Background and Objectives: The object of our study was to estimate the prevalence of psychotropic drug use among non-institutionalised elderly people 65 years or older and identify possible conditioning factors. Methods: A cross-sectional, observational study was carried out of 1161 subjects aged 65 years and older. Participants were randomly selected from health care registry listings. The main outcomes of interest were based on self-reporting and included consumption of psychotropic and other drugs (filed by the ATC Classification System), mood (based on the GDS-VE), cognitive status (Pfeiffer Questionnaire), physical-functional assessment based on Katz score, health problems (ICPC-2 classification WONCA) and socio-demographic variables. Results: The prevalence of self-reported psychotropic drug consumption was 20.5% (95% CI: 18.2 to 22.8). Anxiolytics and hypnotics were consumed by 16.6% of the elderly, antidepressants by 7.0% and antipsychotics by only 2.1%. In multivariate logistical analyses, the use of psychotropics was independently associated with other drug consumption (non-psychotropics), (OR: 4.0, 95% CI: 1.7 to 9.5), presence of established depression (OR: 3.2, 95% CI: 1.3 to 7.6), presence of 4 or more comorbidities (OR: 2.7, 95% CI: 1.9 to 3.8), being female (OR: 2.1, 95% CI: 1.5 to 3.0) and being dependent for basic activities of daily living (OR: 1.7, 95% CI: 1.0 to 2.6). Conclusions: The prevalence of psychotropic drug use among the elderly from Albacete is high. Several factors were identified as potential determinants of psychotropic drug use. It will be important to evaluate the misuse of these drugs in order to inform effective, efficient and safe prescription strategies.

RESUMO CONTEXTO E OBJETIVO: Um clima frio para a atenção primária na academia médica constitui uma barreira para escolher Medicina de Família (MF) como opção de carreira. Este estudo foi concebido para determinar se o conhecimento e as atitudes dos estudantes de medicina em relação à MF predizem a escolha da carreira. TIPO DE ESTUDO E LOCAL: Estudo de coorte realizado em duas faculdades de medicina. MÉTODOS: Depois de terem completado um curso de Cuidados Primários na Faculdade de Medicina de Albacete, em 2005-2006, 81 alunos do segundo ano foram convidados a responder a um questionário. No seu sexto ano (2009-2010), 79 estudantes de Albacete assim como 42 de Sevilha, tomados como coorte não exposta, foram convidados a responder também. Todos eles foram investigados sobre a escolha da especialidade em 2011. RESULTADOS: Em Albacete, 79 e 76 estudantes responderam no segundo e sexto anos, respectivamente, e 26 em Sevilha. Depois de terem concluído o curso de cuidados primários, 69,3% disseram que gostariam de se tornar médicos de família. Esta percentagem diminuiu para 40,3% no final da graduação (P < 0,0001). No sexto ano, as atitudes com relação à MF pioraram, mas estas foram significativamente mais favoráveis do que as de Sevilla. Apenas 12 alunos escolheram a MF; eles obtiveram pontuação significativamente piores no exame do que seus pares (P < 0,0001). CONCLUSÃO: Na Faculdade de Medicina de Albacete, a opinião dos alunos sobre a MF ao longo da graduação piorou; contudo ainda era melhor que as dos estudantes de Sevilha. Em qualquer caso, MF foi opção minoritária.

ABSTRACT: CONTEXT AND OBJECTIVE: A cold climate towards primary care (PC) within medical academia could form a barrier against choosing family medicine (FM) as a career option. This study was designed to determine whether medical students' knowledge of and attitudes towards FM predicted their career choice. DESIGN AND SETTING: Cohort study conducted at two different medical schools. METHODS: After completing a PC course at the Albacete Medical School in 2005-2006, 81 second-year students were asked to give responses to a questionnaire. In their sixth year (2009-2010), 79 students in Albacete and 42 in Seville (taken as an unexposed cohort) were asked to give responses too. Their choice of specialty was investigated in 2011. RESULTS: In Albacete, the questionnaire was answered by 79 second-year and 76 sixth-year students; in Seville, it was answered by 26 sixth-year students. After completing the PC course, 69.3% said they would like to become a family doctor. This percentage decreased to 40.3% at the end of the undergraduate course (P < 0.0001). In the sixth year, the attitudes towards FM worsened, yet these were significantly more favorable than those in Seville. Only 12 students chose FM; they obtained significantly worse scores in their specialty selection examination than their peers (P < 0.0001). CONCLUSION: In the Albacete Medical School, the students' opinion about FM worsened over the undergraduate course, although it was still better than the Seville students' stance. In any case, FM was seen to be a minority option.

