Table of Contents
The Issue in Brief
Andrew L. Sussman, PhD, MCRP, and colleagues
Background Human papillomavirus (HPV), which is linked to cervical cancer, is the most common sexually transmitted infection in the United States. The first HPV vaccine, for females 9 to 26 years old, was approved in 2006. Primary care clinicians play an important role in counseling patients about preventing sexually transmitted diseases; this study looks at factors that influence their counseling of adolescent patients about HPV and cervical cancer prevention.
What This Study Found Primary care clinicians believe they should counsel adolescents about sexual risk taking, because these patients may take part in risky behaviors. Clinicians tailor their approaches to counseling, based on cues from patients and parents. In this study, clinicians did not usually discuss HPV in counseling for sexually transmitted diseases because of the complexities of the topic and because of other important tasks to be accomplished in the patient visit. They did counsel for HPV when the patient had abnormal Pap results or genital warts, but in these cases the adolescent is not a candidate for HPV vaccination. The study also found that parents accompany younger adolescents to most of their primary care visits. This is a consideration, because the HPV vaccine is most beneficial if administered before an individual is sexually active and because clinicians prefer to talk to the patient privately, without a parent present.
Implications
- This study provides a step toward better understanding factors that influence primary care clinicians in their decisions about counseling adolescent patients on HPV and cervical cancer prevention.
- Primary care clinicians need strategies that address the complexities of HPV counseling, the limitations of the HPV vaccine, the need to counsel for HPV and cervical cancer prevention at younger ages as a result of the vaccine, and the need to accomplish many other tasks during visits with adolescent patients.
- Primary care clinicians may need to shift their counseling methods to address sexual activity and the HPV vaccine with preadolescents with their parents present.
Clinical Diagnosis of Herpes Zoster in Family Practice
Wim Opstelten, MD, Phd, and colleagues
Background Herpes zoster is a common virus that can cause nerve inflammation and eye problems. It is often diagnosed clinically by the presence of a rash, but this can occasionally result in a false-positive diagnosis with unnecessary treatment. This study tests the effectiveness of family physicians� diagnosis of herpes zoster by comparing their clinical judgment with a laboratory test called dried blood spot analysis.
What This Study Found In 91% of patients studied, family physicians� clinical diagnosis of herpes zoster, based on patients� signs and symptoms, was correct according to the dried blood spot analysis. The dried blood spot analysis, a laboratory test, is a convenient method of testing.
Implications
- Family physicians have good clinical judgment in diagnosing herpes zoster. They do not often need additional testing to confirm the diagnosis.
James M. Nicholson, MD, MSCE, and colleagues
Background Cesarean deliveries, which tend to have more medical complications than vaginal births, are increasing in North America. Clinicians have developed a method for inducing labor in women who are near the upper limit of the safest and most advantageous time period for their delivery. This study compares cesarean section rates between practitioners who often use this process (called the Active Management of Risk in Pregnancy at Term, or AMOR-IPAT) and those who do not.
What This Study Found In this 4-year study at a rural hospital, patients of clinicians who practiced AMOR-IPAT had a significantly lower cesarean delivery rate than patients of other clinicians. Women who received AMOR-IPAT did not have higher rates of other birth complications.
Implications
- As rates of cesarean deliveries rise, the authors encourage clinicians to consider the potential benefits of AMOR-IPAT as an alternative method of maternity care.
- The authors call for more study of this possible approach to preventing cesarean deliveries.
Allen J. Dietrich, MD, and colleagues
Background In an earlier study, called Prevention Care Management (PCM), women who received health care from federally funded Community Health Centers and were not up-to-date for breast, cervical, or colorectal cancer screening, received reminder telephone calls and other assistance from trained telephone staff. The current study explores whether a streamlined version of PCM is effective when offered through a Medicaid managed care organization.
What This Study Found The modified Prevention Care Management program can be implemented and modestly improves cancer screening rates. Women in the modified PCM program were 1.69 times more likely to be up-to-date for colorectal cancer screening tests than women in a comparison group. Screening rates for cervical and breast cancer did not differ significantly between the groups.
Implications
- Like the original Prevention Care Management program, the streamlined study increases cancer screening. This finding suggests that a telephone care management program for cancer screening can be translated to a real-world setting.
- This approach has the potential to improve cancer-screening rates in settings that can provide telephone support to women known to be overdue for cancer screening.
Javier I. Escobar, MD, and colleagues
Background Patients with medically unexplained physical symptoms are often seen in primary care. This study tests the effectiveness of a 10-session mental health program for primary care patients with medically unexplained symptoms that are not highly severe. The program is administered by trained psychologists and aims to reduce the patient�s physical distress and preoccupation with physical symptoms.
