The Journal of family practice

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This paper presents a brief description of the phenomenon of the problem patient, the response of the physician, and alternatives to the impass which frequently occurs in the problem patient-physician relationship. There may be great utility in viewing the problem-patient problem as a patient-physician relationship problem. If this is done, the physician may be able to re-examine his/her expectations of the helping role and choose an alternate mode of relating to the patient, to the benefit of both the patient and physician.
 
Extract The Data for Orogenic Studies project has aimed to demonstrate that profuse and complex geological information from the Mesozoic-Cenozoic orogens can be collected in a systematic and organized fashion. The particular method used—a questionnaire designed to elicit factual information—has resulted in a collection of objective data, in which gaps in knowledge are also revealed. The accumulation of these data into a convenient and uniform format will, it is hoped, enable them to fully yield their part in the story of the evolution of the lithosphere in Mesozoic-Cenozoic times. In particular, it should facilitate the progression of geological ideas from the evidence to the hypotheses rather than (as is common) the reverse. The aim of this summary is to follow this method and indicate the major groups of data, particularly the historical information, which have been collected and briefly to evaluate their significance. The major part of the information in the volume is focussed on the rocks that build the orogenic belts. The major type of information yielded by the rocks is historical: the history of the accumulation, intrusion, vulcanism, plutonism, deformation, metamorphism, uplift, etc., which produced the present orogenic belts. Information of a geometrical nature (geometry of tectonic structures and of the orogenic crust, palaeogeography, palinspastic reconstructions, etc.) is, because of its greater complexity, not as definitely or as widely known. The volume has aimed at a world-wide coverage but is incomplete in two respects. Articles are missing for several areas, principally the U.S.S.R., the western United States, southern South
 
Indapamide is an effective antihypertensive drug with diuretic and vasodilating activities. The common starting dose has been 2.5 mg to 5 mg. A lower dose formulation (1.25 mg) is now available. The safety and efficacy of switching patients from indapamide 2.5 mg to indapamide 1.25 mg was evaluated in this randomized, double-blind, multicenter clinical trial. Three hundred seventy-eight adult patients with mild to moderate essential hypertension were enrolled in a washout period, during which patients received single-blind placebo for 4 weeks. All 378 patients qualified for the study and received open-label treatment with indapamide 2.5 mg for 8 weeks. Of the 378 patients, 265 responded to indapamide 2.5 mg and were randomized to receive double-blind treatment with either indapamide 1.25 mg (n = 132) or 2.5 mg (n = 133) for 8 weeks. Overall, 245 of the 378 patients who were initially enrolled completed the study. The primary efficacy variable was the number of patients in each treatment group who maintained a supine diastolic blood pressure of < or = 90 mm Hg (treatment success) by the end of the double-blind period (week 16). Treatment with indapamide 1.25 mg once daily was as efficacious as the 2.5-mg once-daily dose. No significant difference was observed for the percentage of patients who achieved treatment success between the patients switched from indapamide 2.5 to 1.25 mg (74%) and the control group maintained on indapamide 2.5 mg (70%). The incidence of drug-related adverse events during the double-blind period was similar between the two treatment groups. The mean change from pretreatment baseline to endpoint in serum potassium was -0.2 mEq/L (-0.2 mmol/L) in the indapamide 1.25 mg treatment group, compared with -0.4 mEq/L (-0.4 mmol/L) in the indapamide 2.5 mg treatment group. Indapamide 1.25 mg given once daily for 8 weeks was as effective as 2.5 mg once daily in reducing systolic and diastolic blood pressure in patients with mild to moderate hypertension.
 
