Diagnostic costs: a research in a family medicine outpatient clinic

The aim of this study is to evaluate the direct diagnostic costs for disease groups and other variables (such as gender, age, seasons) that are related to the direct diagnostic costs based on a 3-year data. The population of the study consisted of 31,401 patients who applied to family medicine outpatient clinic in Turkey between January 1st, 2016 and December 31st, 2018. With this study, we determined in which disease groups of the family medicine outpatient clinic weremost frequently admitted. Then, total and average diagnostic costs for these disease groups were calculated. Three-year data gave us the opportunity to examine the trend in diagnostic costs. Based on this, we demonstratedwhich diseases' total and average diagnostic costs increased or decreased during 3 years. Moreover, we examined how diagnostic costs showed a trend in both Turkish liras and USA dollars' rate for 3 years. Finally, we analysedwhether the diagnostic costs differed according to variables such as age, gender and season. There has been relatively little analysis on the diagnostic costs in the previous literature. Therefore, we expect to contribute to both theoristsand healthcare managers for diagnostic costs with this study.

Exploring the Face-to-Face: Revisiting Patient-Doctor Relationships in a Time of Expanding Telemedicine.

The patient-doctor relationship lies at the heart of medicine. Confronted with the challenges of COVID-19, we find ourselves unable to provide care and comfort in the same physical space as our patients. As we are forced to reckon with telemedicine visits and contemplate continuing them in a postpandemic future, it is important to understand the difference relationally between telemedicine and face-to-face encounters. I will argue that face-to-face visits remain essential in establishing the most fundamentally human components of relationships: responsibility and vulnerability. This established bond assures fidelity in subsequent encounters, whether by phone, video, or in person.

[Usefulness and reliabitlity of musculoskeletal point of care ultrasound in family practice (2): Muscle injuries, osteoarthritis, rheumatological diseases and eco-guided procedures]. / Utilidad y fiabilidad de la ecografía clínica musculoesquelética en medicina familiar (2): lesiones musculares, artrosis, enfermedades reumatológicas y procedimientos ecoguiados.

This article is a continuation of the review initiated in the previous issue about the usefulness of musculoskeletal point of care ultrasound in Primary Care, completing the scenarios of muscle injuries, osteoarthritis, rheumatological diseases and eco-guided procedures.

Manejo de lesiones óseas: osteocodroma / Management of bone lesions: osteochondroma

Presentamos el caso clínico de un varón de 30 años que presentaba un osteocondroma a nivel del cuello femoral, una localización poco habitual de asentamiento de este tipo de tumores. A pesar de ser un tumor relativamente frecuente, nuestro objetivo es describir las principales características de diferentes lesiones óseas, sean o no de origen tumoral, independientemente de que se descubran de manera casual o a raíz de un síntoma, como el dolor articular en este caso (AU)

We present the case of a 30-year-old male with an osteochondroma at the femoral neck, an unusual location for this type of tumor. In spite of being a relatively frequent tumor, our objective is to describe the main characteristics of different bone lesions, whether they are tumor-derived or not, regardless of whether they are discovered incidentally or due to a symptom, such as joint pain in this case (AU)

Therapeutic Dermoscopy to Facilitate Detection and Extraction of Foreign Bodies.

Foreign bodies are occasionally seen by family physicians. Plantar foreign bodies in particular pose a special challenge because they involve weight-bearing regions that are difficult to access. If left undetected long enough, these may lead to hospitalization, surgery, or even longstanding complications such as tumors, contractures, infections, and chronic ulcers. Dermoscopy of the cutaneous surface allows early detection of indwelling foreign bodies with a far greater degree of accuracy than with the naked eye. Furthermore, use of a polarized dermatoscope provides ideal illumination and 3-dimensional visualization of the involved site, and facilitates extraction of the penetrating object. This technique could be used for similar injuries involving other body surfaces.

The impact of a point-of-care testing device on CVD risk assessment completion in New Zealand primary-care practice: A cluster randomised controlled trial and qualitative investigation.

