provide service, or the involuntary support of taxpayers of healthcare workers and patients is unacceptable, still holds and follows directly from the principle of voluntarism.

About Primary Care

The primary research focus is on the prevention, early diagnosis and management of common illness in general practice - particularly childhood infection, cancer, cardiovascular disease and stroke. Primary care has recently developed a new stream of clinical research which seeks to improve the conceptual understanding and effectiveness of early and more reliable diagnosis and monitoring in a number of chronic diseases. The primary aim is that Primary care has an international reputation for developing innovative methods of research synthesis and research use to ensure that research findings change clinical practice.

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