Clinical training of psychologists in family practice settings: an examination of special issues

This article considers issues of education and preparation relevant to psychology trainees in departments of family medicine. Special issues unique to training in a medical setting, such as confusion about professional identity and divergence in world views, are discussed. This article also addresses a range of relational issues, including trainee relationships with residents, patients, and attending physicians. Supervision of the psychology trainee is also considered, eg, teaching, counseling, and advocacy supervisor roles. This article concludes with specific suggestions and guidelines for future training of psychologists in family medicine settings.     

The effects of 18 alpha,beta-glycyrrhetinic acid on the hormonal induction of tyrosine aminotransferase in rat primary cultured hepatocytes

Complementary medicine (CM) is popular with patients but physicians do not feel at ease with this situation and some fear that the patient might be the loser. Their fear is based on the perception that some CM practitioners have dubious qualifications and competence and that too little is known about the efficacy and safety of many complementary therapies. It follows that, in the interest of the patient and all other parties involved, we urgently need more and better research to fill the void. Integration of complementary medicine into mainstream care requires a minimum of essential evidence. As in all areas of medicine, there can be no short cut to rigorous research.     

The effects of malpractice on Mississippi physicians

Medical malpractice and its effects on physicians in Mississippi is reviewed to assess its effects upon decisions in practice, patient care, and the physical and emotional toll on physicians. Through a random survey of 500 physicians in Mississippi across all areas of medicine it was determined that 47.3% of the respondents had been involved in malpractice litigation, a higher percentage than the United States average in 1989. The predominant emotional response to litigation was anger. Most physicians did not seek outside help as an aid in coping.     

The disintegration of superEBA cement in solutions with adjusted pH and osmolarity

OBJECTIVE: To determine how physicians respond to a request for an expensive, unindicated test. DESIGN: Cross-sectional observational study. SETTING: Four sites of a group-model HMO. PARTICIPANTS: Thirty-nine internist volunteers. INTERVENTION: A standardized patient requesting magnetic resonance imaging (MRI) of the head to rule out multiple sclerosis (MS) was inserted unannounced into physicians' regular schedules. The patient's only complaint was fatigue with no neurologic symptoms. MEASUREMENTS AND MAIN RESULTS: Physicians and standardized patients completed assessments after each visit. Thirty-five (90%) of 39 physicians "had no idea" that the patient they saw was the standardized patient, and the remaining four participants (10%) were only "somewhat suspicious." Three (8%) of the physicians agreed to the MRI at the initial visit, and eight (22%) said they might order an MRI in the future. All doctors who refused the MRI told the patient this was based on lack of a medical indication for the test; seven (19%) also cited the test's expense. Twenty physicians (53%) of 38 agreed to a neurology referral. In response to the standardized patient's concerns, nine physicians (23%) verbalized that MS is scary, and four (10%) asked the patient about their friend's experience with MS. A few physicians appeared to dismiss the patient's concerns, such as by telling the patient they were being "paranoid." CONCLUSIONS: Few physicians agreed to a standardized patient's request for a medically unindicated MRI, but more than half agreed to refer this patient to a specialist. As physicians practice cost-conscious medicine, they may need to focus on good communication to maintain patient satisfaction.     

The German health-care system

The German health-care system is characterized by a statutory health insurance based on the principle of social solidarity. Nonprofit sickness funds and regional associations of physicians are the central components of the German system. The historical development of the system for more than 100 years has been characterized by negotiations, rather than confrontation, among physicians, patients, and insurance carriers. With the increasing sophistication of modern medicine, medical expenditure is rising, and great demands are facing the health-care systems of the industrialized world. The hope is that the German system will be able to preserve the principle of solidarity and remain a one-tier health-care system rather than allow health care to be viewed as essentially a private consumption good, in which case availability and quality are allowed to vary with family income. As a means to achieve this goal, the autonomy of the sickness funds and regional associations of physicians will be increased substantially, and the governmental authority will be decreased. Strengthening of autonomy must be accompanied by incentives for self-responsibility and self-participation of Germany's citizens.     

