Health, homelessness, and poverty. A study of clinic users.

When seeking medical care, homeless persons often turn to health centers that were designed to treat the poor who have homes. To provide for effective medical care, personnel in such facilities need to know how the health care needs of the homeless are different from those of other clinic users. To compare the physical health of these two groups, we conducted a health survey and screening physical examination of 464 patients who attended the general adult and homeless clinic sessions of one of the main neighborhood health centers in Los Angeles County, California. As compared with the poor who have homes, homeless persons were more likely to have dermatological problems (32% vs 21%), functional limitations (median, 2 vs 0 per person), seizures (14% vs 6%), chronic obstructive pulmonary disease (21% vs 12%), social isolation, serious vision problems (22% vs 12%), foot pain, and grossly decayed teeth (median, 1 vs 0 per person). We conclude that to care more optimally for homeless adults, health centers must pay attention to their functional disabilities, substance abuse, skin abnormalities, vision impairment, dental problems, and foot problems.

Faculty development in general internal medicine. Perceptions concerning academic survival.

To understand the educational needs of faculty general internists in academic hospital environments, surveys of general internal medicine division chiefs, department of medicine chairmen, and members of the Society for Research and Education in Primary Care Internal Medicine were undertaken. Results indicated considerable interest in faculty development activities among all physicians sampled. Division chiefs and department chairmen viewed such activities as feasible, potentially effective, and were willing to assume considerable responsibility in providing educational opportunities to their faculty. Although some physicians viewed self-learning as a potentially effective educational method, the vast majority preferred learning in a small group taught by an expert. Specific content areas for faculty development were assessed, as were the skills thought to be essential for personal job satisfaction, academic promotion, and organizational effectiveness.

Recent sexual behaviors among homosexual men seeking primary medical care.

We studied the sociodemographic characteristics, knowledge, and beliefs about acquired immunodeficiency syndrome transmission and sexual practices of 823 gay or bisexual men seeking primary care. During the previous 2 months, 64% had engaged in at least one sexual behavior considered unsafe. These patients compared with those having safer sex, were younger, of lower socioeconomic status, and from a racial minority, especially Latino. The unsafe group also had more sexual partners, engaged in sexual acts more often, felt less in control over their sexual behavior, used recreational drugs more frequently, and were less likely to talk about safe sex with partners. The unsafe group had less adequate knowledge about human immunodeficiency virus transmission but felt safer from the risk of acquired immunodeficiency syndrome even when engaging in unsafe sex. Educational programs dealing more directly with belief systems and the potential addiction to recreational drugs and sexual behaviors need to be developed for primary care settings.

Crimes against discharged mental patients in board-and-care homes.

A survey of 278 persons discharged from mental hospitals who were living in board-and-care homes showed that one-third of them had been victims of crime during the preceding year. In a comparison of nonvictims, victims of theft, and victims of violence, it was found that victims of violence were younger, were more active socially, reported more psychopathology and less satisfaction with their lives, and engaged in more criminal behaviors themselves than the other groups. Both victim groups used emergency mental health services more than nonvictims did during the preceding year. Strategies for future research and interventions are discussed.

Mental health, alcohol and drug use, and criminal history among homeless adults.

As part of a community-based survey of 529 homeless adults, the authors analyzed factors associated with their use of mental health services. Homeless persons who had had a previous psychiatric hospitalization were the least likely to sleep in an emergency shelter, had been homeless nearly twice as long as the rest of the sample, had the worst mental health status, used alcohol and drugs the most, and were the most involved in criminal activities. The majority had not made an outpatient mental health visit in 5 years. It is suggested that diverse systems of care are needed for homeless persons.

Chronic mental patients: the quality of life issue.

Quality of life issues must be addressed more vigorously in the care of chronic mental patients. In a survey of 30 large board-and-care homes in Los Angeles, 278 mentally disabled residents described their life conditions and satisfaction in eight areas: living situation, family relations, social relations, leisure activities, work, finances, safety, and health. Residents were less satisfied than the general population in most life areas, especially finances, unemployment, safety, and family and social relations (p less than .001). Of particular concern was the finding that 34% had been recent victims of crime. The results underscore the need for better social programs for these patients.

Physicians' perceptions about increased glove-wearing in response to risk of HIV infection.

Glove-wearing attitudes of 375 physicians, representing 56% of all physicians surveyed, were ascertained. Although the majority were comfortable with their current glove use, 33% preferred wearing them more frequently. The most common reasons for not wearing gloves were a low likelihood of disease transmission and fear of offending patients. Many physicians felt that more frequent glove use in examining human immunodeficiency virus- (HIV)-positive patients might reduce rapport and diminish the adequacy of physical examination procedures, but only 11% felt that increased glove use would compromise overall care of HIV-positive patients. With regard to all patients, 33% felt that increased glove use in examinations would compromise care. Additionally, 56% of physicians stated that they were somewhat concerned about HIV infection. Glove-wearing preferences were significantly associated with greater concern about infection, a younger age and more frequent exposure to blood and body secretions. Contact with high-risk patient groups was not associated with glove-wearing preferences.

Differences in health status between older and younger homeless adults.