In the last 15 years, family physicians and general internists have adopted flexible fiberoptic endoscopy as a procedure to screen patients at risk of premature death from colorectal cancer. There has been controversy regarding the ability of non-fellowship-trained primary care physicians to extend this experience to full colonoscopy. The results of 1048 consecutive colonoscopy examinations performed by a family physician over a 9-year period were tabulated. Outcomes measured included the reach-the-cecum rate (RCR), use of medication, complication rate, and diagnostic yield. In a convenience sample of 110 cases, the effectiveness of the non-narcotic analgesic ketorolac was assessed by the RCR. Outcomes of cases in which ketorolac was used were compared with cases in which traditional sedation and analgesia were used. A high diagnostic yield without significant complications was noted. The RCR for nonmedicated patients was 36%. Among all medicated cases, the RCR was 93%. In patients who were given the non-narcotic analgesic ketorolac, the RCR was 96%, compared with 95% in patients not given ketorolac. A family physician in rural practice was able to attain and sustain a state-of-the-art, reach-the-cecum rate over a 9-year period. This service resulted in a high diagnostic yield, high degree of safety, and satisfactory results for the community. Ketorolac is an effective alternative for patients who may be hypersensitive to narcotic analgesia/sedation.
 
The 105-cm flexible sigmoidoscope was studied for the feasibility of its use in a family practice setting in screening for colorectal cancers and polyps. A total of 49 examinations were performed. The average length of colon examined was 71 cm. Insertion to 105 cm was accomplished in 14 patients (29 percent) and exceeded 65 cm in 28 patients (57 percent). No complications of the procedure were encountered. The study indicated that some patients, with no special preparation or medications and no additional discomfort, might benefit by the more thorough screening afforded by 105-cm flexible sigmoidoscope. What is not yet known is the efficacy of large-scale screening for cancers and polyps utilizing the 105-cm flexible sigmoidoscope in the family practice setting.
 
One hundred eleven cases of poisoning (over a 4 1/2-year period) were retrospectively reviewed at a military medical center. Results of the review included the following: (1) two peak age ranges for poisoning were identified: the 1 1/2- to 4-year-old child who accidently ingests both drugs and non-drugs, and the female adolescent who ingests drugs as a suicide attempt or gesture; (2) hydrocarbons and aspirin were the most common agents ingested; however, if grouped, drugs with anticholinergic effects would replace aspirin as the second most common poison; (3) emergency treatment included emesis or lavage in four fifths of poisonings except in ingestions of hydrocarbons or caustics where its use is controversial; (4) incidence of recurrence of poison ingestion was three percent, and morbidity and mortality combined were less than one percent; and (5) two thirds of patients were asymptomatic on admission and hospitalized primarily for observation.
 
One hundred twenty-one patients with acute epididymitis or epididymo-orchitis were evaluated retrospectively according to their clinical symptoms, duration of symptoms, physical examination, and laboratory studies. The patients younger than 30 years of age usually showed less severity of symptoms than the patients older than 50 years of age. The latter often demonstrated evidence of outflow obstruction. Eighty-two percent of patients with demonstrated urographic abnormalities had lower tract abnormalities, mainly secondary to outflow obstruction. All of these patients were older than 50 years of age. An intravenous pyelogram is indicated only in patients over 50 years of age and in young adults with positive bacteriologic urine culture.
 
The assessment of a vasectomy technique should be based on the incidence of complications resulting from the procedure. Differing diagnostic criteria for defining complications and the belated occurrence of some adverse events, however, have made such appraisals difficult. The purpose of this paper is to suggest criteria for defining vasectomy-related problems and to present the results of a long-term study of 1224 vasectomies. The records of 1224 men who had a vasectomy performed by the same technique during a 4-year period were reviewed, and documented complications were tabulated and evaluated. Patients were referred residents of the lower mainland of British Columbia, and the majority were married. The group included a wide spectrum of ages, races, and occupations. Twelve categories of potential complications were defined, of which 10 were actually encountered in the study group. Infection was defined as having had antimicrobial drugs prescribed, and regret as having returned to discuss a reversal; all other complications were diagnosed based on a documented clinical diagnosis. Complications had been documented in 124 cases (10.6%) and included 46 minor infections (3.8%), 2 serious infections (0.16%), 23 instances of epididymitis (1.9%), 16 cases of sperm granuloma (1.3%), and 4 minor hemorrhages (0.33%). Of 3 failures, only one (0.08%) was due to recanalization. No serious hemorrhages or late failures were seen. Satisfactory results were believed to be related to surgical technique and the liberal use of antimicrobial drugs. The low recanalization rate was attributed to the treatment of the ends of the vas with multiple loops of polyglycolic acid ligature.
 
