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Table of Contents

March 01, 2009; Volume 7,Issue 2

The Issue in Brief

Ann Fam Med 7: 0.

Ambulatory Care Provided by Office-Based Specialists in the United States

Jose M. Valderas , and colleagues

Background There are conflicting opinions about whether the United States needs more medical specialists. To help inform the debate, this study describes the nature and content of specialist care provided in community settings.

What This Study Found One-half of visits to specialists were for routine and preventive care for patients already known to the doctor, and most of these visits resulted in a follow-up appointment. Less than one-third of all specialty care visits were the result of a referral from another health care professional.

Implications

  • Many services provided by specialists could be managed in primary care settings. This would reduce demand for specialists and improve coordination of care.
  • Having the primary care doctor do follow-up care would be more efficient and would allow specialists to focus on those aspects of care which demand their unique skills.

Influence of Watchful Waiting on Satisfaction and Anxiety Among Patients Seeking Care for Unexplained Complaints

Marloes A. van Bokhoven , and colleagues

Background Blood tests are often ordered for patients with unexplained symptoms. Although such tests may not provide a diagnosis, many doctors feel they will reassure patients. The purpose of this study is to determine whether immediate ordering of tests, compared with watchful waiting (in which the doctor observes the patient's condition but doesn't take immediate action), influences patient satisfaction with the doctor visit and anxiety after the visit.

What This Study Found Among patients with unexplained symptoms, ordering blood tests does not increase satisfaction with the visit or lower their anxiety. Instead, patients value specific aspects of physician-patient communication, such as feeling that they are taken seriously, discussing testing with the doctor, and understanding the seriousness of their complaints.

Implications

  • Primary care doctors may overestimate the importance of additional testing in patients with unexplained complaints and underestimate how much they themselves can contribute to their patients� well-being by discussing their worries.

Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences

Ruth McDonald and colleagues

Background In order to improve health care quality, payers are increasingly using financial incentives to reward doctors and medical groups that meet specific performance targets. This study examines the effects of financial incentives in England and California to understand how differences between the programs influence their impact in primary care settings.

What This Study Found Both programs had unintended consequences, but these differed between the programs. English doctors were more likely to report that the incentive program, which has more performance measures and more use of computerized reminders, changed the nature of the office visit. California doctors were more likely to express resentment about pay for performance and appeared less motivated to act on financial incentives, even in the program with the highest rewards.

Implications

  • Unintended consequences of incentive programs relate to the way in which these programs are designed and implemented.
  • Although unintended, these consequences are not necessarily unpredictable.
  • When designing incentive plans, more attention needs to be paid to factors that could produce unintended consequences.

Declining Trends in the Provision of Prenatal Care Visits by Family Physicians

Donna Cohen and colleagues

Background Family physicians make an important contribution to maternity care, particularly in rural areas. The number of family physicians providing maternity care declined in the 1980s and 1990s, but there have been no recent studies showing whether and how these numbers have changed. This study measures the proportion of prenatal visits to family physicians between 1995 and 2004, and the characteristics of prenatal visits to family doctors as compared with those to obstetricians.

What This Study Found Over a 10-year period, the proportion of prenatal visits to family physicians in the United Sates declined nearly 50%. Using data representing more than 244 million prenatal visits, researchers document a decrease in percentage of prenatal visits to family physicians from 11.6% to 6.1%. Family physicians are more likely than obstetricians to provide prenatal visits to women who are younger, live in rural areas, or have Medicaid insurance.

Implications

  • Rural and medically underserved areas have experienced significant declines in maternity care by family physicians. This could affect women�s access to prenatal care in communities throughout the United States.
  • As family physicians provide less maternity care, it may be difficult to support family medicine-based curriculum, recruit faculty members, identify community role models, or develop sustainable models for residency graduates to include maternity care in their practices, leading to further declines in accessible prenatal care providers.

How Often Do Physicians Address Other Medical Problems While Providing Prenatal Care?

Andrew Coco

Background Family physicians often address multiple problems during patient visits. This study compares the extent to which family physicians and obstetricians diagnose other medical problems while providing prenatal care.

What This Study Found Family physicians diagnosed other medical problems not related to the pregnancy during 18% of prenatal visits, compared with 8% for obstetricians. Family physicians served as both primary care doctor and prenatal care provider during 92% of maternity care visits; fewer than 27% of obstetricians served as their maternity patients' primary care doctor.

Implications

  • Prenatal care by family physicians can benefit women by receiving care for multiple health problems in a single visit.
  • A decline in prenatal care by family physicians could affect access to nonobstetrical services for pregnant women.

