Showing papers in "Journal of Family Practice in 1979"

The relationship of health beliefs and a postcard reminder to influenza vaccination.

Abstract: The relationship of certain health beliefs to influenza vaccination and the effect of a postcard reminder on vaccination rates was studied among 232 high-risk patients. In agreement with the Health Belief Model tested, the patients vaccinated believed influenza to be more serious, believed they were more susceptible to influenza, and believed the vaccine to be more efficacious than did patients not vaccinated. Those not vaccinated were less satisfied with their medical care and felt the vaccine was more expensive than those vaccinated. A postcard reminding patients of influenza vaccination was an effective way to increase the vaccination rate. Patients receiving the card had a 59.7 percent vaccination rate compared to a 30.0 percent rate among those not receiving the postcard. This study suggests that a reminder postcard is an effective means to promote influenza vaccination and that these beliefs are important determinants of vaccination behavior.

Failed appointments: a review.

Abstract: Failed appointments disrupt office operations. Most studies involved hospital clinics with low socioeconomic populations, which have shown fail rates between 19 and 28 percent. Family practice centers report fail rates which vary from 5 to 11 percent. Young adults, adults with young children, and patients in low socioeconomics groups tend to increase the fail rate. Sex and race are probably not a factor. Reasons for failing appointments include communication problems, the absence of a sense of urgency for keeping the appointment, and the lack of a personal physician. An interval greater than two weeks between appointment scheduling and the appointment date places patients most at risk for failing the appointment. Mail and telephone reminders significantly reduced the fail rate and are cost efficient. Incentives are also used in reducing the fail rate. By examining the process, the patients, the provider, and the environment with respect to appointment keeping behavior, a more quantitative approach to research on the subject can be effected.

The quality of medical care: a concept in search of a definition.

Abstract: Patient care has two components: technical and interpersonal. The quality of technical management depends on the balance of its expected benefits and risks. The quality of the interpersonal process consists in conformity to legitimate patient expectations and to social and professional norms. Since this conformity is expected to result in social and personal benefit, a unified definition of quality can be derived by including the benefits and risks of both aspects of care. When the patient's health and welfare are judged by professional criteria, and the cost of care is not considered, one has an "absolutist" definition of quality. By contrast, an "individualized" definition accepts the informed patient's valuation of the consequences of care, and includes the cost to the patient as an unwanted consequence. The "social" definition includes monetary cost even when not borne directly by the patient, may place a different valuation on patients and their interests, and pays attention to the social distribution of the cost and net benefits of care. Thus, the physician who wishes to do the best for each patient may be in conflict with what society dictates to be the best of all. The health care professions must resolve this moral dilemma.

Effects of an educational feedback strategy on physician utilization of thyroid function panels.

Abstract: Physician overutilization of clinical laboratory tests has been well documented, but previous attempts aimed at changing this behavior have met with limited success. An educational feedback strategy was used to try to change physician behavior in ordering thyroid function panels (TFPs) in the Duke-Watts Family Medicine group practice. The rate of TFP ordering significantly decreased for three months following the intervention but rose to the preintervention level within six months. Senior residents appeared to be more responsive to the educational feedback than junior residents. Results obtained in this and other studies suggest that other factors compete with educational approaches in motivating physician behavior, and these override rational decision making.

Attitudes of women toward the gynecologic examination.

Abstract: This study was undertaken to determine why patients feel uncomfortable during the gynecologic examination, to assess general knowledge about the procedures, and to find out what would make the patient feel better about the examination. Nine hundred seventy-seven women sampled in 14 different health care facilities in the Salt Lake area in Utah filled out a two-page, self-administered questionnaire while waiting for a medical appointment. Results show that women feel less comfortable during the pelvic examination than they do during the breast examination; physical discomfort of the pelvic examination is the reason most frequently cited. There were 77.1 percent who stated they would feel better about the examination if the physician told them what was going to happen. Over 70 percent wanted to know more about their female organs, normal sexual functions and emotions, and reasons and procedures for the pelvic examination; 68.3 percent felt that knowing more would make them more comfortable. There were 46.5 percent who thought the use of a mirror for the woman to observe the examination was a good idea. Only 28.9 percent knew the rectum was examined. This study shows that women need and want to be educated about the gynecologic examination.