OBJECTIVES: To assess the effect of a point of care (POC) device for testing lipids and HbA1c in addition to testing by community laboratory facilities (usual practice) on the completion of cardiovascular disease (CVD) risk assessments in general practice. METHODS: We conducted a pragmatic, cluster randomised controlled trial in 20 New Zealand general practices stratified by size and rurality and randomised to POC device plus usual practice or usual practice alone (controls). Patients aged 35-79 years were eligible if they met national guideline criteria for CVD risk assessment. Data on CVD risk assessments were aggregated using a web-based decision support programme common to each practice. Data entered into the on-line CVD risk assessment form could be saved pending blood test results. The primary outcome was the proportion of completed CVD risk assessments. Qualitative data on practice processes for CVD risk assessment and feasibility of POC testing were collected at the end of the study by interviews and questionnaire. The POC testing was supported by a comprehensive quality assurance programme. RESULTS: A CVD risk assessment entry was recorded for 7421 patients in 10 POC practices and 6217 patients in 10 control practices; 99.5% of CVD risk assessments had complete data in both groups (adjusted odds ratio 1.02 [95%CI 0.61-1.69]). There were major external influences that affected the trial: including a national performance target for CVD risk assessment and changes to CVD guidelines. All practices had invested in systems and dedicated staff time to identify and follow up patients to completion. However, the POC device was viewed by most as an additional tool rather than as an opportunity to review practice work flow and leverage the immediate test results for patient education and CVD risk management discussions. Shortly after commencement, the trial was halted due to a change in the HbA1c test assay performance. The trial restarted after the manufacturing issue was rectified but this affected the end use of the device. CONCLUSIONS: Performance incentives and external influences were more powerful modifiers of practice behaviours than the POC device in relation to CVD risk assessment completion. The promise of combining risk assessment, communication and management within one consultation was not realised. With shifts in policy focus, the utility of POC devices for patient engagement in CVD preventive care may be demonstrated if fully integrated into the clinical setting. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12613000607774.

Despistaje de aneurisma de aorta abdominal en Atención Primaria / Abdominal aneurism screening in Primary Care

Objetivos. Obtener el porcentaje de aneurismas de aorta abdominal (AAA) detectados en varones entre 65 y 74 años en un centro de salud mediante ecografía y describir la distribución de factores de riesgo en la muestra. En relación con la presencia de aneurismas, determinar cuántos se diagnostican en el hospital y las dudas diagnósticas. Pacientes y método. Estudio transversal realizado entre septiembre de 2014 y febrero de 2015 en un centro de salud. Del total de 212 pacientes seleccionados aleatoriamente, se realizó entrevista clínica y ecografía a 115 varones, de entre 65-74 años, de los 171 que cumplían criterios de inclusión. Se realizó la captación mediante llamada telefónica. Las variables cuantitativas se estudiaron mediante medidas de tendencia central y de dispersión, y las cualitativas, mediante frecuencias absolutas y relativas. Resultados. El porcentaje hallado de AAA infrarrenal en la muestra fue de 2,6% [IC 95% 0,54-7,4]. El 51,3% tenían HTA y el 76,1% eran fumadores o exfumadores. Los 3 AAA hallados, uno con duda diagnóstica, fueron confirmados en el Hospital Universitario Fundación Jiménez Díaz. No hubo pérdidas. En la muestra, todos los pacientes con AAA eran fumadores activos y tenían al menos otro factor de riesgo. Conclusión. El porcentaje del 2,6% de pacientes con AAA fue menor del esperado (4%), pero superior a la prevalencia encontrada en los estudios en los que no se tenía en cuenta el tabaco como criterio de inclusión (AU)

Objectives. To obtain the percentage of abdominal aortic aneurism (AAA) determined in men between 65-74 years old in a health centre using ultrasound, and to describe the distribution of risk factors in the whole sample and in patients with aneurism, as well as determining how many AAA are confirmed at the hospital and those cases of uncertain diagnosis. Patients and Method. A cross-sectional study conducted on patients included from September 2014 to February 2015. From a total of 212 randomised patients, a clinical interview and abdominal ultrasound were performed on 115 men, aged 65 to 74, telephone-recruited from a total of 171 that fulfilled inclusion criteria. Results. An infra-renal AAA was found in 2.6% of the sample (95% CI 0.54-7.4). Just over half (51.3%) of the sample had arterial hypertension, and 76.1% were smokers or former smokers. The 3 AAA found, one of which had an initial doubtful diagnosis, were confirmed by the Hospital Universitario Fundación Jiménez Díaz. There were no losses. All of the patients with AAA were active smokers and had at least one other risk factor. Conclusion. The percentage of infra-renal AAA in the sample was lower than expected, but higher than the percentage found in other studies that did not consider smoking in the inclusion criteria (AU)

