Illuminating the 'black box'. A description of 4454 patient visits to 138 family physicians.

BACKGROUND: The content and context of family practice outpatient visits have never been fully described, leaving many aspects of family practice in a "black box," unseen by policymakers and understood only in isolation. This article describes community family practices, physicians, patients, and outpatient visits. METHODS: Practicing family physicians in northeast Ohio were invited to participate in a multimethod study of the content of primary care practice. Research nurses directly observed consecutive patient visits, and collected additional data using medical record reviews, patient and physician questionnaires, billing data, practice environment checklists, and ethnographic fieldnotes. RESULTS: Visits by 4454 patients seeing 138 physicians in 84 practices were observed. Outpatient visits to family physicians encompassed a wide variety of patients, problems, and levels of complexity. The average patient paid 4.3 visits to the practice within the past year. The mean visit duration was 10 minutes. Fifty-eight percent of visits were for acute illness, 24% for chronic illness, and 12% for well care. The most common uses of time were history-taking, planning treatment, physical examination, health education, feedback, family information, chatting, structuring the interaction, and patient questions. CONCLUSIONS: Family practice and patient visits are complex, with competing demands and opportunities to address a wide range of problems of individuals and families over time and at various stages of health and illness. Multimethod research in practice settings can identify ways to enhance the competing opportunities of family practice to improve the health of their patients.

Adolescent injury and death: the plagues of accident, self-infliction and violence.

Motor vehicle-related accidents and firearm-related violence are the first and second leading causes of adolescent morbidity and mortality. Fortunately, considerable progress has been made in reducing motor vehicle-related injuries and death through state-level legislation designed to decrease alcohol use and increase seat belt use. Homicide and suicide, however, are increasing dramatically among teenagers. Family violence and the epidemic of gang activity also contribute significantly to both; violence portrayed on television, in movies, and in adolescent music also has become a more significant part of teen life. Family physicians are encouraged to implement preventive strategies for combating the problems of injury and violence in their offices, their communities, and on the broader states of medical education and public policy.

Dementia and Down syndrome.

Through deinstitutionalization, more adults with mental retardation are living in the community under the care of family physicians. Patients with Down syndrome are at high risk for early Alzheimer's disease. This case report describes a 43-year-old woman with Down syndrome whose progressive functional decline over 3 years was attributed to dementia of the Alzheimer type.

Family physicians' disagreements with the US Preventive Services Task Force recommendations.

BACKGROUND: The 1989 recommendations of the US Preventive Services Task Force (USPSTF) represent an emerging consensus about which clinical preventive services should be delivered. However, practicing physicians disagree with a number of the recommendations in the Task Force prevention guidelines, and the reasons for disagreement have not been widely explored. METHODS: A survey questionnaire assessing physician agreement or disagreement with the USPSTF recommendations was sent to all 1784 active members of the Ohio Academy of Family Physicians in October 1990. A factor analysis was performed on the items with which at least 5% of physicians disagreed. Associations of physician demographics and attitudes with the factor scores were then examined. RESULTS: At least 5% of the 898 responding physicians disagreed with 67 of 150 USPSTF recommendations. Physicians disagreed with the USPSTF recommendations in three ways: (1) they believed that screening for some cancers is appropriate, even though not recommended by the USPSTF; (2) they believed that screening for other diseases in some populations is appropriate, even though not recommended by the USPSTF; and (3) they disagreed with some USPSTF recommendations for screening that is considered time-consuming or intrusive. Further analyses showed that practice setting and experience with the USPSTF guidelines were predictive of all three disagreement factors. Physician age, race, residency training, and reasons for disagreement were associated with two of the three factors. CONCLUSIONS: Physician disagreement with the USPSTF recommendations was not random but clustered into three distinct factors. An opportunity exists to design educational interventions for targeted subgroups of physicians. The views of practicing physicians should be incorporated into future guidelines.

Adherence to screening flexible sigmoidoscopy in asymptomatic patients.

The purpose of this study was to assess patient adherence to physician-recommended screening flexible sigmoidoscopy. In the setting of a family practice residency program, adherence rates in asymptomatic patients (N = 333, age > or = 50 years) were compared among a Usual Care Group; an Intervention Group that received educational materials and a phone reminder; and a Continuity Group, which had longstanding continuity with a single physician. Data from mailed questionnaires (N = 180) were used to examine the associations of demographic factors and attitudes with adherence. Adherence was 30.3% overall, with a nonsignificant increase in the Intervention Group compared with the Usual Care Group. In a pooled analysis of the Usual Care and Continuity Groups, the half of the sample with the highest continuity had a significantly higher adherence rate than the rest of the sample (45%; P < 0.001). In a discriminant analysis (78% correct classification, P < 0.001) two history variables (family history of cancer; family history of colon problems), one measure of continuity (number of physician visits), one demographic variable (lower household income), and two attitudinal factors (perception of how painful flexible sigmoidoscopy would be; perception of how well the physician explained its importance) made statistically significant contributions to the prediction of adherence. Results of the study show that screening flexible sigmoidoscopy is acceptable to asymptomatic patients, and that continuity is likely to have a positive impact on adherence. Because attitudes offer the potential for modification, we suggest that physicians reassure patients that flexible sigmoidoscopy is not unduly painful and discuss with patients individually its importance to their health.