Depression in family practice: changes in pattern of patient visits and complaints during subsequent developing depressions.

Abstract: This study was done to characterize changes in patient behavior during specific time periods immediately before first, second, third, and fourth episodes of depression. Forty-three patients from a group of 154 depressed patients examined in an earlier study developed 59 subsequent episodes of depression, and these were the patients used in this study. Suitable age and sex matched controls were also examined for the same time periods. The depressed patients and controls were patients in a rural solo practice. The depressed patients showed increased number of patient initiated visits, increased incidence of hospitalization, increased number of functional complaints, increased number of pain complaints, and increased feelings of tension as compared to controls during the seven months prior to the diagnosis date of the first and each succeeding episode of depression. The study results indicate that increased numbers of office visits, functional complaints, pain complaints, and anxiety complaints can be harbingers of a clinical depression, whether it be the index (first) or a subsequent depressive illness.

Continuity of care in a family practice residency program.

Abstract: Continuity of care, one of the basic characteristics of family medicine, was studied over a 12-month period in a family practice residency program. Continuity was measured in three contact areas; office hours, after hours, and on the inpatient service. The intensity of continuity was defined at three levels, from encounters with the personal physician to those with physicians on other medical teams. Continuity was further assessed in relation to family encounters. Third year residents averaged 83 percent continuity with their individual patients and 70 percent with their assigned families. Residents from other years were noted to have lower levels of continuity. Similar figures were noted for family practice inpatients. Continuity of care in private practice occurs in about 80 percent of patient encounters and it seems reasonable and feasible to expect residency training programs to come close to this figure.

Emergency room misuse by medical assistance patients in a family practice residency.

Abstract: Four hundred individual Emergency Room records were retrospectively reviewed. Demographic data, complaint, diagnosis, and treatment were tabulated and analyzed by computer assistance. Judgment was not made regarding the necessity of physician consultation, but whether an Emergency Room visit was warranted considering the duration of the presenting complaint. During a time period when 29 percent of the total outpatient visits to the Family Practice Center Model Office were made by recipients of Medical Assistance, the same population accounted for 53 percent of the Emergency Room visits reviewed. Twenty-five percent of the 400 visits were judged to be unnecessary according to the pre-established criteria. Sixty-four percent of the unnecessary visits were by Medical Assistance patients. Of 304 total families represented, 73 were responsible for multiple visits. Thirty-one percent of these visits were unnecessary, whereas 21 percent of the visits made by families with single visits were unnecessary. In this family practice setting, it is concluded that Medical Assistance patients have a greater tendency toward inappropriate use of the Emergency Room when compared to non-Assistance patients.

Does continuing medical education improve the quality of medical care? A look at the evidence.

Abstract: Although continuing education has a long tradition within the medical profession, mandated continuing medical education is of very recent origin. The conceptual framework used to justify continuing medical education is that it exposes physicians to new knowledge, changes physician behavior, and favorably alters patient outcomes. Considerable evidence exists that physician knowledge can be increased, and that behavior can be changed, but there is very little to show an effect on patient outcomes. The effectiveness of continuing medical education is further clouded by such issues as consumerism, licensure politics, and professional standards review organization legislation. Family physicians should have a role in determining the outcome of the continuing medical education debate, as participants, as policy-setters, and as informed critics.

The nature and management of telephone utilization in a family practice setting.

Abstract: Study of the telephone practice in four family practice settings reveals a complex interaction between patients, physicians, and receptionists. Patients present a limited number of complaints--80 percent of complaints represent 25 common chief complaints, and 95 percent represent 50 chief complaints. Little difference was observed between the symptoms reported by patients to the physicians as compared to those received by the receptionist staff. Physicians are more likely to use the telephone contact to treat the patient's complaint with home care advice or a prescription. Receptionists are more likely to use the telephone contact for scheduling an office visit.