Multiple perceptions of discharge planning in one urban hospital

Since the advent of diagnosis-related groups (DRGs), advocacy groups have claimed that although hospital discharge planners perceive the discharge planning process as helpful, elderly patients and their families do not. This article explores how the discharge planning process was perceived by 40 discharge planners and 40 family caregivers. Planners greatly overrated caregiver influence and the amount adequacy of information shared about posthospital health care, choice of discharge to home or nursing home, and time to decide. Caregivers perceived that nursing homes were forced on patients by social workers and physicians. DRGs, physicians, and hospital administrators appeared to pressure social workers to coerce mentally competent patients into nursing homes. Excessive concern by hospital staff about patient safety after discharge may override patients' rights to autonomy and self-determination, violating the NASW Code of Ethics. Implications for practice, policy, and future research are discussed.     

Utilization of outpatient diagnostic imaging. Does the physician's gender play a role?

OBJECTIVE: To examine physician and patient characteristics related to the ordering of imaging studies in a general medicine practice and to determine whether physician gender influences ordering patterns. DESIGN: Retrospective cohort study. SETTING: Hospital-based academic general medicine practice of 29 attending physicians. PATIENTS: All 8,203 visits by 5,011 patients during a 6-month period. METHODS: For each visit the following variables were abstracted from the electronic patient record: patient age, patient gender, visit urgency, visit type, and physician seen. All diagnostic imaging studies performed within 30 days of each outpatient visit were identified from the hospital's Radiology Information System. Screening mammography was not included in the analysis. Physician variables included gender and years since medical school graduation. Logistic regression analysis was used to evaluate the effect of various patient, physician, and visit characteristics on the probability of a diagnostic imaging study being ordered. RESULTS: Patient age, urgent visits, visit frequency, and the gender of the physician were all significantly related to the ordering of an imaging study. Correcting for all other factors, the ordering of an imaging study during an outpatient medical visit was 40% more likely if the physician was female (odds ratio = 1.40; 95% confidence interval [CI] 1.01, 1.95). Female physicians were 62% more likely (95% CI 0.99, 2.64) than male physicians to order an imaging study for a male patient and 21% more likely (95% CI 0.87, 1.69) to order an imaging study for a female patient. CONCLUSIONS: Physician gender is a predictor of whether an outpatient medical visit generates an imaging study. Reasons for this observation are unclear, but may be the result of different practice styles of male and female physicians or unmeasured patient characteristics.     

Physician practice styles and patient outcomes: differences between family practice and general internal medicine

OBJECTIVES: This study compared patient health status, patient satisfaction, and physician practice style between family practice and internal medicine. METHODS: New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care. Practice styles were characterized by the Davis Observation Code. Self-reported health status (Medical Outcomes Study, Short Form-36) and patient satisfaction also were measured. RESULTS: There were no significantly different changes in self-reported health status or patient satisfaction between family practice and internal medicine physicians during the course of the study. Family practice initial encounters, however, were characterized by a style placing greater relative emphasis on health behavior and counseling, whereas internists used a more technical style. Improved health status scores after treatment were predicted by a practice style emphasis on counseling, whereas improvements in patient satisfaction scores were predicted by a style of care stressing patient activation. Although this is the first known randomized trial studying this issue, the conclusions are limited by a 38% loss of patients from enrollment to care and a loss of 18% at the 1-year follow-up evaluation. CONCLUSIONS: There were significant differences in practice styles between family physicians and internists; however, it was the physician's behavior, not specialty per se, that affected patient outcomes. A practice style emphasizing psychosocial aspects of care was predictive of improvements in patient health status, whereas a practice style emphasizing patient activation was predictive of improvements in patient satisfaction.     