Home visits provided the setting for interim assessments by a clinical psychiatrist and a research assistant between December 1978 and April 1979. Two instruments were used: a standardized 61-question interview and a self-rating checklist. Forty-seven cases of affective disorder, 47 age-sex-marital status matched compeers, and 32 spouses participated. Results show little agreement between family practice records (drug and problem lists) and assessment at home visits. Over 46 percent of adults showed signs of anxiety, depression, or both. Gaps in physician-patient communication account for some of the missed diagnoses. Prospective studies of these common disorders are handicapped by problems of: (1) definition and criteria, (2) fluctuations in sick/well status over time, (3) changing levels of severity and levels of detection, and (4) losses of the sicker persons from the population for follow-up study. A generally useful model for affective disorders emphasizes the interaction between intrinsic factors (subjective stress) and extrinsic factors (objective stress). A flow sheet is used to help the clinician assess the major components of stress, patient's ability to cope, and plan for management.
 
Thirteen cases of epiglottitis are reviewed in this paper. Fever and respiratory distress were the most common presenting symptoms. A lateral neck roentgenogram was a helpful laboratory test. Epiglottitis must be distinguished from viral croup and other causes of upper airway obstruction so that prompt treatment can be instituted. A suggested protocol for management of epiglottitis emphasizes the importance of establishing an artificial airway and administering intravenous antibiotics effective against Hemophilus influenzae type B.
 
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. 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. 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. 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.
 
Carcinoma of the lung has been steadily increasing since World War II, and the family physician can now expect to see a greater incidence of the disease in women and persons under age 50 years. The clinical manifestations of carcinoma of the lung are described, based on a 14-year experience at the University of Michigan. Diagnostic procedures are outlined. The preferred treatment for carcinoma of the lung is pulmonary resection, combined, in appropriate situations, with mediastinal lymph node irradiation. Survival is dependent to some degree on the tumor cell type as well as the extent of metastasis. A new immunotherapeutic adjunct to resection and irradiation is being developed. Five to ten-year survivors of resections for lung cancer and normal persons serve as lymphocyte donors. Transfer factor is extracted from these lymphocytes and injected into selected patients who have recently had resections for lung cancer. It is too soon to evaluate the results of this experiment, but it is hoped that immunotherapy using transfer factor will be of help to patients with carcinoma of the lung.
 
The functions of the traditional home visit in practice and teaching are controversial. A different kind of planned home visit was developed and implemented as part of orientation of first-year family practice residents. The objectives were to get acquainted and establish communications; to facilitate observational skills and awareness of the community; and to improve research parameters of the family record. This kind of home visit is feasible: all residents participated; 92.2 percent of families participated of whom 90.8 percent responded to a follow-up questionaire. Communication patterns between doctor and patient/family were analyzed for skills at listening and speaking clearly. Poor communication was infrequent, occuring in only 8 to 12 percent of the encounters. Ethnic differences between family and resident were important in such visits.
 
The University of Western Ontario Hypertension Study provided an opportunity to study attrition rates over a five-year period in the population of 17 family practices in southwestern Ontario. The baseline population consisted of all patients between the ages of 20 and 65 years who were active in the practices in 1978. During the five years of the study, a medical assistant in each practice recorded data on morbidity, mortality, and patients leaving the practice. The follow-up of nonresponders to a demographic questionnaire provided additional data on patient moves. The overall five-year move rate was 13.2 percent for men and 16.6 percent for women. Those in the 20- to 29-year age group had the highest rates, and those in the 30- to 39-year age group had the next highest. The rates for men stabilized after the age of 40 years to between 8 and 10 percent, and for women after 40 years to between 11 and 13 percent. The move rates were higher in urban than in rural practices. Ninety percent of hypertensive patients received continuous care over the five-year period. In southwestern Ontario, population mobility does not appear to be a major barrier to continuing care.
 