Podophyllum toxicity: case report and literature review.

Abstract: A case is reported of apparent podophyllum toxicity. The patient was a 17-year-old female Indian who had received some 3 to 8 cc of a 20 percent mixture of podophyllum resin in compound tincture of benzoin (approximately equal to 0.4 gm of podophylotoxin) as an application to her vulvar condylomata. She returned to the hospital 20 hours after application in a comatose state. On examination she demonstrated severe toxicity including bone marrow, liver, and central nervous system. She required a charcoal hemoperfusion at the University of Colorado, and six months after the event has several neurologic and physiologic sequelae. Podophyllum is a potentially severely toxic drug. Great care must be taken when treating patients with this drug. A large mass of condylomata or the status of pregnancy should be relative contraindications to the use of podophyllum.

Intestinal parasites in Laotian refugees.

Abstract: Laotian refugees relocated in the Columbus, Ohio, area were screened for intestinal parasites. Eight different pathogens were isolated. The prevalence of the various organisms ranged from 4 to 61 percent of persons affected and 18 to 100 percent of families. These data show a higher prevalence of parasitic disease than that revealed by previous observations by the Center for Disease Control among Southeast Asian refugees. It was also apparent that neither federal nor local programs were adequate to meet the special health care needs of these refugees nor to safeguard the health of communities they entered.

The family and cardiac rehabilitation.

Abstract: Family resources and needs are often overlooked in planning for rehabilitation of the individual following myocardial infarction. The acute ischemic event presents a massive disruption in the psychodynamic balance of the family, but it can provide an unparalleled opportunity for increased awareness and growth for all members of the family. An integrated program of emotional support, education, and physical activity is recommended to facilitate restoration of the individual's self-esteem. Formal family counseling provides a forum for resolution of fears and misconceptions and permits redefinition of roles within the family.

Maximal exercise testing--Bruce protocol.

Abstract: Maximal treadmill exercise testing is feasible for the family physician's office especially in a group setting. The Bruce Exercise Test is described in detail and is helpful in the diagnosis of asymptomatic coronary heart disease, following the course of coronary heart disease, diagnosis of other cardiac disease, and in preventive testing and exercise prescription. Sensitivity and specificity of ST changes may be improved by recognizing factors which cause false positive and negative ST responses. The Bruce Test is safe when the procedure is followed meticulously. There have been 2,490 tests performed in the laboratory of three family physicians without serious morbidity. The screening exercise test with preventive exercise prescription is particularly pertinent to the present day concepts of family practice.

The content of physician/patient communication in family practice.

Abstract: The verbal communication between physicians and patients was quantified in a total of 556 office visits to 22 general practitioners in Florida. 40% of these visits involved follow-up of chronic health conditions while the remaining 60% were for acute conditions of recent onset. The number of units of expression coded per office visit averaged 40 with the physician contributing 56% of the communication. The content of verbal exchanges focused on medical history taking (22%) patient responses to questions (23%) problem resolution of medical matters (23%) and discussion of social and family matters (11%). At 131 visits (24%) patients did not ask any questions. During interaction on medical matters physicians initiated 80% of the interview; in contrast in discussions of social and family matters patients instigated 70% of the interaction. The units of expression per visit varied by social class being 54.2 for upper class patients and only 32.8 for lower class patients. Patients with chronic health conditions also had a relatively high number of units of expression (49.3) per visit. There were too few cases in this study to make a detailed analysis of differences between individual physicians and their communication patterns; however physicians who acted as preceptors for medical students and residents averaged 42.8 units of expression per patient compared with 31.7 units for nonpreceptors. Overall these findings indicate that the acquisition of facts interpretation of symptoms and signs and formulation of a diagnosis are the major thrusts of physician interaction while patients are frequently more concerned with the impact of illness of social and family situations. Thus attention to psychosocial issues should be given more prominence in family practice.

Specialty preference and attitudes toward the aged.