Physician agreement with US Preventive Services Task Force recommendations.

BACKGROUND: No large-scale work has yet assessed the reactions of physicians to the report of the US Preventive Services Task Force (USPSTF), despite its potential for fostering a consensus among practitioners. This study undertook a survey of family physicians to assess their agreement with the recommendations of the Task Force. METHODS: A survey containing the verbatim summary recommendations of the USPSTF was mailed to all 1784 active members of the Ohio Academy of Family Physicians. RESULTS: No evidence of selection bias was found among the 898 responding physicians. The average physician agreed with 88% of the recommendations. For a number of recommendations, however, particularly those in which the Task Force differed with the American Cancer Society, there was a high level of disagreement. Physician disagreement with the recommendations was associated with older age, not having completed a residency, male sex, less prior exposure to the USPSTF guidelines, and greater perception of the impracticality of applying them. CONCLUSIONS: The high level of agreement with most USPSTF recommendations implies that they represent an emerging consensus about which preventive services should be delivered. Attempts at USPSTF guideline dissemination should focus on recommendations with high agreement. Additional research is needed to assess the reasons for disagreement.

Patient preferences regarding educational pamphlets in the family practice center.

Educational pamphlets are widely used in family practice offices despite few studies on patient attitudes toward this educational technique. The purpose of this study was to: 1) determine how frequently patients perceive that pamphlets are used and how often they are desired; 2) determine what is usually done with pamphlets; and 3) determine patient preferences regarding requesting pamphlets, location of unsolicited pamphlets, techniques of getting pamphlets, and style of pamphlets. In this survey of 360 patients, 90% reported wanting a pamphlet at some or all of their office visits. Overall, 67% reported reading or looking through and saving pamphlets received, 30% read or looked through them and then threw them away, and only 2% threw them away without review. Only 11% of males and 26% of females reported ever asking a doctor for pamphlets. Some conclusions are that: 1) more patients desire pamphlets than are receiving them; 2) most patients do save pamphlets; and 3) patients need encouragement and permission to ask for pamphlets.

A five-year demonstration project associated with improvement in physician health maintenance behavior.

The purpose of this demonstration project was to evaluate the effect of a sustained preventive medicine emphasis in a community hospital based family practice residency. A simplified, visually tolerable, and prominent "health maintenance guide" served as the cornerstone of the overall residency educational effort. Screening interventions and intervals were based on the major published recommendations at the initiation of the project. An audit of 100 random adult patient charts was done at baseline and yearly for five years. Physicians received both group and individual feedback regarding screening compliance on a regular basis. Overall physician compliance with screening for six basic parameters improved from 71% to 85% (P less than .0005). Physicians behavior improved significantly in recording or recommending blood pressure, physician breast exam, personal life change, tetanus/diphtheria immunization, mammography, breast self-examination, testicular self-examination, and a prudent diet. Physician use of the guide as a recording device steadily increased.

Fine-needle breast aspiration biopsy.

Fine-needle aspiration biopsy of breast lesions is a safe, accurate, well-tolerated procedure that can easily be done in the family physician's office. It has a specificity and positive predictive value of virtually 100 percent, a sensitivity of 53 to 99 percent (median of 89 percent), and a negative predictive value of 80 to 99 percent (median of 93 percent). It is limited by the nature of the lesion, which must be easily palpable, the physician's technical ability, and the availability of a reference cytopathologist. Complications are rare and usually very benign, such as local hematoma. With proper training and understanding of the procedure, many family physicians could easily introduce the procedure into their office practice.

Health screening examinations: the patient's perspective.

Periodic preventive screening programs will require patient cooperation if they are to be successful. To determine the level of patient interest on a broad scale, 1,788 adult patients were surveyed in 47 family physicians' offices over a statewide area. Seventy percent said they had participated in a screening health checkup in the preceding two years. Nine percent of these patients reported discovering a previously unknown condition as a result of their recent screening examination. The majority of surveyed patients said they would agree to be screened or treated with the complete list of eight suggested procedures for men and ten procedures for women. Rates of patient acceptance of specific health maintenance recommendations ranged from a low of 54 percent for influenza immunization to a high of 91 percent for a blood pressure check. Listing typical costs did not alter the selection rates of patients with insurance coverage compared with those without it. The geriatric age group was the least willing to be screened. Seventy-two percent of patients indicated that they wanted to discuss at least one wellness topic with their physician. Overall, most patients are willing to participate in the concept of a periodic health maintenance examination as recommended to them by their physician.

The association of psychosocial factors with the resolution of abdominal pain.