The researchers evaluated the effectiveness of paroxetine and Problem-Solving Treatment for Primary Care (PST-PC) for patients with minor depression or dysthymia. This was an 11-week randomized placebo-controlled trial conducted in primary care practices in 2 communities (Lebanon, NH, and Seattle, Wash). Paroxetine (n=80) or placebo (n=81) therapy was started at 10 mg per day and increased to a maximum 40 mg per day, or PST-PC was provided (n=80). There were 6 scheduled visits for all treatment conditions. A total of 241 primary care patients with minor depression (n=114) or dysthymia (n=127) were included. Of these, 191 patients (79.3%) completed all treatment visits. Depressive symptoms were measured using the 20-item Hopkins Depression Scale (HSCL-D-20). Remission was scored on the Hamilton Depression Rating Scale (HDRS) as less than or equal to 6 at 11 weeks. Functional status was measured with the physical health component (PHC) and mental health component (MHC) of the 36-item Medical Outcomes Study Short Form. All treatment conditions showed a significant decline in depressive symptoms over the 11-week period. There were no significant differences between the interventions or by diagnosis. For dysthymia the remission rate for paroxetine (80%) and PST-PC (57%) was significantly higher than for placebo (44%, P=.008). The remission rate was high for minor depression (64%) and similar for each treatment group. For the MHC there were significant outcome differences related to baseline level for paroxetine compared with placebo. For the PHC there were no significant differences between the treatment groups. For dysthymia, paroxetine and PST-PC improved remission compared with placebo plus nonspecific clinical management. Results varied for the other outcomes measured. For minor depression, the 3 interventions were equally effective; general clinical management (watchful waiting) is an appropriate treatment option.
 
Two hundred forty-four consecutive diagnoses and procedures appearing on the patient billing records between June 1934 and September 1935 of a general physician practicing in rural southwestern Minnesota were compared with 286 diagnoses and procedures taken from the billing records of patient visits made over a 2-week period to a modern family physician practicing in a comparable rural community in southwestern Ohio. The most common items on the billing records of the physician of the 1930s were follow-up incision and drainage of abscess, 26 (10.7%); diphtheria immunization, 24 (9.8%); follow-up drainage for mastoiditis, 17 (7.0%); and scrotal tap for epididymitis, 14 (5.7%). Many of these patient encounters were at the patient's home. The most common items on the records of the modern physician practicing in rural southwestern Ohio were upper respiratory tract infection, 13 (4.5%); hypertension, 12 (4.2%); hyperlipidemia, 11 (3.9%); and history-taking and physical examination (adult), 10 (3.5%). This study suggests that there are great differences between the diagnostic profiles of the first third of the 20th century and modern family physicians. Many of the common diagnoses seen by the physician of the 1930s required a procedure to be performed. Many of the problems treated by the contemporary family physician did not even exist for the early 20th century general physician. Some of the differences between the modern physician and his predecessor can be explained by the introduction of antibiotics in the late 1930s and early 1940s.
 
An analysis of data collected from a one-year survey of the activities of seven residency trained family physicians practicing in Massachusetts was carried out. These data were compared to a study of activities of Massachusetts general practitioners done in 1967-1968, and to the Virginia Study of 1976. Both hospital and health center encounters were analyzed. The age distribution of the practices paralleled that of the general practitioners, particularly the younger general practitioners. The sex distribution was also comparable. However, over one third of all health problems recorded during the study were for preventive or non-illness visits. This represented a significant percentage increase over the general practitioners as well as the family physicians in the Virginia Study. The site of activity was also different in showing a ten percent increase in office visits over 1967-1968. Women's health issues, which include maternity and family planning care, represented a larger percentage of the practices of the residency graduates than was the case in the Virginia Study. Educational and health manpower implications of the study are discussed.
 