Abstract: The relationship between the attitudes and knowledge regarding the aged and specialty preference of undergraduate medical students at three medical schools was studied. No significant differences in attitudes were found when students were classified by class (freshman, sophomore, junior, or senior) or by sex. A significant though weak relationship between class and level of cognitive knowledge was found. Students indicating a preference for family practice as a specialty demonstrated levels of cognitive knowledge which did not differ significantly from all other students. Similarly, attitudes of family practice students did not differ significantly from attitudes expressed by other students. However, when all students expressing a preference for a primary care specialty were compared to students expressing preferences for non-primary care specialties, primary care students had significantly more positive attitudes toward the aged than their peers. Levels of cognitive knowledge did not differ significantly. The data appeared to suggest that students selecting primary care specialties are somewhat more humanistic and empathetically oriented, at least in regard to the aged, than their peers while exhibiting essentially identical levels of cognitive knowledge. The implications of these findings for family practice education are discussed.

Orthopedic problems in family practice: incidence, distribution, and curricular implications.

Abstract: The spectrum of orthopedic problems encountered by family physicians in everyday practice has received little study in the past. This paper presents and analyzes the incidence and distribution of orthopedic problems in general/family practice based on four sources of secondary data. These sources include the National Ambulatory Medical Care Survey, a Family Practice Service in a large military teaching hospital, a state wide study in Virginia, and two community-based family practice settings in Washington State. Orthopedic problems constitute about ten percent of all office visits in family practice. Over one half of these involve chronic, nontraumatic musculoskeletal problems. Major differences are noted in the distribution of sprains, strains, and fractures in adults and children. Fractures of the hand, foot, forearm, lower leg, and clavicle comprise between 50 and 80 percent of fractures seen in the settings under study. This kind of information should be helpful in better defining goals and methods for graduate training of family practice residents in orthopedics.

Family practice residents' perceptions of behavioral science training, relevance, and needs.

Abstract: Fifty-six family practice residents representing programs in 23 different states were surveyed concerning their training experience in behavioral science. Questions covered three basic areas of concern: experiential content, subsequent relevance to family practice, and suggestions for curriculum improvement at the residency level. The results point out definite knowledge of medical psychology, psychiatric consultation to medical patients, and practical intervention skills. Suggestions are made concerning curriculum development in behavioral science which (1) emphasize some new areas of concern raised by the residents, (2) recommend a more practical, integrated approach beginning in the medical school training, and (3) emphasize a dual approach requiring skills in medical psychology and skills more traditionally subsumed under the "mental health" field.

A homestyle delivery program in a university hospital.

Abstract: The Homestyle Delivery Program, an alternative birth service at the University of California Davis Medical Center, Sacramento, is presented. The program was developed jointly by the departments of family practice, obstetrics, and pediatrics, in response to the needs and desires of patients and physicians to participate in a more natural family centered birthing process. A brief description of the program and data from the first 1 1/2 years of operation is given. This program, in contrast to many other alternative birthing programs, involves physicians in training; that is, residents in family practice and obstetrics who are being taught during their obstetrical training how to create and facilitate an intimate family oriented home-like birthing. Satisfaction with the program on the part of the participating families as well as physicians and program staff has been very high. Today, more families in this society are demanding this kind of alternative birthing experience; the Homestyle Delivery Program meets their needs and to data has demonstrated no increased risk to mother or infant.

Referral patterns of family physicians in an underserved rural area.

Abstract: This paper examines the rates and patterns of referral of four family physicians in an underserved rural area of Washington State. The majority of referrals made by the family physicians were for management of a particular problem outside the scope of practice of the physician. The referral rates ranged from 1.8 to 3.2 percent of all patient visits and were comparable with those previously reported. A National Health Service Corps physician had the highest rate of referral and a foreign medical graduate had the lowest rate of referral. These results may be explained by practice building incentives as well as the ability to establish ties with the referral network.

The after-hours call in family practice.