'They Don't Ask Me So I Don't Tell Them': Patient-Clinician Communication About Traditional, Complementary, and Alternative Medicine

Brian M. Shelley and colleagues

Background Although the use of traditional, complementary, and alternative medicine (TM/CAM) is widespread, clinicians and patients often don't discuss patients' TM/CAM use. This study explores factors that encourage or discourage communication between clinicians and patients about TM/CAM.

What This Study Found Three main themes help determine whether and how patients and clinicians communicate about TM/CAM: acceptance/nonjudgment, initiation of communication, and safety/efficacy concerns. Most patients who use TM/CAM expect the clinician to initiate discussion of it. It is easier for patients to discuss TM/CAM if the clinician initiates the discussion in a nonjudgmental, accepting way. Discussion is limited by clinicians' belief that there is little TM/CAM use among their patients, lack of understanding about TM/CAM, and limited time in the patient visit. Many clinicians are skeptical about TM/CAM safety and effectiveness.

Implications

  • Clinicians should initiate discussion of TM/CAM with their patients, but they do not have to be experts in TM/CAM therapies. Instead, they should demonstrate interest, nonjudgment, and honesty about their limited knowledge.
  • The study findings provide the foundation for a model of improved patient-clinician communication about TM/CAM. Future research should look at how implementing such a model will affect patient care, satisfaction, and trust, and how clinicians can better integrate the different types of care their patients utilize.

Is Personality a Key Predictor of Missing Study Data? An Analysis From a Randomized Controlled Trial

Anthony Jerant and colleagues

Background In clinical research studies, psychological factors may affect decisions by study participants to drop out of the study, keep data collection appointments, and/or complete items on a questionnaire, but these factors are rarely measured. This study examines the relationship between personality factors and missing data in a randomized controlled trial.

What This Study Found Personality traits help predict missing study data in this randomized controlled trial. Missing data were less likely among participants with higher levels of openness, conscientiousness, and agreeableness.

Implications

  • Personality-related missing data may affect the results of some randomized controlled trials.
  • Assessing personality could be useful in maximizing the completion of data in research studies and in accounting for bias due to missing data in the data analyses.

The Effects of Barley-Derived Soluble Fiber on Serum Lipids

Craig I. Coleman and colleagues

Background Oats, which are high in dietary soluble fibers called beta-glucan, have been shown to lower cholesterol levels. There have been fewer studies of the effects of barley on cholesterol, although barley also contains beta-glucan. This study examines previous research on barley to understand its effects on cholesterol.

What This Study Found Eating barley significantly reduces total cholesterol and triglycerides (the chemical form of fat).

Implications

  • The results of this study support the routine use of soluble fibers in the diets of adult patients both with and without high cholesterol. Barley adds source of soluble fibers, in addition to oats, which can be eaten as part of a healthy, balanced diet.

How Can Primary Care Cross the Quality Chasm? A Report From the NAPCRG Committee on Advancing the Science of Family Medicine

Leif I. Solberg and colleagues

Background To bridge the gap between knowledge and practice in primary care, primary care leaders and clinicians must make changes in concepts, attitudes, and practical issues. These changes include admitting that there are quality problems in primary care that require attention and action; a focus on "optimizing health and health care through research and quality improvement (QI)," instead of "translating research into practice"; developing more partnerships among clinicians, researchers, and care delivery leaders for "engaged scholarship" in research and QI; an emphasis by funders and researchers on the problems of patients and support of practical time frames and research designs; and dissemination and implementation of lessons from QI and practical research.

Suffering, Meaning, and Healing: Challenges of Contemporary Medicine

Thomas R. Egnew

Background As a result of changes in contemporary society, doctors are expected to both cure disease and help patients transcend suffering: to be physician-healers. Physician-healers use the power of the doctor-patient relationship to help patients reconnect to the world beyond illness, find meaning in their illness experience, particularly through their own stories, and cope with the impersonality of technology. A health care delivery system focused on holistic healing would promote accessible, ongoing care; home visits; equitable reimbursement for clinicians to spend time with (rather than doing things to) patients; and equal funding for mental health issues. In addition to better serving the chronically ill, developing the role of physician-healer may help stem the tide of physician burnout and restore a sense of awe and mystery to medicine by reinstating the personal power of the physician as a therapeutic agent.

One Last Question: Opening Pandora's Box?

Janet M. Townsend

Background In their busy practice lives, doctors may concentrate too much on efficiency in conducting visits and completing tasks for patients. This essay tells the story of two patient visits in which an experienced family physician almost missed her patients' deep fears. Asking one last question allowed these patients to reveal their concerns. Doctors worry that asking a last question will "open Pandora's box," but such questions can lead to insights into the patient's world that help share worry and isolation, or mobilize support from family and friends. Connecting to patients through simple personal questions connects them to hope. By opening Pandora's box, doctors make room for listening, reflection, and healing.

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