Unidades de Saude Familiar (USF) represent a model of primary care unknown to many people. Born within the reform of the Portuguese national health system, they arise from the need to provide a quality health care to citizens, improving the satisfaction of both users and professionals who work in it. This article will try to explain the working of these USF thanks to the opportunity to share medical consultation that the authors had at the USF-Oeiras Sao Juliao.

Las Unidades de Saudé Familiar (USF) suponen un modelo de Atención Primaria desconocido para muchos. Nacidas dentro de la reforma del sistema nacional sanitario portugués, surgen ante la necesidad de proporcionar unos cuidados de salud de calidad a los ciudadanos, mejorando la satisfacción tanto de los propios usuarios como de los profesionales que trabajan en ella. En este artículo trataremos de explicar el funcionamiento de estas USF gracias a la oportunidad que tuvimos los autores del mismo de compartir consulta en la USF de Sao Juliao-Oeiras.

The education of house physicians should include an evaluation of the competence they have acquired during their training. The current programme for this speciality establishes a training evaluation system whose aim is to monitor the achievement of teaching objectives. For this purpose tools such as self-assessment of objectives and activities performed, analysis of clinical records, analysis of case studies, demonstrations of diagnostic and treatment techniques, analysis of records in the Specialist in Training Book, analysis of other records concerning theoretical-practical activities, video recordings, objective, structured clinical evaluation, as well as other systems for the evaluation of teaching objectives. Furthermore for the total evaluation, in addition to the above mentioned tools, the following are proposed: a record of the compliance to the activities, a record of attendance to the programmed activities, written multi-test assessments and others that the Evaluation Committee may propose. We propose the use of a new tool: the Script Concordance Test, based on a cognitive theory of the development of clinical expertise ("the scripts theory"). This test places examinees in written, but authentic, clinical situations in which they must interpret data to make decisions. It is a written simulation test and can be either paper- or computer-based and can be used in undergraduate, postgraduate, or continuing medical education. It is designed to probe whether the clinical knowledge of examinees is efficiently organized for making appropriate clinical decisions, whether these are related to diagnosis, investigation or treatment.

La tutorización de residentes debe incluir una evaluación de la adquisición de competencias a lo largo de su formación. El actual programa de la especialidad establece un sistema de evaluación formativa con el fin de monitorizar la consecución de los objetivos docentes, para la que se proponen instrumentos como la autovaloración de objetivos y actividades realizadas, análisis de registros clínicos, análisis de casos clínicos, demostraciones de técnicas diagnósticas y terapéuticas, análisis de los registros anotados en el Libro de especialista en formación, análisis de otros tipos de registros referentes a actividades teórico-prácticas, vídeo-grabaciones, evaluación clínica objetiva y estructurada, no descartando otros sistemas de valoración de objetivos docentes. Por otra parte, para la evaluación sumativa, además de los anteriores instrumentos, se proponen el registro de cumplimiento de actividades, el registro de asistencia a actividades programadas, evaluaciones escritas multitest y otros que puedan ser propuestos por la Comisión de Evaluación. Proponemos el uso de un nuevo instrumento: el Test de Concordancia de Scripts, basado en una teoría cognitiva del desarrollo de la pericia clínica ("teoría de los scripts"). Este test sitúa a los examinados ante situaciones clínicas escritas, pero auténticas, en la que tienen que interpretar datos para tomar decisiones. Pertenece al tipo de simulaciones escritas, pudiendo ser realizada con papel u ordenador, y puede ser usado en no graduados, graduados o en educación médica continuada. El test está diseñado para probar si la organización del conocimiento clínico permite decisiones clínicas adecuadas, ya sean diagnósticas, de investigación o terapéuticas.

