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Showing papers in "Journal of Family Practice in 1981"


Journal Article•
TL;DR: This preliminary investigation suggests that nonverbal behavior of the physician in the patient-physician interview is important in determining patient satisfaction and understanding.
Abstract: The interview portion of 34 patient-physician visits at a family medical center was videotaped. Videotapes were screened by two judges in two major nonverbal categories, immediacy and relaxation. Physician and patient were scored separately at 40-second intervals for 11 component parameters of the two major categories. These scores were correlated with patient satisfaction and understanding, ascertained by post-interview questionnaire. For analytical purposes, patients were assigned to low or high satisfaction groups and low or high understanding groups. Statistically significant (P less than or equal to 05) differences between low and high satisfaction groups were demonstrated with respect to overall physician immediacy; five individual physician nonverbal parameters; and two individual patient nonverbal parameters. Similar statistical results were obtained for understanding groups. This preliminary investigation suggests that nonverbal behavior of the physician in the patient-physician interview is important in determining patient satisfaction and understanding.

163 citations


Journal Article•
TL;DR: Results of correlation analysis indicate that higher patient satisfaction was associated with greater interview length, increases in the proportional time spent by the physician in presenting information and discussing prevention, and shorter chart review times.
Abstract: This study examines the relationship between selected interview characteristics, particularly physicians' verbal behaviors, and levels of patient satisfaction and understanding. Twenty-nine initial patient interviews by 11 physicians at the University of Washington Hospital Family Medical Center were videotaped and rated using a modified Bales' technique. Questionnaires provided measures of patient satisfaction and understanding. Results of correlation analysis indicate that higher patient satisfaction was associated with greater interview length, increases in the proportional time spent by the physician in presenting information and discussing prevention, and shorter chart review times. Increased patient understanding was associated with increases in the proportional time spent presenting both information and opinions, close physical proximity, and reduced chart review time. Implications of the results are discussed as well as methodological issues relating to further research.

126 citations


Journal Article•
TL;DR: Future research in the area of continuity of care must provide reliable measures of the different continuity dimensions followed by well-controlled trials assessing the impact of these dimensions on the satisfaction, comfort, and health status of patients.
Abstract: Continuity of care is central to the philosophy and teaching of family medicine. Studies of continuity have yielded conflicting results with regard to outcomes. Reasons for this include a failure to agree upon a theoretical definition of continuity as well as failure to account for a number of influential determinants of the continuity process. It is suggested that continuity is an attitude based upon prior knowledge of and for each participant in the medical encounter. This attitude is made operational in a process consisting of five continuity dimensions: chronological, geographical, interdisciplinary, interpersonal, and informational. A working model of analysis is proposed, and the results of various studies are critically assessed. Future research in the area of continuity of care must provide reliable measures of the different continuity dimensions followed by well-controlled trials assessing the impact of these dimensions on the satisfaction, comfort, and health status of patients.

58 citations


Journal Article•
TL;DR: In this article, a set of core tacit beliefs which inhibit physicians from thinking psychosocially about their patients are identified and challenged. But these beliefs appear to be rigidly held but not examined or challenged.
Abstract: Although training in family medicine emphasizes a biopsychosocial approach to patients, many residents experience difficulties in carrying out the appropriate psychosocial part of their diagnosis and treatment. Through teaching family medicine residents in a year-long Balint and Difficult Patient seminar, there has emerged a consistent set of core tacit beliefs which inhibit physicians from thinking psychosocially about their patients. These beliefs appear to be rigidly held but not examined or challenged. This paper presents the major of these beliefs and for each a more realistic therapeutic reply. They are grouped into three categories: (1) beliefs concerning physician's role (eg, I must rule out organic disease; only then can I focus on psychosocial problems), (2) beliefs concerning what the patient supposedly wants or does not want (eg, my patients want me to rule out organic problems), and (3) physicians" fears about approaching patients as people (eg, if the patient has the same problem I do, how can I help if I have not helped myself). By making overt these tacit assumptions, this paper attempts to highlight core barriers to the implementation of biopsychosocial care, increase understanding of effective alternatives, and challenge physicians to examine their hidden beliefs about patient care and their approach to patients.