Promoción de la salud: promoción de la salud mental / Health promotion: mental health promotion

No disponible

Un modo de ayudar al «Sr. Minotauro» y a la «Sra. Ariadna» a salir del laberinto de la multimorbilidad: los «problemas maestros» / A way of helping «Mr. Minotaur» and «Ms. Ariadne» to exit from the multiple morbidity labyrinth: the «master problems»

La multimorbilidad parece «infinita» y así no es operativa para tomar decisiones útiles. Presentamos un nuevo concepto: los «problemas maestros», como método cualitativo para facilitar la salida de este laberinto. Para la enseñanza de este concepto se han usado metáforas basadas en el mundo del arte. Estos «problemas maestros» generalmente permanecen ocultos y solo pueden «desvelarse» entre los intersticios de la multimorbilidad, al fijarnos en los detalles del sistema que define el problema. Un problema con «energía» o «problema maestro» es complejo, múltiple y dramático o teatral -todas las cosas de la historia clínica nos hacen mirar hacia ese punto determinado-; es el que nos da un golpe en la boca del estómago, el que hace que nos lata más rápido el corazón, el que nos conmueve a muchos niveles, el que tiene una gran «densidad de emociones», elementos humanos, símbolos sociales, y nos abre soluciones en un paciente (AU)

Multiple morbidity seems to be 'infinite' and so is not easy to make useful decisions. A new concept is introduced: the 'master problems', as a qualitative method to facilitate the exit from this maze of multiple morbidity. Metaphors from the art world have been used to teach this concept. These 'master problems' generally remain hidden and can only 'unravel' between the interstices of multiple morbidity, when the details of the system that defines the problem are explained. A problem with 'energy' or a 'master problem' is complex, multiple and dramatic or theatrical -everything in the clinical history history make us look into that particular question-. It is what gives us a blow to the stomach, which causes our hearts to beat faster, that moves us on many levels, which has a high 'density of emotions', human elements, social symbols, and opens solutions in a patient (AU)

Aprendiendo conceptos del diagnóstico en medicina de familia: a propósito del "signo de Robinson" - las huellas que no deberían estar allí / Learning concepts of diagnosis in family medicine: the “mark robinson sign” - the traces that should not be there

A propósito de cinco casos en donde el proceso diagnóstico se inició en 'la huella que no debería estar allí' o 'signo de Robinson' -como le pasó a Robinson Crusoe que vio una huella humana en la playa de su isla 'desierta': ¿cómo podía encontrarse allí?; era un misterio-, y basándonos en metáforas, revisamos los mecanismos de la operación mental de identificar la enfermedad en medicina de familia. Encuadramos el mecanismo de 'la huella que no debería estar allí' principalmente en la primera fase o intuitiva del razonamiento clínico, pero esta intuición del médico debe mantenerse acompañando a todo el proceso diagnóstico, como el 'bajo continuo' de la música barroca, permitiendo la improvisación y el estilo personal, y de este modo, eventualmente la observación de la huella 'que no tenía que estar allí' puede surgir tanto en la fase analítica como en la de verificación de las hipótesis elaboradas

We review the mechanisms of the mental operation to identify the disease in family medicine, using five cases where the diagnosis process began in 'the trace that should not be there' or 'Robinson sign' as happened to Robinson Crusoe when he saw a human footprint on the beach of the 'desert island'. How could it be there?; It was a mystery, and based on metaphors, we framed the mechanism of 'the trace that should not be there' mainly in the first phase of clinical or intuitive reasoning, but this intuition of the doctor should be accompanied by the diagnostic process, like the 'basso continuo' of Baroque music, allowing improvisation and personal style, and in this way, eventually observing the footprint 'that should not have been there' that may arise in the analytical, as well as in the verification phase of the assumptions made

Military family physicians' perceptions of a pocket point-of-care ultrasound device in clinical practice.