There is a wide variability in the proportion of graduates from the different medical faculties that opt to work in Primary Care. Many articles have been published about the selection of primary care specialities by graduates of medicine. The interest in this mainly arises from the conviction that there are an insufficient number of doctors in primary care to meet the health demands (the aim being that at least 50% of doctors should work in this area). Different theories have been formulated to explain the decisions taken when choosing a career in medicine and student's background, skills, personality and experience have all been proposed as factors that influence this career choice. Graduates choose a career that satisfies their preferences and priorities and is compatible with the restrictions posed by their abilities and lifestyle. Demographic characteristics, their personality and previous experiences all affect how they process the information they receive in the Faculty, which finally determines the career they choose. A preference for primary care has been related to a biosocial orientation, compared to a bioscientific one, and it has also been shown that attitudes towards general medicine and the influence of other people are the factors with the most impact on the students' preference for this healthcare area.

Existe una gran variabilidad en relación con la proporción de graduados de las diferentes Facultades de Medicina que se decantan por la atención primaria. Se ha desarrollado una importante producción de literatura en relación con la selección de especialidades de atención primaria por parte de los graduados en medicina, interés que parte fundamentalmente de la convicción de que el número de médicos de atención primaria es inadecuado para enfrentar las necesidades de salud (con el objetivo de que al menos un 50% de los médicos se dedicaran a atención primaria). Se han formulado diferentes teorías acerca de la toma de decisiones para la elección de carrera en medicina, habiéndose propuesto los antecedentes de los estudiantes, del tipo de habilidad, personalidad y experiencia, como factores que influyen en su elección de carrera. Estos eligen una carrera que satisface sus preferencias y prioridades y es compatible con las restricciones impuestas por sus habilidades y condiciones de vida. Las características demográficas, personalidad y experiencias vitales previas influyen en cómo se enfrentan con la información en el ambiente de la facultad, y esto acaba por determinar la carrera que eligen. Se ha relacionado la preferencia por atención primaria con una orientación biosocial, frente a la biocientífica, al tiempo que se ha subrayado que las actitudes hacia temas de medicina general y la influencia de otras personas tienen el mayor impacto sobre la preferencia de los estudiantes por este nivel asistencial.

Background and objective: The aim of this study was to design and validate a scale to detect major depressive disorders in elderly individuals in primary care (Detection of Depression in the Elderly Scale [DDES]). Methods: We performed an observational and cross-sectional study for the validation of a scale, administered by means of a personal interview, in 259 patients aged 65 years old or older. Available instruments were reviewed and the questions were designed. Subsequently, a first pilot study was performed. In a second pilot study the reproducibility of the instrument was analyzed. The gold standard was the result of a standardized psychiatric interview performed by psychiatrists (DSM-IV criteria and SCAN interviews). Results: The intraclass correlation coefficients corresponding to the test-retest and inter-rater reliability were 0.858 (95% confidence interval [CI], 0.634-0.946) and 0.908 (95% CI, 0.726-0.969) respectively. Two hundred sixteen subjects underwent an assessment, in which primary care and psychiatric evaluations were blinded. Major depression was diagnosed in 81 patients (37.5%; 95% CI, 31.1-44.4). The internal consistency of the DDES was good (Cronbach's alpha = 0.79). Exploratory factorial analysis revealed an 8-component structure (55.8% of explained variance). A cutoff score of 15 or more for the DDES showed sensitivity of 90.1% (95% CI, 80.95-95.33), specificity of 74.8% (95% CI, 66.48-81.71) and a likelihood ratio (+) of 3.58 (95% CI, 2.65-4.83). Conclusions: The DDES is a clinically useful instrument for the detection of major depression in elderly patients in primary care.

