Introduction

Families function as dynamic systems, where the different members stimulate each other to achieve common objectives. Family development is thus conceived as a chain of changes, in form and function, which follow evolution stages. The balance of positive and negative forces inside the family is translated into an evolution, and so the ability to respond to internal or external changes is vital to avoid discrepancies or clashes between the tasks and roles of the different family members.

In this sense, family physicians must be able to identify any potential dysfunction or difficulty inside the family, and to facilitate the compatibility of tasks in order to reestablish the continuity and good functioning of the family.

The family physicians' clinical aptitude is made up of a series of abilities intended to identify any signs and symptoms of dys-function. They must also be skilled in using auxiliary resources for the diagnosis and treatment of all these. Such an aptitude is measured by a structured and validated instrument.

Material and methods

This is an observational, prospective and comparative research of a 450 family physicians sample from 23 first level family health care medical clinics from the National Social Security Institute (Instituto Mexicano del Seguro Social: IMSS). All family physicians working at the clinics were included, excepting those who were at the time on vacation, worked the night shift, attended the ER, were absent or refused to participate.

Clinical aptitude for family dysfunction was measured in three areas: 1. Identification of risk factors for family dysfunction; 2. Diagnosis with an integral point of view and 3. Proposal, identification and guidance, which describes a physician's ability to judge decisions taken on case reports and to propose alternative actions.

Other variables taken into account were sex, age, specialty, years of experience, shift, clinic and type of contract.

Instruments. The instrument was designed to integrate theory and practice. It was conformed by real case reports, which were condensed, divided in sections, and followed by a series of ques-tions with three possible answers: «true», «false» or «I don't know». In total, there were 187 questions, 94 of which were true and 93, false. Correct answers accounted for one point, while incorrect ones rested one point; «I don't know» answers had no effect on the results.

There were 42 lines to explore risk factors; 24 to explore the use of diagnostic resources; 19 to explore the use of therapeutic resources; 36 to evaluate a physician's knowledge of family sociology; 42 to assess family psychology, and 24 designed to evaluate proposal abilities. It was all validated and standardized with a group of post-graduate medical residents in Family Medicine from Mexico City. The Richardson K index was 0.90.

Clinical aptitude was measured using an ordinal scale, where a random level «1» was defined by <60 points; a low «2» level by 60-99 points; an intermediate «3» level by 100-139 points, and a high «4» level by >140 points.

A descriptive and inferential statistical analysis was used with median, percentage, Mann-Whitney's and Kruskal-Wallis' tests. All this was then processed with the EPI INFO-6 and SPSS Plus software packages.

Ethical considerations. This is a risk-free research, as established in the Health Research section of the Mexican Health Law. Ne-vertheless, a signed acceptance form was required from all participants.

Results

Table 1 shows the general characteristics of the study sample. In turn, table 2 presents clinical aptitude to identify family dysfunction, sorted by clinic. Clinics B and D had, respectively, a median of 105 and 102, with similar ranges. There were no statistically significant differences among the subindexes of each clinic. The diagnosis median was higher than that for guidance.

Table 3 reveals a high level of clinical aptitude in 3% of the physicians, an intermediate level in 25%, a low level in 58%, and a random-defined level in 14%. There were no significant differences when clinical aptitude was correlated with sex, shift, type of contract, specialty and years of experience.

Discussion.

The main objective of a family dysfunction diagnosis is to reestablish the normal flow of a family's vital cycle with the support of a specialized physician. It has been reported that clinical aptitude measurement is useful to discriminate and establish the aptitude level of experiment and non-experiment physi-cians with the aim of creating educational opportunities.

A slight advantage, with no significant difference, was appreciated in physicians who attended patients in their offices, which suggests they are in a better position to gain a higher level of trust from their patients. This is due to the fact that they attend a regular set group of patients assigned to their offices.

Since the education of family physicians is aimed at offering an integral care to families, family dysfunction recognition is essential. Results also suggest a non-significant advantage from family physicians with curricular education (not all family physicians working at the IMSS have a degree in Family Medicine).

Experienced physicians (10 to 19 years on the job) showed another non-significant advantage, which pointed to the value of clinical practice. This is a powerful reason to promote continuous educational programs for family physicians.

Family physicians who worked the morning shift showed a non-statistical advantage over their afternoon shift counterparts. This could be explained by the fact that educational and other institutional activities are more likely to take place in the morning.

The educational model of family physicians should promote the physicians' involvement in understanding how to become active elements in gathering their own knowledge. Such a model should promote physicians' initiatives for the development of an experience based on constructive critic.

The current health care model is mainly focused on a biological interpretation of the health-disease process. However, this is only a partial approach which prevents the implementation of an integral clinical practice. From our research, we expect changes in institutional health care orientation and a reframing of the curricula of general and family physicians'.

Although the acquisition of clinical aptitude requires the physicians' experience and involvement in developing their own knowledge, our results do not reflect this ideal condition. This is due to the low percentage of clinical aptitude, which correlates with an evident inability for research and interpretation.

Half of the physicians were capable of elaborating diagnostic hypothesis and two thirds of them showed a adequate use of diagnostic resources, such as clinical tests, functional family diagnostic instruments and a guide to conform an integral family workup. All these should be useful educational tools to establish the social functions diagnosis of a family's members, together with their formal and informal roles and their importance in the healthdisease process.

Guidance requires the ability to judge decisions taken by other professionals and make suggestions for alternative actions in case reports. This latter skill includes the use of therapeutic resources for only less than half of the physicians know how to properly use these resources.

The use of instruments to measure aptitude, competency and work performance is a growing practice in continuous education and human resources formation. Even though these instruments are capable of discriminating high clinical aptitude, they cannot be used to account for this non-significant advantage, because educational activities are conceived as the consumption of infor mation and not as the acquisition of it from each one's experience. Overall, 58% of the family physicians showed a low level of clinical aptitude. Such a result reflects a poor ability to integrate daily experience.