The Institute of Medicine has placed a priority on determining the special health-care needs of elderly homeless persons. As part of a community-based study of 521 homeless adults in two beach communities of Los Angeles, we compared the demographic characteristics and health of older (age rangek 50-78, n = 61) and younger (age range, 18-49, n = 460) homeless individuals. Compared with younger adults, older adults were more likely to be white (85% versus 61%), veterans (59% versus 27%), retired (36% versus 3%), and living in a vehicle (21% versus 8%). Older adults were more likely to report having a chronic disease (69% versus 49%), functional disabilities, no informal social contacts during the previous month (49% versus 27%), observed high blood pressure (42% versus 22%), elevated creatinine (11% versus 2%), and elevated cholesterol (57% versus 36%). Older adults were less likely to have a toothache (3% versus 30%), report psychotic symptoms (25% versus 42%), and to be illegal drug users (15% versus 55%). Although they are chronologically younger, the constellation of health and functional problems of older homeless adults resemble those of geriatric persons in the general population. We suggest that geriatricians could play a significant role in training other primary-care providers to evaluate and treat socially isolated older homeless adults in a more comprehensive way than is currently standard in practice (e.g., interdisciplinary team care and emphasis on functional status, rehabilitative medicine, and assessment for sensory impairment).

Physician attitudes toward the "laying on of hands" during the AIDS epidemic.

Attitudes of 227 faculty and 148 housestaff physicians toward touching patients were studied in relationship to socio-demographic and job characteristics, previous exposure to and concern about HIV infection, and attitudes toward glove-wearing. Although a majority of the physicians felt that touching patients was personally satisfying, facilitated healing, and established rapport, such positive attitudes were more to be likely expressed by the younger physicians and those who worked longer hours, spent more time in primary care, and spent less time teaching. Positive attitudes were also related to less favorable attitudes toward glove-wearing and greater belief that more frequent glove use would have a negative effect on patient care.

Psychiatric consultation in a medical clinic: what do medical providers want?

A participant observation needs assessment of the use of a psychiatrist in a primary care medical setting was undertaken to quantify details of the interaction between a psychiatrist and primary care providers. Two hundred seventeen encounters involving 63 providers were recorded over a five and one-half month period. Utilization of the psychiatrist was widespread but skewed, with only 17% of the sample using 50% of the services. The mean number of encounters for all providers was 3.44. Consultation occurred mainly in a private area of the clinic, usually in an unplanned fashion. Only 21% of encounters involved seeing a patient. The range and content of these interactions was broad. Initial reasons for consultation were often redefined as the consultation ensued. The kinds of help most frequently requested involved discussing nonpsychopharmacologic treatments (35%), assisting providers with evaluations (31%), and exploring unresolved feelings about patients or patient care issues (29%). Slightly more than 50% of encounters required some type of follow-up. The findings suggest that psychiatrists who wish to work in primary care settings must have expertise in a multitude of areas and must be flexible in adapting themselves to the setting in which the primary care providers work.

Physician-patient agreement about depression: notation in medical records.

Medical patients were prescreened for depression; their physicians were given the results of the screening to see if such intervention altered the frequency of the physicians' appropriate notations about depression in the medical record. As part of this study, physicians' and patients' global ratings of patient depression were examined in relation to Zung Self Rating Depression Scales (SDS) Scores and medical record notation. On their initial encounter in a University General Internal Medicine Clinic, physicians and patients were in close agreement about the extent to which patients felt sad or blue, and these global ratings correlated significantly with patients' self-reports on the SDS. In general, physicians tended to rate patients as more depressed than patients rated themselves. However, although medical record notations about depression were highly correlated with patient and physician global ratings of mood and with SDS scores, notations about depression appeared in only about 70% of charts where the physician assessed the patient's mood as being significantly depressed.

Initial clinical judgments by internists, family physicians, and psychiatrists in response to patient vignettes: I. Assessment of problems and diagnostic possibilities.

A sample of 146 physicians from internal medicine, family medicine, and psychiatry responded to two written clinical vignettes describing patients with combinations of commonly seen somatic and psychologic complaints. The physicians included housestaff of all levels of training, full-time academic faculty, and community-based clinical faculty. Enormous variation was seen in all specialties in the numbers and types of problems and diagnoses suggested by the physicians. Aside from one or two areas, there were few differences among the specialties or by level of training with regard to the numbers or types of problems identified and tentative diagnoses recorded. The variability within specialty groups was greater than among the groups. Physician behavior in response to one vignette was highly correlated with responses to the second vignette.

Initial clinical judgments by internists, family physicians, and psychiatrists in response to patient vignettes: II. Ordering of laboratory tests, consultations, and treatments.

In response to two written clinical vignettes describing patients with commonly seen somatic and psychologic complaints, 146 physicians from internal medicine, family medicine, and psychiatry recorded the tests and initial treatments they would order. As with the problems and diagnoses suggested by the physicians, enormous variation was seen in all specialties. The number and to some extent the nature of tests, procedures, and initial treatments ordered varied by specialty and within specialty subgroups (i.e., housestaff, full-time academic, and volunteer clinical faculty members). Physician test ordering responses to one vignette was highly correlated with responses to the second vignette, suggesting that test ordering among physicians is partly based on personal habits and characteristics and not alone on the patient's signs and symptoms.

