Managing difficult encounters: understanding physician, patient, and situational factors.

Family physicians commonly find themselves in difficult clinical encounters. These encounters often leave the physician feeling frustrated. The patient may also be dissatisfied with these encounters because of unmet needs, unfulfilled expectations, and unresolved medical issues. Difficult encounters may be attributable to factors associated with the physician, patient, situation, or a combination. Common physician factors include negative bias toward specific health conditions, poor communication skills, and situational stressors. Patient factors may include personality disorders, multiple and poorly defined symptoms, nonadherence to medical advice, and self-destructive behaviors. Situational factors include time pressures during visits, patient and staff conflicts, or complex social issues. To better manage difficult clinical encounters, the physician needs to identify all contributing factors, starting with his or her personal frame of reference for the situation. During the encounter, the physician should use empathetic listening skills and a nonjudgmental, caring attitude; evaluate the challenging patient for underlying psychological and medical disorders and previous or current physical or mental abuse; set boundaries; and use patient-centered communication to reach a mutually agreed upon plan. The timing and duration of visits, as well as expected conduct, may need to be specifically negotiated. Understanding and managing the factors contributing to a difficult encounter will lead to a more effective and satisfactory experience for the physician and the patient.

Reported practice behaviors for medical care of patients with diabetes mellitus by primary-care physicians in Pennsylvania.

OBJECTIVE: To compare the American Diabetes Association standards for the medical care of diabetic patients with reported care patterns. RESEARCH DESIGN AND METHODS: These standards were compared with reported care patterns obtained from a stratified random telephone survey of general practitioners, family physicians, and general internists in Pennsylvania. A total of 610 physicians completed the survey for a response rate of 73%. RESULTS: All primary-care physicians reported measurement of glycosylated hemoglobin, routine referrals to eye doctors, and patient self-monitoring of blood glucose less than recommended. Nearly all physicians performed foot exams, but the exams were infrequent for many of the physicians. Significant and independent differences (P less than 0.05) were noted between different groups of physicians. Older physicians and general practitioners reported patterns of care most different from the recommended standards for referral to eye doctors, measurement of glycosylated hemoglobin, and use of patient self-monitoring of blood glucose. General practitioners reported the lowest frequency of foot exams. CONCLUSIONS: Educational programs on diabetes for primary-care physicians should focus on reported behaviors most different from recommended standards and may need to target subgroups of physicians to achieve a more uniform level of care for all diabetic patients.

Screening for erectile dysfunction in the primary care practice: results of a survey.

To evaluate the screening patterns of primary care physicians (PCP) with regards to erectile dysfunction, a study was performed using an Institution Review Board Approved SHIM (Sexual Health Inventory for Men) questionnaire of 131 male patients presenting to the Family Practice Clinic at West Virginia University School of Medicine in Morgantown. A total of 109 surveys were completed and the data were compiled and analyzed with descriptive statistics using SPSS version 10.0 software. Of these patients, over 92% were Caucasian. The average age bracket for the study population was 40-50, and the average number of risk factors for ED, not including age, was 1.65. Forty-one percent of patients had a SHIM score less than or equal to 21, indicative of an element of ED. A total of 84% had primary care physicians, 22% of patients with a PCP were screened for ED. Of those who were screened by their PCP over half were initiated by the patient. As a result of this study, we believe the SHIM instrument should be performed on patients with any identifiable risk factor since effective treatment of ED is available, and ED can be associated with occult cardiac disease.

A review of studies concerning effects of sleep deprivation and fatigue on residents' performance.