54 citations


Journal Article•
TL;DR: The structure, goals, and history of the COOP Project are described, together with the design, cost, and output of its computerized medical information system.
Abstract: This is the first of two papers describing the Primary Care Cooperative Information Project (COOP Project), a program that integrates the interests of community physicians, medical school faculty, and health policymakers. This integration has been accomplished through the uniting of 44 rural medical practices in Maine, New Hampshire, and Vermont with faculty at Dartmouth Medical School in clinical research, quality assurance, practice management, and continuing medical education activities. This paper describes the structure, goals, and history of the COOP Project, together with the design, cost, and output of its computerized medical information system.

44 citations


Journal Article•
TL;DR: A four-level model is proposed for clinical decision making in the investigation of lymphadenopathy, which takes into account knowledge of the problem's natural history, key initial findings, the value of time, and the costs and usefulness of laboratory studies.
Abstract: This paper presents data on the incidence and clinical spectrum of lymphadenopathy, then offers guidelines for clinical decision making in regard to this problem. Eighty cases were identified and reviewed, for an annual incidence of 0.5% in the study population. Most (70%) cases were discovered by patients themselves. Several clinical parameters important to the evaluation of lymphadenopathy were incompletely recorded in the medical record. Excepting node enlargement, few associated physical and laboratory findings were discovered. Isolated cervical nodes accounted for 44% of all cases while 24% of patients had enlarged nodes in more than one anatomic region. The most frequently performed laboratory test was the complete blood count (34%), and the most frequently positive test was the throat culture (30%). Twenty percent of patients received antibiotics. No cases of malignancy were discovered. A four-level model is proposed for clinical decision making in the investigation of lymphadenopathy. This takes into account: (1) knowledge of the problem's natural history, (2) key initial findings, (3) the value of time, and (4) costs and usefulness of laboratory studies.

43 citations


Journal Article•
TL;DR: There is a major need to improve the mental health component of residency training, which will enable physicians to better manage psychosocial problems in practice settings.
Abstract: A questionnaire survey of residency trained graduates and nonresidency trained family physicians showed both groups reporting relatively infrequent practice of behavioral medicine. Referrals and counseling sessions/visits produce a combined total of 20 activities per month, or two to four percent of all patient encounters, even though the physicians in the sample reported that 33 percent of their diagnoses were behavioral/psychological. More than 85 percent of the physicians reported access to more than one mental health provider. The six most common health problems encountered in the office were depression, anxiety, obesity, marital discord, alcohol abuse, and sexual problems. Physicians responding to this survey expressed an interest in continuing education programs that emphasize individual, marital, and parenting counseling, and psychopharmacology. There is a major need to improve the mental health component of residency training, which will enable physicians to better manage psychosocial problems in practice settings.

43 citations


Journal Article•
TL;DR: A survey of recent obstetrical research fails to document superior clinical results when this strategy is employed in routine obstetrical care, and doctors should adopt a flexible approach and match the degree and type of intervention to actual patient needs.
Abstract: Many currently accepted obstetrical practices exemplify a maximin strategy: making the best of the worst possible outcome, regardless of the actual probability of that outcome occurring. But a survey of recent obstetrical research fails to document superior clinical results when this strategy is employed in routine obstetrical care. Most research has studied obstetrical technologies in isolation rather than as parts of systems of interconnected interventions: this approach has tended to underestimate the risks of intervention and to overestimate the utility of a maximin strategy. Physicians practicing obstetrics should adopt a flexible approach and match the degree and type of intervention to actual patient needs. Better methods of assessing preventable prenatal risk are needed to allow identification of the rare-obstetrical patient requiring maximal intervention.

