Table of Contents

The Issue in Brief

The Unexpected in Primary Care: A Multicenter Study on the Emergence of Unvoiced Patient Agenda
By Michael Peltenburg, MD, FAAPP, and colleagues
Unexpected topics often arise during a visit to a primary care doctor. In a study of 2,243 European patients, topics that neither the patient nor the doctor expected to address came up in nearly 1 of every 7 visits. Doctors can help develop the agenda for the medical visit by encouraging patients to raise issues they may be hesitant to discuss.

Why We Don't Come: Patient Perceptions on No-Shows
By Naomi L. Lacy, PhD, and colleagues
In some clinics, as many as 45% of patients fail to keep their scheduled appointments. Interviews with patients revealed 3 reasons why they are "no-shows": (1) Some patients are afraid and anxious about the cause of their symptoms, the procedures they might have to undergo, and the bad news that they might receive. (2) Some patients may feel disrespected by the health care system. This includes a sense that health care staff do not respect them, and do not value their time, opinions, and feelings. (3) Some patients do not understand the scheduling system. They may not be aware of the financial impact of missing an appointment and may think that a no-show helps a busy clinic. Medical practices might decrease the number of no-shows by reviewing the amount of time that patients have to wait, helping patients address their medical fears, and considering patients' feelings about personal respect.

Are Frequent Callers to Family Physicians High Utilizers?
By David E. Hildebrandt, PhD, and colleagues
Patients who make frequent after-hours telephone calls to physicians' offices use more health resources than other patients. Frequent callers are often female patients experiencing anxiety, depression, chronic illness, or pain. Compared with other patients, they have 3 times as many office visits, medical diagnoses, and medication prescriptions, and 8 times as many hospital admissions. Strategies to better meet the needs of these patients, particularly their need for care of anxiety, depression, and pain, may decrease the numbers of calls and the amount of health services they use. Strategies could include providing targeted education and treatment to frequent callers.

Health Care Seeking Among Urban Minority Adolescent Girls: The Crisis at Sexual Debut
By M. Diane McKee, MD, MS, and colleagues
In-depth interviews revealed that urban adolescent black and Latina girls dramatically shift how and where they seek help for health needs after becoming sexually active. Before the onset of sexual activity, most girls meet health needs within their families, relying heavily on mothers for health care and advice. Once sexually active, girls attempt to meet reproductive needs by extending their search for advice and care to "mother alternatives," such as older female family members. Although sexually active girls turn to new sources, they still want their care to be personalized, as was the care they received from their mothers. Many sexually active adolescent girls fail to establish trusting relationships with either health care professionals or "mother alternatives" and, as a result, they have unmet sexual health needs.

Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-Being
By Polly Hitchcock No�l, PhD, and colleagues
Treatment of depression may lead to more dramatic improvements in the health of elderly patients than treatment for other chronic illnesses. Researchers found that patients' mental functioning, disability and quality of life are affected more by the severity of a patient's depression than by other chronic medical conditions like diabetes, lung disease, hypertension, cancer, chronic pain and heart disease. Patients with more severe depression experience lower quality of life, lower physical and mental functioning, and more disability. Late-life depression can be treated, and improved recognition and treatment of this condition could significantly improve patients' lives, in spite of other medical illnesses.

Race, Rural Residence, and Control of Diabetes and Hypertension
By Arch G. Mainous III, PhD, and colleagues
Blacks living in rural areas not only have higher rates of diabetes and hypertension than urban blacks and both rural and urban whites, according to this study they also have significantly worse control of the diseases. Researchers found that rural blacks with diabetes have higher blood glucose levels, and rural blacks with hypertension have higher diastolic blood pressure than other groups with the same conditions. Efforts are needed to address the health problems of patients living in rural areas, especially those who are of lower income and are black. The authors of this study call for more people, programs, and resources to address these important health needs.

Improving Test Ordering in Primary Care: The Added Value of a Small-Group Quality Improvement Strategy Compared With Classic Feedback Only
By Wim H. J. M. Verstappen, MD, PhD, and colleagues
Physicians who participate in specially designed meetings with their peers order fewer diagnostic tests than physicians who receive only written reports about test ordering. The small-group meetings were held among primary care physicians in the Netherlands to discuss tests they ordered for patients with cardiovascular conditions (such as high cholesterol levels) and upper and lower abdominal complaints, and to review national guidelines on those topics. Meeting participants ordered fewer tests than physicians who received only written feedback about their test-ordering behavior. This strategy may be an effective way to reduce unnecessary test ordering and is being implemented throughout the Netherlands.

The Biopsychosocial Model 25 Years Later: Principles, Practice, and Scientific Inquiry
By Francesc Borrell-Carri�, MD, and colleagues
In the mid-1970s, George Engel, MD, developed a "biopsychosocial model" of medicine. According to this approach, illness has not only medical/scientific aspects but also psychological and social aspects. In this article, researchers expand the biopsychosocial model and suggest ways that it can be a guide for applying medical knowledge to meet the needs of each patient. According to these suggestions, doctors should: (1) be aware of themselves, physically and mentally, in order to be aware of patient needs, recognize errors, and act compassionately; (2) create an atmosphere of trust with patients; (3) keep an open mind and ongoing curiosity about patients and their health; (4) be aware of any bias they might have toward a patient; (5) learn new emotional skills to help diagnose conditions and form stronger relationships with patients; (6) trust their intuition and later try to determine whether a hunch was based on observations that were not easy to describe at the time; and (7) communicate clinical findings to patients in a way that is understandable.

Lay Understanding of Familial Risk of Common Chronic Diseases: A Systematic Review and Synthesis of Qualitative Research
By Fiona M. Walter, MA, MSc, FRCGP, and colleagues
In an effort to prevent disease, health professionals often ask patients about their family history of cancer, heart disease, and diabetes. Knowing the number of family members who had a disease and their age at illness and death can help determine whether a patient is at greater risk for that disease. Patients also consider these factors when thinking about their risk for diseases, but they consider other factors as well. These include such factors as their similarity and emotional closeness to the ill relative, and their experience of the relative's illness. As health professionals learn more about genetic risks for disease, it is important that they explore ways in which patients understand and feel at risk for inherited disease.

Effect on Health-Related Outcomes of Interventions to Alter the Interaction Between Patients and Practitioners: A Systematic Review of Trials
By Simon J. Griffin, MSc, DM, and colleagues
Communication between doctors and patients is an important part of medical care. A limited amount of research has examined methods for changing the way that doctors and patients communicate in an office visit and how those methods affect patient health. A new study summarized this research and found that many approaches can influence communication between doctors and patients, and may improve patient health.

A Bag of Worms
By James L. Glazer, MD
A family physician describes his experience as a resident physician working to resuscitate the victim of a drunk-driving accident while at the same time caring for another patient undergoing his 10th admission for detoxification. He relates what it was like, as he attempted to resuscitate the victim, to hold a beating heart for the first time.