Point-of-care ultrasonography with a pocket ultrasound device, General Electric Medical Systems Vscan (Milwaukee, Wisconsin), has been shown to be effective and easy to learn. However, no studies to date have evaluated its use in the military primary care setting where its portability and value in bedside diagnosis would be especially beneficial. We tested the feasibility of the Vscan in the day-to-day care of patients by family physicians in their clinic, inpatient wards, and its potential for use in the military-deployed setting. Participants were trained and credentialed in the use of the point-of-care ultrasonography. Then, participants were provided with a pocket ultrasound device to use in their normal day-to-day practice. Additionally, participants completed surveys and provided ratings on their perceptions regarding the use of the device. According to the survey analysis, participants found the devices to be easy to use, valuable in discerning a diagnosis, and were not prohibitively time consuming. Moreover, patients were perceived by the participants to have been satisfied with the use of the device. Overall, participants had high satisfaction with the Vscan and perceived that the device would be highly valuable in the military-deployed setting.

Viaje a lo esencial invisible: aspectos psicosociales de las enfermedades / Journey to what is essentially invisible: pysochosocial aspects of disease

Los médicos pueden estar bien equipados para los aspectos biológicos de la enfermedad, pero no para sus dimensiones psicosociales, y este tema ha estado ausente en la medicina de familia. Los aspectos psicosociales de las enfermedades son los factores que intervienen en los modos de reaccionar del paciente frente a la enfermedad, y tienen un papel en la expresión de los síntomas y las enfermedades, y en las implicaciones que producen en la vida de las personas. Además, los efectos biológicos (específicos) y psicosociales (inespecíficos) no son simplemente aditivos, sino que interactúan. Los médicos deben ser conscientes de esta morbilidad psicosocial oculta de los pacientes −lo esencial invisible− y deben incorporar las intervenciones biopsicosociales a la atención médica de rutina para ser más eficaces. Además, el tener en cuenta estos aspectos dentro del marco asistencial aporta elementos propios de la medicina de familia (AU)

Physicians may be well equipped for the biological aspects of disease, but not for its psychosocial dimensions, an issue that has been absent in family medicine. The psychosocial aspects of the disease are the factors involved in how patients react to the disease, play a role in the expression of symptoms and disease, and have implications on the lives of patients. Moreover, the biological effects (specific) and psychosocial effects (non-specific) are not simply additive but interactive. Physicians should be aware of this hidden, essentially invisible patient psychosocial morbidity, and must incorporate bio-psychosocial interventions into routine medical care to be more effective. In addition, to consider these aspects in the context of care contributes to the distinctive elements of family medicine (AU)

Dermoscopy for the family physician.

Noninvasive in vivo imaging techniques have become an important diagnostic aid for skin cancer detection. Dermoscopy, also known as dermatoscopy, epiluminescence microscopy, incident light microscopy, or skin surface microscopy, has been shown to increase the clinician's diagnostic accuracy when evaluating cutaneous neoplasms. A handheld instrument called a dermatoscope or dermoscope, which has a transilluminating light source and standard magnifying optics, is used to perform dermoscopy. The dermatoscope facilitates the visualization of subsurface skin structures that are not visible to the unaided eye. The main purpose for using dermoscopy is to help correctly identify lesions that have a high likelihood of being malignant (i.e., melanoma or basal cell carcinoma) and to assist in differentiating them from benign lesions clinically mimicking these cancers. Colors and structures visible with dermoscopy are required for generating a correct diagnosis. Routinely using dermoscopy and recognizing the presence of atypical pigment network, blue-white color, and dermoscopic asymmetry will likely improve the observer's sensitivity for detecting pigmented basal cell carcinoma and melanoma. A two-step algorithm based on a seven-level criterion ladder is the foundation for dermoscopic evaluation of skin lesions. The first step of the algorithm is intended to help physicians differentiate melanocytic lesions from the following nonmelanocytic lesions: dermatofibroma, basal cell carcinoma, seborrheic keratosis, and hemangioma. The second step is intended to help physicians differentiate nevi from melanoma using one of several scoring systems. From a management perspective, the two-step algorithm is intended to guide the decision-making process on whether to perform a biopsy, or to refer or reassure the patient.

Use and teaching of pneumatic otoscopy in a family medicine residency program.