Previous analyses of published clinical trials have identified major deficiencies in reporting, design, analysis, and overall quality. The purpose of this study was to determine the strengths and weaknesses of published clinical trials in family practice, and to identify predictors of quality in these trials. Randomized controlled clinical trials published in The Journal of Family Practice from 1974 to 1991 were eligible for the study. Two raters independently evaluated the adequacy and appropriateness of reporting, design, and analysis for each clinical trial, using the Chalmers index for assessing clinical trial quality. Multiple linear regression was used to determine the predictors of quality. The 53 trials included in the study showed deficiencies in reporting, design, and analysis, although fundamental design issues, such as blinding, were a relative strength. On average, the trials scored 35% of the possible points on the scale. Three factors were positively associated with overall quality: year of publication, number of pages of the published report, and the type of intervention. Trials with pharmacologic and non-medication therapy interventions, such as diet, had higher quality scores than did trials with psychosocial or educational interventions. The overall quality of these clinical trials was less than optimal but comparable to previously analyzed groups of trials. The improvement in quality over time may be related to improvement in the quality of the trials themselves, or more exacting editorial standards, or a combination of the two.
 
This paper examines the spontaneous evolution of original work in the field of family practice as published in this journal over the past ten years. An analysis was carried out by principal content, by type, and by source of the more than 1,700 papers published during that period. More than one half (currently 60 percent) of published papers have dealt with biomedical subjects; a majority of the remaining papers have dealt with health services and educational subjects. The most common type of paper has been observational research, with case studies, reviews, methods, opinion, and experimental research following in that order. The last five years have seen a continuing increase in the proportion of observational research papers, a slight decrease in reviews and opinion, and a marked decrease in methods papers. Sixty percent of published papers have been contributed by family physicians or others working in family practice settings. About three fourths of papers have been contributed from university or medical school settings, with one fourth from various community settings. All parts of the country have contributed to the publication of original work in the field. The trends that have been identified over the first ten years in terms of focus and content of the literature of record seem quite appropriate for the current and next stages of development of family practice as a clinical specialty.
 
Recent years have seen increasing interest in the use of audiovisual teaching materials throughout medical education. There is good evidence that different individuals learn best in different ways according to their particular learning styles, personalities, and learning needs. Audiovisual materials can provide flexible approaches to meet varied learning needs and facilitate self-instruction. In the past, there has been no systematic method of identification and evaluation of audiovisual teaching materials relevant to family practice. This paper describes the experience of a review process which was initiated three years ago. A complete list is presented of audiovisual teaching materials which have been reviewed for family practice and future directions of the review process are discussed.
 
This paper examines the spontaneous evolution of original work in family practice as published in The Journal of Family Practice over the 15-year period since it began publication in 1974. An analysis was carried out by principal content and type of paper for the last five years in a manner comparable to an earlier analysis of the journal's first ten years of publication. Trends that emerge from this reanalysis provide a window to observe the further development of family medicine as a scientific and academic discipline. The last five years have seen a marked increase in clinical content of papers (from approximately 60 to 80 percent of published papers) together with continued emphasis on health services subjects. There has been a concurrent sharp increase in research papers, continued strong representation of case studies, and some decrease in both reviews and methods papers. Descriptive research continues to predominate among research papers. Although experimental research still represents only 5 percent of published papers, this percentage has more than doubled over the last five years. The reanalysis also revealed a substantial decline in the proportion of educational papers, as other journals in the field have assumed the primary role for this content area. It appears that the manuscript supply represented by original work in the field is still limited and that there is at present adequate or even surplus journal capacity for publication of work carried out in family practice settings. The quality and type of work continue to mature consistent with the needs of family medicine as a scientific and academic discipline.
 