37 citations


Journal Article•
TL;DR: The results suggest that an increased emphasis be placed on the diagnosis of common psychiatric problems such as depression in family practice residency programs.
Abstract: The focus of this study was on the diagnosis of depression by family practice residents. The sensitivity and specificity of the residents for depression were determined by comparing their diagnoses with the results of an objective assessment of depression for a group of 222 ambulatory patients from a family practice center. The objective assessment involved the administration of the Beck Depression Index to the patients, whereas charts were audited for resident diagnoses. The results indicated that the sensitivity and specificity of the residents' diagnostic acumen for depression were .18 and .90, respectively. In addition, the operation of a sex stereotype was suggested by an analysis which revealed that a disproportionate number of females were diagnosed as depressed by the residents. These results suggest that an increased emphasis be placed on the diagnosis of common psychiatric problems such as depression in family practice residency programs.

34 citations


Journal Article•
TL;DR: Synthesis of the psychosocial and physical aspects of illness will occur naturally if the family physician is the teacher of family system concepts and the role model for their application in practice.
Abstract: Teaching the family system concept to physicians is difficult, as it entails a new way of thinking, at odds with the familiar linear medical model that focuses on the individual patient. This conceptual difference and the confusion between working with families in family medicine and family therapy explain the slow or superficial acceptance of family as the unit of care. Five principles have been found to be useful in teaching: (1) specific teaching techniques should take into account previous training and current time constraints; (2) evidence for the relevance of system theory to diagnosis, treatment, and prevention should be evaluated early in the teaching program; (3) clarity of expectations is crucial; (4) emphasis should be on the natural role of the family physician as first-line family advisor and the use of interviewing and observational skills already well developed; and (5) synthesis of the psychosocial and physical aspects of illness will occur naturally if the family physician is the teacher of family system concepts and the role model for their application in practice.

31 citations


Journal Article•
TL;DR: The physician can perform a range of important functions in the management of the patient and family and 12 are listed which may serve as a guide for clinical practice.
Abstract: The treatment objective of medical care for the demented patient is to maximize the level of functioning and the quality of life for both the patient and the family or caregivers. The majority of patients with dementia are in the community, and most families prefer to keep their relatives out of institutions as long as possible, usually until the family's resources are exhausted. The impact of dementing illness on family health can be severe, and family members can develop physical and psychiatric disorders. The physician can perform a range of important functions in the management of the patient and family and 12 are listed which may serve as a guide for clinical practice.

Journal Article•
TL;DR: Although there were disparities in the proportions of family physician/general practitioners with certain hospital privileges among regions, the vast majority in each region indicated that the privileges afforded them were appropriate.
Abstract: In 1980 the American Academy of Family Physicians sampled those active members who were nonfederal, office based physicians in direct patient care to ascertain the characteristics of their hospital practices. The sample was stratified by the nine US census regions: 83.7 percent of the 5,216 active members in the sample responded. The vast majority of family physician/general practitioners in direct patient care in an office based setting have hospital admission privileges in one or more hospitals. A higher percentage of family physicians/general practitioners in census regions west of the Mississippi River were likely to have privileges in obstetrics and surgery than those in eastern regions. Moreover, family physicians/general practitioners in the nonmetropolitan areas of each census region were more likely to have hospital privileges at any level than were their colleagues in the metropolitan areas of the same region. Although there were disparities in the proportions of family physician/general practitioners with certain hospital privileges among regions, the vast majority in each region indicated that the privileges afforded them were appropriate.

Journal Article•
TL;DR: The participants in this study were nearly unanimous in their feeling that the CPS accurately simulates cardiology bedside findings and is a valuable teaching tool with which they would like to again be taught in the future.
Abstract: "Harvey," the cardiology patient simulator (CPS), is the result of a new type of simulation technology that allows for repetitive practice of bedside cardiology skills and provides feedback to the learner. "Harvey" is able to realistically simulate an essentially unlimited number of both common and rare cardiac disease. This report describes the use of the CPS in continuing medical education programs conducted for members of the American Academy of Family Physicians. Cardiovascular disorders constitute a significant percentage of the practice of family physicians. The CPS teaching system has great potential for helping them keep their cardiovascular diagnostic skills current and for promoting better understanding of recent advances in the diagnosis and treatment of heart disease. The participants in this study were nearly unanimous in their feeling that the CPS accurately simulates cardiology bedside findings and is a valuable teaching tool with which they would like to again be taught in the future.