OBJECTIVE: To determine to what extent FPs teach and use pneumatic otoscopy and to identify the chief influences on this behaviour. DESIGN: Mixed-methods descriptive study conducted between March and May 2011. SETTING: The family medicine residency program at Laval University in Quebec city, Que. PARTICIPANTS: Directors of the family medicine teaching units (FMTUs), teachers, and residents. METHODS: We used questionnaires to assess the availability of pneumatic otoscopy equipment in 12 FMTUs, current behaviour and behavioural intention among physicians (residents and teachers) to use or teach pneumatic otoscopy, and facilitators and barriers to these practices. We also conducted 2 focus groups to further explore the facilitators of and barriers to using pneumatic otoscopy. We used descriptive statistics for quantitative data, transcribed the qualitative material, and performed content analysis. MAIN FINDINGS: Eight of the 12 FMTUs reported having pneumatic otoscopy equipment. Four had it in all of their consulting rooms, and 2 formally taught it. Nine (4%) of 211 physicians reported regular use of pneumatic otoscopy. Mean (SD) intention to teach or use pneumatic otoscopy during the next year was low (2.4 [1.0] out of 5). Teachers identified improved diagnostic accuracy as the main facilitator both for use and for teaching, while residents identified recommendation by practice guidelines as the main facilitator for use. All physicians reported lack of availability of equipment as the main barrier to use. The main barrier to teaching pneumatic otoscopy reported by teachers was that they did not use it themselves. In focus groups, themes of consequences, capabilities, and socioprofessional influences were most dominant. Residents clearly identified role modeling by teachers as facilitating the use of pneumatic otoscopy. CONCLUSION: Pneumatic otoscopy is minimally used and taught in the family medicine residency program studied. Interventions to increase its use should target identified underlying beliefs and facilitators of and barriers to its use and teaching.

Diferencias de género en la percepción del logro profesional en especialistas de medicina familiar y comunitaria / Gender differences in the perception of professional achievement in family medicine, Spain

Fundamentos: El concepto de logro es clave para estudiar el desarrollo profesional. En medicina existen desigualdades de género en la carrera profesional. El objetivo fue conocer y comparar la percepción de resultados y atribuciones de logro en médicas y médicos de familia de Andalucía. Método: Estudio cualitativo con 12 grupos de discusión. Población: médicas y médicos de familia que trabajan en atención primaria. Muestra: intencional segmentada por edad, sexo y ocupación de la dirección del centro de salud. Realizamos por sexo: dos grupos de jóvenes, dos grupos de mayores y dos de directores/as; total 32 médicas y 33 médicos. Análisis de contenido. Resultados: Médicas y médicos perciben de igual modo los logros internos y coinciden en considerar como logros externos aspectos inherentes a la profesión. La diferencia más importante es que las médicas relacionan el logro con los vínculos afectivos y los médicos con méritos institucionales. Para las médicas las atribuciones internas son más importantes y destacan la importancia de la familia, la organización de la jornada laboral y el balance familia- trabajo. Para los médicos las atribuciones más importantes son sus pacientes, la formación continuada, los recursos disponibles y el sistema informático. Conclusiones: Existen similitudes y diferencias entre médicas y médicos en la percepción de logro. Las diferencias se explican por el sistema de género. La percepción de logro de las médicas cuestiona la cultura profesional e incorpora nuevos valores. Las atribuciones reflejan el impacto desigual de variables familiares y organizacionales y apunta a que las médicas estarían modificando rasgos de la socialización de género(AU)

Background: The concept of achievement is important to study the professional development. Inmedicine there are gender inequalities in career. The purpose was to know and compare the professional achievement's perceptions and attributions of female and male primary care physicians inAndalusia. Method: Qualitative study with 12 focus groups (October 2009 to November 2010). Population: primary care physicians. Sample: intentionally segmented by age, sex and health care management. Were conducted by sex: two groups with young physicians, two groups with middle aged and two with health care management. Total: 32 female physician and 33 male physicians. Qualitative content analysis with Nuddist Vivo. Results: Female and male physicians agree to perceive internal achievements and to consider aspects inherent to the profession as external achievements. The most important difference is that female physician related professional achievement with affective bond and male physician with institutional merit. Internal attributions are more important for female physician who also highlight the importance of family, the organization of working time and work-family balance. Patients, continuing education, institutional resources and computer system are the most important attributions for male physician. Conclusions: There are similarities and differences between female and male physicians both in the understanding and the attributions of achievement. The differences are explained by the gender system. The perception of achievement of the female physicians questions the dominant professional culture and incorporates new values in defining achievement. The attributions reflect the unequal impact of family and organizational variables and suggest that the female physicians would be changing gender socialization(AU)