One thousand eighty-six studies were reviewed to determine the prevalence, characteristics, and quality of measures of religion or religiosity in The Journal of Family Practice for the decade ending in 1986. Religious variables occurred at a relatively low rate, even among articles with some psychosocial content. The clear preponderance of religious measures pertained to patients rather than to providers, and religious variables were generally analyzed descriptively, not inferentially. In spite of an encouraging use of some measures of religious beliefs and practices, there remained a significant focus on denominational measures of religious status. These findings suggest that the consideration of religious variables in the family medicine literature has not been commensurate with the emerging picture of the role of religious commitment in health status and mental health status. It is suggested that increased emphasis on developing an original literature of record about religious variables in family medicine will promote the empirical assessment of the beneficial, neutral, and harmful effects of religion among family medicine patients and providers.
 
Audiovisual teaching materials have found increasing use in medical education in recent years, and a large number of excellent materials have been produced. The plethora of existing audiovisual teaching programs has made it difficult for educators and potential users to be aware of what is available and to select programs relevant to specific learning needs. The Audiovisual Review Committee has functioned over the last five years as a subcommittee of the Education Committee of the Society of Teachers of Family Medicine. This paper describes the experience of this group over the last two years and presents a complete listing of audiovisual teaching materials which have been reviewed and appraised during that period.
 
Physician compliance with widely recommended colorectal cancer screening methods was studied over a five-year period in a university-based family medicine residency program. Indicated examinations were being avoided in symptomatic as well as asymptomatic patients aged over 50 years. The introduction of flexible sigmoidoscopy created significant change in previously documented poor resident and faculty compliance. Baseline measurement of outcomes was noted by audit of 189 adult medical records (year 1). Educational reemphasis by lecture and intragroup commitment produced no change by the end of year 2 (n = 189). Introduction of the flexible sigmoidoscope yielded a sevenfold increase in physician compliance in year 3 (n = 192). This compliance increased as measured by chart audit in years 4 (n = 166) and 5 (n = 190). All audited groups were mutually exclusive. The documented diagnostic superiority of this instrument was readily obtainable by family physician faculty and residents in training. With Papanicolaou smear activity serving as a control group, the findings indicated a significant and sustained effect. Two additional primary care training programs were audited during the final year of the study period. These control audits revealed continued poor compliance with rigid sigmoidoscopy. The flexible sigmoidoscope is an important addition to the diagnostic and screening armamentarium of a family medicine residency program.
 
Although audiovisual teaching materials are commonly used in medical education at all levels, it remains difficult for educators and interested learners to become aware of what is available, of good quality, and relevant to specific learning needs. The Audiovisual Review Committee has functioned since 1974 as a subcommittee of the Education Committee of the Society of Teachers of Family Medicine. This paper lists the audiovisual materials that have been reviewed during the last two years, and briefly comments upon the review process that has been used over the last seven years.
 
Three hundred twenty-three patients who underwent abortion counseling between 1982 and 1984 were interviewed to determine the cause of birth control failure. Twenty-three percent employed no birth control and 27 percent used diaphragms, the majority either inconsistently or incorrectly. Twenty-two percent of the pregnancies were due to oral contraceptive-related failures; and the remainder were due to spermicide, condom, rhythm method, multiple method, and intrauterine device failures. Overall, fewer than one quarter of unwanted pregnancies among the predominantly white, middle-class population studied resulted from failure to obtain contraception, and only 19 percent represented technical failure despite correct and consistent use. The majority (51 percent) occurred because of human error, ie, either incorrect or inconsistent use of available contraceptive modalities. These findings contrast sharply with those of a similar study performed between 1969 and 1974. At that time failure to obtain contraception accounted for more than one half of the failures. Whereas the development and distribution of contraceptive technology was the challenge of the 1960s and the 1970s, reducing the number of birth control failures through anticipatory patient counseling is the challenge of the current decade.
 
Top-cited authors
John Jordan
  • The University of Western Ontario
Wayne Weston
  • The University of Western Ontario
Susan A Flocke
  • Oregon Health and Science University
Stephen J Zyzanski
  • Case Western Reserve University
Edward J Callahan
  • University of California, Davis, School of Medicine