Possible effects of sleep deprivation and fatigue on the performance and well-being of residents have received little scientific examination until recently. This article is a review of the studies on this topic published since 1970. All those studies that dealt with residents' moods and attitudes demonstrated deleterious effects of sleep deprivation and fatigue. The implications of this finding for patient care deserve exploration. Residents' acuity on performance tests requiring prolonged vigilance tended to deteriorate with acute sleep loss, while their performances on most brief psychomotor tests measuring manual dexterity, reaction times, and short-term recall were not adversely affected. The data presently available suggest that sleep-deprived or fatigued house officers can compensate for sleep loss in crises or other novel situations. However, sleep-deprived residents may be more prone to errors on routine, repetitive tasks and tasks that require sustained vigilance, which form a substantial portion of residents' workload. The authors concur with the recommendation of the Executive Council of the Association of American Medical Colleges that the total working hours for residents should not exceed 80 hours per week averaged over four weeks.

Continuing medical education on diabetes by primary care physicians.

The actual and preferred methods of continuing medical education (CME) on diabetes were determined from a telephone survey of a stratified random sample of over 600 primary care physicians in Pennsylvania. A response rate of 73% was obtained. Journal articles were identified as the leading source of information that affected practice behavior related to diabetes. However, no single journal was read by a majority of physicians, and information provided in diabetes journals reached fewer than 10% of primary care physicians. Local educational programs and programs offered by hospitals were the preferred choices for continuing medical education. When reported patterns of care for diabetic patients were compared with published standards of care, no statistical differences were found between physicians who had and physicians who had not attended a CME course. To be most effective, CME courses should be intensive and may need to be presented locally to reach the widest possible audience.

Characteristics of strong departments of family medicine: results of a Delphi survey.

BACKGROUND: The establishment and support of strong university-based departments of family medicine is central to the success of family practice. The purpose of this study was to provide existing and developing departments of family medicine with information on the characteristics of strong established departments. METHODS: Chairs of existing departments were asked to identify the five strongest university-based departments in the country. Based on an 80% response rate, a select group of 24 chairs representing the strongest departments was surveyed using a Delphi technique. RESULTS: A systems and contingency model was used as the basis for organizing the Delphi responses. Seven core factors were identified and ranked by the chairs for each of the six systems and subsystems of the model describing university-based departments. CONCLUSIONS: Key ingredients that are common to most strong departments are the ability of the department to respond to the external environment, the presence of state and federal financial support, leadership and vision by the chair, strong clinically oriented faculty, management practices that keep everyone informed, and mutual support and respect within the department.

The effects of sleep loss on cognitive performance of resident physicians.

Although the long hours worked by resident physicians have raised concern in the public, legislators, and members of the medical profession, the consequences of sleep loss on the ability of residents to perform in clinical settings is unknown. The present study examined the effects of various amounts of reported sleep on cognitive performance measured by the American Board of Family Practice in-training examination. A total of 353 family practice residents in 21 programs who took the examination in Pennsylvania in 1988 were studied. Linear regression analysis demonstrated a statistically significant (P less than .05) decline in composite test score with decreasing sleep on the night before the examination for residents in each year of training. Loss of one night's sleep resulted in changes in test scores that were approximately equivalent in magnitude to the change that occurred in test scores between residents in the first and third year of training. The results suggest that prolonged testing over several hours may be necessary to detect the subtle but significant differences in cognitive performance that are present with relatively mild degrees of sleep loss.

What would make us stay in West Virginia?: perspectives of the state's medical students.

In summer 1994, a questionnaire was sent to all of the 822 allopathic and osteopathic medical students in West Virginia. They were asked if they planned to practice primary care in the state, and to rate the importance of financial, lifestyle, and educational factors that may impel them to practice in rural areas. The response rate was 51.8%. The results indicated that 70.2% of the students were unsure about their career plans, but they were considering staying in the state as primary caregivers. Financial factors such as tuition waivers, loan repayment programs, the improvement of Medicaid and Medicare reimbursement, and the elimination of the 2% healthcare provider tax were the most important incentives that students stated would influence them to remain in the state. Responses also indicated that lifestyle factors such as the quality of schools for children and having backup may increase participation in rural care. Educational factors were not found to be important reasons affecting students' decisions to practice in rural areas, and many students stated they were unhappy with the current mandatory rotations in rural care. Out-of-state students displayed great interest in both staying in West Virginia and in becoming primary care physicians. Few differences were found between students depending on what school they attended or their gender.