What This Study Found The mental health program was effective in managing an ethnically diverse sample of patients with unexplained physical symptoms in the primary care setting. About 60% of the patients who completed the treatment had significant relief of medically unexplained physical symptoms. This improvement continued months after the intervention, although the degree of improvement gradually decreased. The program also led to a decrease in depression symptoms, but this effect was less likely to continue with time.
Implications
- This program may be relatively easy to implement in primary care offices in which mental health consultants are available.
- Some patients may require fewer sessions or a less-intensive program while others may require more. Therefore, a staged approach to treatment should be considered.
Operational Definitions of Attributes of Primary Health Care: Consensus Among Canadian Experts
Jeannie Haggerty, PhD, and colleagues
Background In 2004, the authors consulted with Canadian primary health care experts. Their goal was to develop definitions of key primary care system features to be evaluated in Canada�s health care system.
What This Study Found This process resulted in 25 operational definitions of features of primary health care. Those that are specific to primary care are first-contact, accessibility, relational continuity, family-centered care, population orientation, and intersectoral teamwork. (The last 2 refer to community-oriented models of primary care.)
Implications
- These measurable definitions will help in efforts to assess initiatives to renew primary health care and will serve as a guide for instrument selection.
- To get a valid and global evaluation of primary health care, data are needed from a variety of sources, including patients, clinicians, and administrative data.
Information Needs and Information-Seeking Behavior of Primary Care Physicians
Ana I. Gonzales-Gonzales, MD, and colleagues
Background Primary care clinicians, on average, address more than 500 clinical topics in their practices and so have very broad information needs. The aim of this study is to determine the information needs and information-seeking patterns among primary care physicians in Spain.
What This Study Found In this study, the most frequent questions asked by doctors relate to diagnosis and treatment of patients� conditions. The most frequent generic type of question was "what is the cause of symptom X?" Doctors searched for answers to 23% of questions, most often finding answers in a summary of drug information, a textbook, or from a colleague.
Implications
- Primary care doctors� questions cover a wide range of topics, reflecting the broad scope of primary care practice. These questions are often complex and patient-specific.
- Doctors in this study had short patient visits, allowing time to answer only 1 in 5 of their questions. Better methods are needed to provide answers to questions that arise in short visits.
Do Religious Physicians Disproportionately Care for the Underserved?
Farr A. Curlin, MD, and colleagues
Background Many religions encourage their members to care for people who are poor and marginalized. This study looks at religious characteristics and a sense of calling among doctors. In particular, it examines whether doctors who are more religious, and/or who view their practice of medicine as a calling, are also more likely to care for underserved patients.
What This Study Found Doctors who report that they practice among the underserved describe themselves as highly spiritual. Their religious beliefs tend to influence their practice of medicine, and they tend to come from families that emphasize serving the poor. Doctors who are more religious in general are more likely to view the practice of medicine as a calling but not more likely to practice among the underserved.
Implications
- Doctors who are more religious do not care for the underserved more than other doctors. Those who report being highly spiritual, however, are more likely to report practice among the underserved.
- The authors call for ongoing research over the course of doctors� medical training to determine how their religious and spiritual commitments, sense of calling, and other factors lead some, but not others, to practice among the underserved.
Specialty Referral Completion Among Patients: Results from the ASPN Referral Study
Christopher B. Forrest, MD, PhD, and colleagues
Background When primary care doctors refer patients to specialists, they may not be aware of whether the visit takes place. This lack of information could result in patients receiving duplicate medical services or not receiving needed services at all. This study set out to understand more about referrals of patients to specialists from the viewpoints of both patients and doctors.
What This Study Found About 8 in 10 patients visit a specialist within 3 months of being referred by their primary care doctor. The most common reasons for not visiting the specialist are lack of time, a belief that the health problem has resolved, or disagreement with the doctor about the need for a specialist. Patients in Medicaid plans are less likely than others to visit the specialist and more likely to have the referral denied by their health plan. Patients who have a longer relationship with the primary care doctor and those whose appointment is scheduled by the primary care doctor�s office are more likely to visit the specialist.
Implications
- Primary care offices can encourage referred patients to visit specialists by helping to schedule the appointment and promoting an ongoing relationship between the patient and the primary care doctor.
Five Careers and Eight Airplanes: An Oral History of John Geyman, MD
John J. Frey, MD
Background This essay and oral history provide insights into the life of John Geyman, MD, one of the founders of family practice in the United States. In addition to being a rural family physician, he was one of the first residency directors in family medicine and the first editor of the discipline�s first academic journal. His career demonstrates a commitment to the work of clinical practice, a sense of responsibility for strengthening clinical education, a belief that clinical care should be based on science and delivered within a rational system of health care, and a love of flying. Dr. Geyman exemplifies the generation of general practitioners who started family medicine but who kept a personal understanding of both the complex nature of independent practice and a reliance on community.