A study of physician preferences in the management of depression in the general medical setting.

Although more than 30% of ambulatory medical patients are depressed, little is known about how their depression is managed in the primary care setting. We surveyed 282 primary care physicians at two internal medicine and four family medicine programs. We asked these physicians to describe how they actually managed depression in their depressed medical patients and how they would manage ten hypothetical depressed medical patients. Demographic and attitudinal data were also obtained. Physicians reported that they utilized a wide variety of treatments for their depressed patients. They indicated that they would recommend counseling twice as many depressed patients as they would recommend medicating or referring. Over 30% of the variance in self-reported preferences to recommend particular treatments for depression was accounted for by physician characteristics. Prior experience with a treatment strategy was a significant factor in predicting a recommendation for future use of a treatment independent of other considerations such as endorsement of positive attitudes about the efficacy or benefits of a treatment. Prior experience was also more important than physician sociodemographics as a predictive variable. The clinical and educational implications of these findings for psychiatrists and primary care physicians are discussed.

Differences in the numbers and costs of tests ordered by internists, family physicians, and psychiatrists.

One hundred forty-six physicians responded to two written patient vignettes by recording problem lists, diagnostic impressions, and the tests and procedures they would have ordered after the initial encounter with the hypothetical patient described in each vignette. Wide variations within medical specialty were found in the number and types of tests or procedures ordered and their costs. We conclude that little consensus exists among physicians as to types of tests and procedures to order, and that private habits or rituals may account for much of the variation in ordering patterns. These findings point to the need for intensive study of how physicians respond to clinical ambiguity as well as how test-ordering habits and rituals arise and persist in different practice settings even within the same specialty. The health care cost implications are substantial.

Primex trainees under stress.

In summary, it seems clear from the data presented in this report that nurses engaged in becoming a family nurse practitioner in the program studied undergo a considerable amount of social, physical, and psychological discomfort. However, the data on the first class trained does suggest that the psychological and to a lesser extent the physical stress students experience during formal training subsides during the preceptorship. Nevertheless, it is out contention that certain stressful periods in training cannot be avoided because of the nature and intensity of the course content as well as the role change necessary for becoming a responsible, dicisive practitioner. Yet, experience with training two classes does suggest that although high stress probably cannot be avoided, at least the length of intense periods can be shortened. In order to accomplish this, it is necessary to have a curriculum which is well-organized, clear in its purpose, and one which provides the opportunity for tension-release, discussion and development of role, and emotional support. Finally, with regard to the perisitence of social stress both during and after training, there appears to be a need to provide continued support to students during their preceptorship in order to assure that role change and development continues. In this regard, periodic continuing education sessions for students seem crucial as do discussions of role with both students and preceptors. As the family nurse practitioner role evolves, it becomes increasingly clear that at times these new health professionals are neither doctors or nurses and at other times they are both. However, nurse practitioners cannot meaningfully sustain their new and somewhat ambiguous role without the mutual cooperation and support of both the medical and nursing establishments in which they practice.

Variation in hospital charges for total joint arthroplasty: an investigation of physician efficiency.

Total joint arthroplasty is a common procedure for which consistent, clinically satisfactory outcomes are expected. Data from 796 total joint procedures performed by 20 surgeons at one center were evaluated to identify sources of variability in costs (as measured by hospital charges) where clinical outcome is expected to remain constant. Stepwise multivariate regression characterized the contribution of six variables to hospital charges listed in order of explanatory power: postoperative length of stay, surgical time, patient preoperative morbidity, units of blood transfused, perioperative complications, and procedure type (hip or knee) accounted for 46% of variability in hospital charges (multiple R2). In a subsequent analysis, after statistical adjustment for preoperative comorbid diagnoses, the sampling distribution of mean values for surgical time, total units of blood transfused, and total hospital charges were summarized and compared among surgeons. Despite adjustment for comorbid diagnoses, substantial variation and significant differences remained between surgeons in markers of resource utilization and "surgical efficiency." These findings suggest there is substantial variability in hospital charges not attributable to patient characteristics or category of procedure--a distinct and economically significant portion of this variability is practitioner specific.

Dental health of homeless adults.

As part of a community-based study, we were able to assess the number of grossly decayed and missing teeth, as well as recent use of dental services, among 529 homeless adults. We found that 27% reported having had a toothache during the previous month (only one-tenth of these individuals had sought help from a dentist for their toothache). Homeless adults, as compared with a general population, were half as likely to have made a dental visit within the preceding year (26.7% versus 55.0%) and had more grossly decayed teeth (means = 2.3 versus means = 1.4). Individuals with more tooth decay and missing teeth were more likely to be older, have physical health problems, smoke more cigarettes, use more alcohol, and have worse personal hygiene. Age, not length of homelessness, was the most important predictor variable of missing teeth. Thus, homeless adults have a higher degree of dental pathosis as well as a lower use of dental services than the general population. On the basis of these findings, more accessible dental services need to be designed for the homeless population.