Molecular genetics and control of iron metabolism in hemochromatosis

To determine how physicians might participate in the prevention of nuclear war in the post-Cold War era, we review, from a medical perspective, the history of the nuclear weapons era since Hiroshima and the status of today's nuclear arsenals and dangers. In the 1950s, physicians were active partners in governmental civil defense planning. Since 1962, physicians have stressed prevention of nuclear war as the only effective medical intervention. Public advocacy by physicians helped end both atmospheric nuclear testing in the 1960s and superpower plans for fighting a nuclear war in the 1980s. Today's dangers include nuclear arms proliferation, an increasing risk of nuclear terrorism, and the 35000 warheads that remain in superpower-nuclear arsenals, many still on hair-trigger alert. Physicians have recently joined with military and political leaders and over 1000 citizens' organizations in calling for the complete elimination of nuclear weapons. Global medical collaboration in support of a verifiable and enforceable Nuclear Weapons Convention would be a major contribution to safeguarding health in the 21st century.     

Reperfusion injury delays healing of intestinal anastomosis in a rat

This SAEM position paper clarifies the role of emergency medicine in health care delivery. It builds upon the working definition of emergency medicine developed by the American College of Emergency Physicians in 1994 by describing the health care role of emergency physicians (EPs). EPs are first-contact providers who care for all patients regardless of age, gender, time of presentation, or ability to pay. They remain the only continuously accessible specialty for patients seeking help and solace in the health care system. They are an essential link in the health care continuum between primary care physicians, specialists, the out-of-hospital system, the patient, inpatient services, and communication services. The EP's role is in organizing and monitoring the emergency care delivery system. Part of this role is to better align the health care provider training and ability with the specific medical needs of a patient. The emergency health care system remains the essential medical safety net for all individuals needing care in this country.     

Do estimates of emergency physician workforce underestimate current needs?

STUDY OBJECTIVE: Two widely used formulas for calculating the number of practicing emergency physicians (EPs) are based on the total number of US emergency departments and patient visits. In this study we hypothesized that the number of physicians now working in EDs is significantly greater than the estimates yielded by these formulas. Therefore we attempted to determine the accuracy of these methods for predicting the true number of practicing EPs. We also examined the training, board certification, and distribution of EPs. METHODS: The EDs of all hospitals listed by the Missouri Hospital Association (MHA), excluding children's and psychiatric hospitals, were surveyed over a 9-month period in 1994 with regard to the number and board status of all physicians practicing in their EDs and the numbers of full-time equivalents (FTEs) required for adequate staffing. These numbers were compared with 1994 estimates for Missouri based on two common methods of calculation. RESULTS: Of 134 hospitals with EDs, 118 (88%) completed our survey. These EDs employed 458 full-time EPs and 690 part-time EPs, with 41% and 7% board-certified in emergency medicine, respectively. Board-certified emergency physicians were concentrated in large cities and at university hospitals and were sparsely represented in rural areas. Adequate staffing of these EDs required 677 FTEs, compared with estimates of 358 (formula A) and 555 (formula B). Previously published formulas underestimate the need for EPs in our state by 47% (formula A) or 18% (formula B). CONCLUSION: Current staffing estimates regarding EPs working in Missouri greatly underestimate actual staffing needs. Board-certified EPs are in severe shortage and are unequally distributed in Missouri. Extrapolated nationally, these estimates may negatively affect funding and available residency positions for emergency medicine.     

Institutional influences on the primary cesarean section rate in Utah, 1992 to 1995

OBJECTIVES: Our purpose was to evaluate institutional and organizational influences on cesarean section rates in Utah and to adjust such rates for differences in patient acuity. STUDY DESIGN: Data on cesarean section rates were derived from the Utah Hospital Discharge Database and adjusted for patient acuity by correcting raw cesarean rates for those patients undergoing cesarean section meeting regional gestational age transport criteria. RESULTS: When analyzed by means of 1-way analysis of variance, the following factors had a significant negative correlation (P < .05) with cesarean section rate: presence of a newborn intensive care unit and maternal-fetal medicine subspecialists, presence on the medical staff of obstetrician-gynecologist(s) as opposed to family physicians only, delivery volume >1500/y, urban location, and 24-hour in-house anesthesiology. When cesarean rates were corrected for acuity, facilities with maternal-fetal medicine specialists and a newborn intensive care unit had significantly lower rates (P < .001) and more uniform rates than otherwise similar institutions. CONCLUSIONS: More medically sophisticated physicians and institutions have lower cesarean rates when patient acuity is taken into account.     