Abstract: Patient care after hours continues to be an important part of the work of family physicians, in spite of the trend towards increasing Emergency Room utilization. In this paper the literature concerning after-hours care in family practice is reviewed in terms of definition, demography, utilization, morbidity, and patient stereotypes. In the Family Practice Residency Program of the University of North Carolina, 4,760 after-hours calls were recorded over two years by residents and faculty physicians. Seventy-two percent of the calls were handled purely on the telephone with little variation for patient age groups. The overall call rate was 474 calls per 1,000 patients per year. Fever and skin wounds were the most frequent symptoms recorded and respiratory tract infections, minor trauma, and anxiety were the commonest diagnoses. Thirteen percent of the contacts engendered anger or frustration in the physician. A survey of patients calling after hours demonstrated a lack of congruence between physician and patient concerning the main reason for the call in over 30 percent of contacts.

Behavioral science and family practice: a status report.

Abstract: The purpose of this study was to assess the current status of behavioral science instruction in family practice residency training programs. The primary areas of interest were: (1) characteristics of those who teach behavioral science (number of persons teaching behavioral science by discipline and academic degree, number and percent of time behavioral science personnel employed, work responsibilities, academic unit responsible for instruction, description of those who provide inservice training in behavioral science ), (2) the relative importance of various behavioral science topics as perceived by faculty/staff (21 topics), and (3) preferred methods of instruction. The data revealed a wide variety of persons involved in behavioral science instruction, a strong emphasis placed on communication and counseling skills, and similar, but not innovative, teaching methods used for behavioral science instruction.

Effectiveness of faculty development workshops in family medicine.

Abstract: Family medicine programs need faculty well trained in the roles of educator, administrator, researcher, and clinician. While the need for faculty development is recognized in all colleges and departments, it is a particular problem in family medicine due to the shortage of faculty, diverse backgrounds of existing faculty, and current pressures to develop the research base for the discipline of family medicine. This study was conducted to gather information about the effectiveness of the two-to-three day workshop format for faculty development in family medicine. In a pre-post comparison and a nine-month follow-up of four faculty development workshops, significant and persistent changes were found in participants' ratings of their abilities to do faculty related skills. The three-day residential workshop was found to be an effective means for promoting faculty development.

The costs of a family practice residency ambulatory care program.

Abstract: The cost of patient care service and education occurring in a family practice residency unit of a community based prepaid health program was determined from accounting records. The cost of producing the same number of patient visits in comparable family practice units which did not have residents on-site was determined in a similar manner. The cost per visit in the residency unit was $15.53 while that in the nonresidency unit was $13.92. There was an excess cost of $1.61 per visit in the residency, or, based on the number of residents present, a net cost of $7 per resident per day. None of the costs of central residency program administration or of ambulatory based subspecialty rotations were included. While a small increase (ten percent) in productivity or efficiency would result in the residency patient care unit itself being self-sustaining, this study casts considerable doubt on the ability of the model family practice residency unit to offset the full costs of the ambulatory care portion of family practice residency training.

Teaching interpersonal skills in family practice: results of a national survey.

Abstract: The increasing recognition of the importance of a well-developed set of interpersonal skills to the competent family physician has resulted in a rapid growth in the formal teaching of interpersonal skills within family practice residencies. Of the 168 programs responding to a national survey of family practice residencies, 88 percent indicated that they have formal programs in interpersonal skills. It is estimated that there are well over 500 family practice faculty members who have special responsibilities in teaching interpersonal skills. While most programs address the component skills of the interpersonal process (eg, demonstrating empathy, information gathering, information giving, and psychological intervention), it is of concern that only about half offer explicit training in patient education (53 percent), specific types of counseling (eg, family counseling, 55 percent), or some of the specific interpersonal skills important in team practice and practice management (eg, supervisory skills). One of the most striking findings was that 88 percent of the reporting programs use videotechnology, with 77 percent of these planning to increase their use. Although most programs evaluate their interpersonal skills training using both indirect and direct assessment methods, only 25 percent attempt to use patient outcome as a measure of teaching effectiveness.