Journal Article•
TL;DR: The developmental problems encountered and the results of some initial clinical, quality assurance, and practice management studies conducted by the Primary Care Cooperative Information Project are described.
Abstract: Many of the obstacles inherent in the conduct of primary care research have been overcome by an experimental program in northern New England, the Primary Care Cooperative Information Project. This project uses a medical information network in 44 rural medical practices to carry out both clinical and management research. This paper describes the developmental problems encountered and the results of some initial clinical, quality assurance, and practice management studies conducted by the network and presents observations on its future research directions.

Journal Article•
TL;DR: Stool examinations of 186 Indochinese refugees and 90 immigrants from Mexico resettled in Contra Costa, County, California, have shown that 60 percent of refugees and 39 percent of immigrants are infected with one or more species of pathogenic protozoa and helminths.
Abstract: Stool examinations of 186 Indochinese refugees and 90 immigrants from Mexico resettled in Contra Costa, County, California, have shown that 60 percent of refugees and 39 percent of immigrants are infected with one or more species of pathogenic protozoa and helminths. The mean prevalences of infections among refugees and immigrants, respectively, were: hookworms, 25 and 2 percent; whipworm, 22 and 12 percent; Ascaris, 20 and 12 percent; Giardia lamblia, 11 and 11 percent; Strongyloides, 9 and 1 percent; and Entamoeba histolytica, 2 and 4 percent. clonorchis sinensis was found in 13 percent of refugees and dwarf tapeworm in 9 percent of immigrants. Rates of infection varied with age and sex. Treatment of these parasitic infections is important and justified because: the prevalence is high; some species are highly pathogenic and directly transmittable; most species have long life spans; and safe broad-spectrum drugs are now available.

Journal Article•
TL;DR: Although help with bereavement is generally regarded as an integral function of the Hospice, respondents in this study reported that it was not an important area with which the hospice needed to concern itself.
Abstract: A home based hospice was evaluated by means of questionnaires filled out by surviving relatives of patients who had participated in the hospice program prior to their deaths. Respondents reported that the hospice was helpful in reducing the prevalence of pain, physical disabilities, and anxiety to the dying patient. It was even more helpful in reducing anxiety in relatives of the patient than in the patient himself. Participants approve of the concept of a person dying at home and all would recommend the program to others. Problems in the physician-patient relationship were identified. Although help with bereavement is generally regarded as an integral function of the hospice, respondents in this study reported that it was not an important area with which the hospice needed to concern itself.


Journal Article•
TL;DR: The differential diagnosis of patients who are abusive of or seem addicted to medical care is discussed using the approach outlined in the new Diagnostic and Statistical Manual III of the American Psychiatric Association.
Abstract: The differential diagnosis of patients who are abusive of or seem addicted to medical care is discussed using the approach outlined in the new Diagnostic and Statistical Manual III of the American Psychiatric Association. These are generally chronic disorders and their managements, using the substance abuse/addiction model, are aimed at protecting both patients and physicians from unnecessary, expensive, and potentially lethal medical interventions. The disorders considered include somatization disorder (Briquet's syndrome), psychogenic pain disorder (psychalgia), hypochondriasis, factitious disorder, and malingering.

Journal Article•
TL;DR: The aim of the program is to help physician teachers to become more flexible in matching a teaching style to a particular teaching context.
Abstract: As part of an effort to train family physicians to be more effective teachers in family medicine, a teaching styles workshop program was developed. The aim of the program is to help physician teachers to become more flexible in matching a teaching style to a particular teaching context. The program consists of three components: (1) a scheme for classifying teaching behaviors as belonging to one of the four basic styles identified, (2) videotaped models of each of the four basic styles, and (3) structured role playing by workshop participants in which the four styles are practiced and critiqued. The program, as used in two different sets of faculty development workshops, is described and recommendations for its use by others given.