Problems encountered by primary care physicians in the care of patients with diabetes.

OBJECTIVE: The purpose of this study was to identify problems encountered by primary care physicians in the care of patients with diabetes in order to develop appropriate education programs for physicians. METHODS: A random, stratified telephone survey of 832 physicians in Pennsylvania who listed their specialty as internal medicine, family practice, or general practice was conducted. The response rate was 73%. RESULTS: Following diet and weight control were by far the most common problems reported by physicians for patients with insulin-dependent and non-insulin-dependent diabetes mellitus. Although physicians reported that education regarding diet is discussed during office visits, fewer than 25% of the physicians routinely refer patients to a dietician or health educator. Maintaining glucose control and dealing with the complications of diabetes were the next most common problems for patients with insulin-dependent diabetes mellitus, while compliance issues were common problems for patients with non-insulin-dependent diabetes mellitus. CONCLUSIONS: Efforts to improve the care of patients with diabetes need to recognize and address the problems identified by primary care physicians. Education programs for physicians should deal with attitudes as well as knowledge and should focus on problems such as diet, compliance, referrals to eye doctors, and methods to improve glucose control, such as the use of multiple injections.

[Estimation of vital statistics in rural areas of northern Haiti using a simplified sampling method]. / Estimación de estadísticas vitales en zonas rurales del norte de Haití mediante un muestreo simplificado.

In September 1983, we selected 30 villages in four rural counties of northern Haiti for a partial census and malaria prevalence survey. A cohort of 1,577 persons was enumerated in this census. Survey teams revisited the same houses in these villages in September 1984 and updated the previous census, inquiring about all listed family members. We administered an additional questionnaire to each household concerning the occurrence over the past year of deaths, births, pregnancies, and migration. Among the 1,218 persons who had been followed for one year, there were 21 deaths (crude mortality rate: 17 per 1,000 population; 95% confidence interval [95% CI]: 12 per 1,000, 25 per 1,000) and 35 births (birth rate: 29 per 1,000 population year; 95% CI: 19 per 1,000, 38 per 1,000). The infant mortality rate was 171 per 1,000 live births (95% CI: 81 per 1,000, 315 per 1,000), and the mortality rate for children less than 5 years old was 36 per 1,000 (95% CI: 24 per 1,000, 56 per 1,000). Although small sample surveys are subject to limitations of precision dependent on sample size, they can be a simple method by which researchers may estimate vital statistics for rural areas of less-developed countries.

Self-reported HIV and AIDS experience, practices, and knowledge of Pennsylvania family physicians.

BACKGROUND: Patients with disease caused by the human immunodeficiency virus (HIV), while still more commonly treated in urban settings, are being seen in nonurban areas in numbers rapidly outstripping the local availability of specialists with expertise in HIV or acquired immunodeficiency syndrome (AIDS). METHODS: A questionnaire designed to measure self-assessed experience, practices, and knowledge regarding basic aspects of HIV was mailed in 1989 to the 2177 members of the Pennsylvania Academy of Family Physicians. RESULTS: The response rate was 72 percent. Approximately 95 percent of physicians surveyed had been asked questions by patients about AIDS, 30 percent had a patient with a confirmed positive blood test, and 27 percent had a patient with symptomatic HIV disease in their practice. CONCLUSIONS: Although most family physicians indicated that they were comfortable in recognizing persons at risk, counseling, and using tests to diagnose HIV and AIDS, more than one-half reported practice patterns at variance with published guidelines. Respondents were most uncomfortable with their knowledge and skills regarding legal issues, state and community resources, and caring for patients with AIDS. Continuing medical education courses at local hospitals and written materials were the two methods of AIDS education most likely to be used by respondents.