Although abdominal pain is a common presenting complaint in the family practice setting, its natural history and psychosocial associations have not been clearly described. A prospective study was conducted of 92 patients who presented with abdominal pain to the University of Iowa and Cedar Rapids Family Practice Centers between September 1982 and March 1983. Patients were given a self-administered questionnaire for measuring stress, family functioning, and psychological symptoms. All patients were followed for at least six weeks. Resolution of the pain was documented by chart audit, telephone, or mail follow-up. Two-thirds of the patients experienced resolution of their pain within six to eight weeks. The scores on the Hopkins Psychological Symptom Checklist, Family APGAR, and the Daily Hassles Stress Scale did not predict resolution of pain. Age, sex, education, occupation, and final diagnosis also did not predict resolution of pain. Marital status was not associated with pain resolution, though widowed and separated individuals more often had pain at follow-up.

An assessment of the effect of "DOC talk" on school children in rural Iowa.

The effectiveness of family physicians as health educators through a community health organization (Doctors Ought To Care/DOC) was studied. Seventh-grade students in a rural school system received a series of uniquely prepared slide presentations (DOC talks) on smoking, alcohol, drug use, and venereal disease to study the effect of such talks on knowledge gain and behavior change. The presentations were made during the semester in which the students were also taking a required health education course. A second group of seventh graders in the same school system did not receive the presentations but had the same health education course and served as the control group. Both groups showed similar gains in knowledge during their semester of health education. However, only the group which received the DOC talks showed a continuation of knowledge gains on a follow-up questionnaire. Also, only the group which saw the presentations showed positive behavior changes including decreased substance use. While aware of the study's methodologic limitations, we believe the results support the value of the community physician presenting DOC talks to supplement the usual school health curriculum.

What do patients really want? Redefining a behavioral science curriculum for family physicians.

This study replicates the design reported by Schwenk et al and addresses a key methodologic issue in their paper. The original questionnaire by Schwenk et al was administered to one half of the sample of patients, while the other half completed a reworded questionnaire asking what they "want" in the area of psychosocial help, as opposed to what they think their family physician "would" do (the original wording). The hypothesis was that expectations for physician involvement will be higher if patients are asked what they want as opposed to what they expect. Patients were asked to complete a four-page questionnaire, alternating the questions described by Schwenk et al with the reworded questionnaire, in which they were required to rank the level of involvement requested from their physician regarding 45 psychosocial problems (level 1 = no involvement, level 4 = major involvement). Results using the originally worded questionnaire closely paralleled findings of Schwenk et al, whereas asking people what they "wanted" showed statistically significant differences in 18 of the 45 items. The paper concludes with discussion of patient preferences vs patient expectations, with implications for the behavioral science curriculum.

DOC as an integral part of the community medicine curriculum.

Involving family practice residents in community medicine experiences can be a challenging task, and various programs have approached this curricular problem in different ways. The Cedar Rapids program has integrated the activities of the local Doctors Ought to Care (DOC) chapter into the residency with the goal of exposing residents to the concepts of community health education. DOC, a national organization interested in community health promotion and education, takes a lively approach to information sharing using image-based techniques.

A five-year experience with throat cultures.

This study addresses the usefulness of the throat culture in a family practice residency setting and explores the following questions: (1) Do faculty physicians clinically identify streptococcal pharyngitis better than residents? (2) With time, will residents and faculty physicians improve in their diagnostic accuracy? (3) Should the throat culture be used always, selectively, or never? A total of 3,982 throat cultures were obtained over a five-year study period with 16 percent positive for beta-hemolytic streptococci. The results were compared with the physician's clinical diagnosis of either "nonstreptococcal" (category A) or "streptococcal" (category B). Within category A, 363 of 3,023 patients had positive cultures (12 percent clinical diagnostic error rate). Within category B, 665 of 959 patients had negative cultures (69 percent clinical diagnostic error rate). Faculty were significantly better than residents in diagnosing streptococcal pharyngitis, but not in diagnosing nonstreptococcal sore throats. Neither faculty nor residents improved their diagnostic accuracy over time. Regarding age-specific recommendations, the findings support utilizing a throat culture in all children aged 2 to 15 years with sore throat, but in adults only when the physician suspects streptococcal pharyngitis.

Alteration of emergency room usage in a family practice residency program.

A patient education program was instituted that emphasized the importance of telephoning the physician prior to making an emergency room visit and defined an inappropriate visit in simple terms. The purpose of the program was to reduce the percentage of nonurgent or inappropriate emergency room visits each month. A total of 3,825 emergency room visits were reviewed. The percentage of inappropriate visits dropped from 29 percent in the control period to 18 percent in the patient education period (P less than or equal to .001). This included significant decreases in the four major reimbursement groups: self-paying (P less than or equal to .005), group insurance (P less than or equal to .001), Medical Assistance (P less than or equal .01), and Medicare (P less than or equal to .01). Also during the patient education period there was a trend toward increased telephone calls prior to emergency room visits.