Journal Article•
TL;DR: A prospective study collating demographic, medical, psychiatric, and illness behavior characteristics of 60 consecutive patients referred for consultation to a psychiatric liaison physician attending in a family medical clinic showed that the most frequent psychiatric diagnosis in these patients was primary affective disorder depression.
Abstract: This paper describes a prospective study collating demographic, medical, psychiatric, and illness behavior characteristics of 60 consecutive patients referred for consultation to a psychiatric liaison physician attending in a family medical clinic. The data were accumulated to add to the developing body of information about the characteristic psychosocial problems family physicians treat. Results showed that the most frequent psychiatric diagnosis in these patients was primary affective disorder depression. The presence of somatic complaints often obscured the recognition and management of psychiatric syndromes such as depression, anxiety neurosis, personality disorder, family and marital discord, psychosis, and alcoholism. The importance of training in psychopharmacology and time limited psychotherapy was underscored by the frequent consultant recommendations for the use of these treatment modalities by the family physician. Patients averaged 2.4 illness problems (psychosocial problems and reactions that arise from a perceived illness), pointing to the need to systematically evaluate and treat them concomitantly with traditional disease problems.

Journal Article•
TL;DR: Physicians must maintain a high index of suspicion for adverse reaction to nitrofurantoin, particularly in the elderly in whom declining renal function may lead to inadvertent toxic accumulations and use of alternative antimicrobial agents with higher benefit-to-risk ratios for treatment of urinary tract infections should be considered.
Abstract: An elderly woman taking 50 mg of nitrofurantoin daily for six months for suppression of recurrent urinary tract infections developed increasing dyspnea and bilateral pulmonary infiltrates. An open-lung biopsy confirmed diffuse interstitial fibrosis consistent with chronic nitrofurantoin pulmonary reaction. A chronic disabling respiratory illness persists in this person 10 months after discontinuing nitrofurantoin. Nitrofurantoin produces adverse pulmonary reactions more commonly than any other antimicrobial. There is an acute and a chronic form of pulmonary reaction to nitrofurantoin. Each is thought to result from a separate immunologic and/or toxic injury to the lung. Both the acute and chronic form can rarely result in fatal pulmonary reactions. Physicians must maintain a high index of suspicion for adverse reaction to nitrofurantoin, particularly in the elderly in whom declining renal function may lead to inadvertent toxic accumulations. Use of alternative antimicrobial agents with higher benefit-to-risk ratios for treatment of urinary tract infections should be considered. Persons suffering serious adverse reactions to nitrofurantoin should carry written warnings about reexposure.

Journal Article•
TL;DR: On the whole, physicians overestimated the costs of the drugs and reported prescribing generically more often than practicing physicians, while residents were the most accurate.
Abstract: In this study practicing physicians, residents and teaching faculty estimated cost to the patient of ten commonly prescribed drugs. Physician estimates were compared to averaage pharmacy prices. On the whole, physicians overestimated the costs of the drugs. Practicing physicians had the highest estimated while residents were the most accurate. Accuracy of price estimates differed greatly among the drugs. Physicians were also asked about their sources of drug price information and their prescribing policies in relation to cost. Residents and faculty relied heavily on pharmacists for the drug price information, whereas practicing physicians rellied on sales representatives and patients. Virtually all responders assign at least some importance to drug costs when prescribing. Residents and faculty reported prescribing generically more often than practicing physicians.