Fundamento y objetivo: Elaborar y validar una escala para detectar trastornos depresivos mayores (TDM) en ancianos que utilizan las consultas de atención primaria (Escala para la Detección de Depresión en Ancianos [EDDA]). Métodos: Estudio observacional transversal para validar una escala, administrada mediante entrevista personal, en 259 pacientes de 65 o más años. Tras revisar los instrumentos disponibles y elaborar los ítems, se realizó una primera prueba piloto o pretest. En una segunda prueba piloto se analizó la reproducibilidad del instrumento. El estándar de oro fue el resultado de una entrevista psiquiátrica estandarizada realizada por psiquiatras (criterios DSM-IV y entrevista SCAN). Resultados: Los coeficientes de correlación intraclase (CCI) correspondientes a la fiabilidad intra e interobservador fueron, respectivamente, de 0,858 (intervalo de confianza [IC] del 95%, 0,634-0,946) y 0,908 (IC del 95%, 0,726-0,969). El número de sujetos válidos para el estudio fue de 216 ancianos, en quienes se realizó, de forma ciega, una valoración en consultas de atención primaria y de psiquiatría. En éstas se objetivó la existencia de un TDM en 81 de ellos (37,5%; IC del 95%, 31,1-44,4). La EDDA mostró una elevada coherencia interna (* de Cronbach = 0,79). El análisis factorial determinó que existían 8 factores capaces de explicar el 55,8% de la varianza total. Para una puntuación mayor o igual a 15, la EDDA presenta una sensibilidad del 90,1% (IC del 95%, 80,95-95,33), una especificidad del 74,8% (IC del 95%, 66,48-81,71) y un cociente de probabilidad positivo de 3,58 (IC del 95%, 2,65-4,83). Conclusiones: La EDDA es un instrumento clínicamente útil para la detectar los TDM de los ancianos en la atención primaria.

Background and objective: The aim of this study was to design and validate a scale to detect major depressive disorders in elderly individuals in primary care (Detection of Depression in the Elderly Scale [DDES]). Methods: We performed an observational and cross-sectional study for the validation of a scale, administered by means of a personal interview, in 259 patients aged 65 years old or older. Available instruments were reviewed and the questions were designed. Subsequently, a first pilot study was performed. In a second pilot study the reproducibility of the instrument was analyzed. The gold standard was the result of a standardized psychiatric interview performed by psychiatrists (DSM-IV criteria and SCAN interviews). Results: The intraclass correlation coefficients corresponding to the test-retest and inter-rater reliability were 0.858 (95% confidence interval [CI], 0.634-0.946) and 0.908 (95% CI, 0.726-0.969) respectively. Two hundred sixteen subjects underwent an assessment, in which primary care and psychiatric evaluations were blinded. Major depression was diagnosed in 81 patients (37.5%; 95% CI, 31.1-44.4). The internal consistency of the DDES was good (Cronbach's alpha = 0.79). Exploratory factorial analysis revealed an 8-component structure (55.8% of explained variance). A cutoff score of 15 or more for the DDES showed sensitivity of 90.1% (95% CI, 80.95-95.33), specificity of 74.8% (95% CI, 66.48-81.71) and a likelihood ratio (+) of 3.58 (95% CI, 2.65-4.83). Conclusions: The DDES is a clinically useful instrument for the detection of major depression in elderly patients in primary care.

Fundamento y objetivo: Elaborar y validar una escala para detectar trastornos depresivos mayores (TDM) en ancianos que utilizan las consultas de atención primaria (Escala para la Detección de Depresión en Ancianos [EDDA]). Métodos: Estudio observacional transversal para validar una escala, administrada mediante entrevista personal, en 259 pacientes de 65 o más años. Tras revisar los instrumentos disponibles y elaborar los ítems, se realizó una primera prueba piloto o pretest. En una segunda prueba piloto se analizó la reproducibilidad del instrumento. El estándar de oro fue el resultado de una entrevista psiquiátrica estandarizada realizada por psiquiatras (criterios DSM-IV y entrevista SCAN). Resultados: Los coeficientes de correlación intraclase (CCI) correspondientes a la fiabilidad intra e interobservador fueron, respectivamente, de 0,858 (intervalo de confianza [IC] del 95%, 0,634-0,946) y 0,908 (IC del 95%, 0,726-0,969). El número de sujetos válidos para el estudio fue de 216 ancianos, en quienes se realizó, de forma ciega, una valoración en consultas de atención primaria y de psiquiatría. En éstas se objetivó la existencia de un TDM en 81 de ellos (37,5%; IC del 95%, 31,1-44,4). La EDDA mostró una elevada coherencia interna (* de Cronbach = 0,79). El análisis factorial determinó que existían 8 factores capaces de explicar el 55,8% de la varianza total. Para una puntuación mayor o igual a 15, la EDDA presenta una sensibilidad del 90,1% (IC del 95%, 80,95-95,33), una especificidad del 74,8% (IC del 95%, 66,48-81,71) y un cociente de probabilidad positivo de 3,58 (IC del 95%, 2,65-4,83). Conclusiones: La EDDA es un instrumento clínicamente útil para la detectar los TDM de los ancianos en la atención primaria.