Journal Article•
TL;DR: This model uses three overlapping circles of a Venn diagram to represent the host (family system), the environmental, and the agent (stressor) systems and is an interactive, multisystem, multivariate model.
Abstract: Drawing on knowledge from various behavioral science disciplines and epidemiology, a conceptual model for use in practice, education, and research in family medicine has been developed This model uses three overlapping circles of a Venn diagram to represent the host (family system), the environmental, and the agent (stressor) systems The central overlapping area of the three circles is the "resultant adjustment" of all the multiple interacting variables, and reflects the current state of the family This concept has been designated the Family Epidemiological Model and is an interactive, multisystem, multivariate model Some of the educational and practical implications of its comprehensive and exhaustive approach are discussed

Journal Article•
TL;DR: Though the family physicians in this sample had more direct communication with children than reported in previous research, it is argued that greater involvement of children in all phases of pediatric visits is warranted.
Abstract: To determine how family physicians divide their attention between children and parents, 115 videotaped pediatric encounters of children (aged 4 to 14 years) and parents with family physicians in a family medicine center were analyzed. It was learned that physicians tended to involve children actively in the diagnostic stages of interviews but much less so in discussions of treating or dealing with their problems. Physicians did not alter this pattern as they advanced in training. Older children were more likely to receive direct communication from physicians in all phases of office encounters. Though the family physicians in this sample had more direct communication with children than reported in previous research, it is argued that greater involvement of children in all phases of pediatric visits is warranted. A developmental framework indicates that children gradually evolve their attitudes, concepts, and behaviors around illness and health. Family physicians and family medicine programs are in an excellent position to explore and utilize the practice of actively incorporating a child in a medical interview.


Journal Article•
TL;DR: Physicians should limit colorectal cancer screening to persons at relatively high risk: persons aged over 45 years, with a family history of bowel cancer, or with polyps, and protocols should be designed to ensure high specificity.
Abstract: Colorectal cancer remains a major cause of mortality in the United States. Of all persons diagnosed with this tumor, less than 50 percent survive five years. Useful preventive measures have not been established. Screening programs, however, offer the prospect of detecting cancers early in their course, when the prognosis for survival is more favorable. To date, no screening test has clearly demonstrated its effectiveness in reducing mortality from colorectal cancer. Periodic rigid sigmoidoscopy and stool occult blood testing have gained many advocates, but have yet to be proved worthwhile in adequately controlled clinical trials. Uncontrolled studies indicate that both these techniques discover approximately 2 cancers per 1000 screenees. There is suggestive evidence that the cancers discovered are more likely to be localized. For the present, physicians should limit colorectal cancer screening to persons at relatively high risk: persons aged over 45 years, with a family history of bowel cancer, or with polyps. Protocols should be designed to ensure high specificity. The recommendations of the National Cancer Institute's consensus conference provide practical guidelines pending the outcome of randomized controlled trials.


Journal Article•
TL;DR: It is suggested that family physicians can and need to become better prevention specialists and they must document the smoking habits of all their patients before attempting to counsel or intervene with smoking cessation programs.
Abstract: Family physicians have an essential, unique, and vital role to play in preventive health care. However, the actual practice of and emphasis upon preventive medicine varies widely. Cigarette smoking is the leading preventable cause of illness and high medical costs in the United States today. This study examined the recognition of smoking patients by family physicians. The results show that physicians fail to recognize large numbers of their patients who smoke and that physician behavior is disease oriented rather than preventive. A modest educational program was very successful in improving physician awareness and recognition of smoking patients. This study suggests that family physicians can and need to become better prevention specialists and they must document the smoking habits of all their patients before attempting to counsel or intervene with smoking cessation programs.

Journal Article•
TL;DR: An overview analysis of the hospital admission and practice privileges of the 3,021 respondents actively practicing family medicine in the United States finds that respondents in census regions west of the Mississippi River were more likely to have privileges in obstetrics and surgery than were respondents in eastern regions.
Abstract: In 1979 the American Academy of Family Physicians, as the first phase of a long-range study of family practice residency outcomes, surveyed graduates for the years 1970 through 1978 who were diplomates of the American Board of Family Practice. This report is limited to an overview analysis of the hospital admission and practice privileges of the 3,021 respondents actively practicing family medicine in the United States. A higher percentage of respondents in census regions west of the Mississippi River were more likely to have privileges in obstetrics and surgery than were respondents in eastern regions. Respondents in nonmetropolitan areas were more likely to have hospital privileges than were respondents in metropolitan areas.