Somatic or sympathetic block for reflex sympathetic dystrophy. Which is indicated?

Patients with reflex sympathetic dystrophy (complex regional pain syndromes) are often referred to pain medicine physicians for assistance in providing pain control during rehabilitation of their painful upper extremity. When deciding which pain control technique to use in an individual patient, physicians must consider both somatic and sympathetic blocks. Each of these nerve blocks has advantages and disadvantages that may be tailored to an individual patient's pain state and rehabilitation program to optimize recovery.     

A survey about management of febrile children without source by primary care physicians

BACKGROUND: The management of young children with fever without source is controversial, and differences between physician specialties have been noted previously. The emergence of penicillin-resistant Streptococcus pneumoniae, the sharp decline in invasive Haemophilus influenzae infections in immunized populations and publication of practice guidelines have potentially altered physician practices. OBJECTIVE: To determine the present practice preferences of pediatricians, family medicine physicians (FP) and emergency medicine physicians (EP). METHODS: We mailed a checklist survey to 1600 randomly selected pediatricians, family medicine practitioners (FP) and emergency medicine physicians (EP) in the United States and replicated the methodology of a 1991/1992 survey. Physicians were asked about their evaluation and management of children of various ages (3 weeks, 7 weeks, 4 months and 16 months) with fever without source. RESULTS: Most primary care physicians would admit the 3- and 7-week-old infants. For the 4-month-old infant 59% of EP, 45% of pediatricians and 28% of FP would give empiric antibiotic(s) as an outpatient (P=0.005 for FP compared with pediatricians and P=0.02 for EP compared with pediatricians). The majority of physicians would manage the 16-month-old child as an outpatient without antibiotic therapy. Ceftriaxone was the preferred antibiotic for outpatient empiric therapy. There was a 3-fold increase (28% vs. 9%) for pediatricians in the use of empiric outpatient antibiotics for the 7-week-old infant in the present survey compared with the 1991/1992 survey. CONCLUSIONS: Physicians in the United States generally agree in their management of the young febrile infant, but with increasing patient age there is considerable variation. FP were the least aggressive in their evaluation and EP were the most aggressive.     

Reversal of liver failure in sickle cell vaso-occlusive crisis

Issues concerning patient advocacy and nursing advocacy are explored in relation to the nurse's role and the UKCC code of conduct. The author's personal experiences of being an advocate are described. Potential conflict between the nurse's role and doctor's role in relation to advocacy is identified. The best person to take on the role of patient advocate is discussed.     

Family medicine in Minnesota: office costs and productivity

Clinics representing more than half of Minnesota's family physicians participated in a statewide study on the practice of family medicine conducted by the Minnesota Academy of Family Physicians. The survey was designed to provide direction for individual physicians, administrators, and the Minnesota Academy of Family Physicians as an organization. The survey identified some concerns regarding access to care. In the central portion of the state, 71% of the full-time equivalent family physicians were in practices with Medicaid patient restrictions. In the most sparsely populated towns, 35% of the reporting family physicians who provided obstetrical care three years ago discontinued that service due to the cost or availability of professional liability coverage. Statewide in 1989, 57% of the family physician positions recruited for by the practices studies were unfilled at year's end, with 82% unfilled in the most sparsely populated areas.     

Physicians' prevention-related practice behaviors in treating adult patients with asthma: results of a national survey

To improve the health outcome of adults with asthma, it is important to understand the current practice behaviors of physicians related to the prevention and treatment of asthma. A national survey was conducted to ascertain the practice behaviors of physicians in five specialty areas: internal medicine, pulmonary, allergy/immunology, occupational health, and family health. Similarities and differences in practice among the specialty areas are indicated. The data provide a basis for recommendations to improve the management of asthma by standardizing history taking, increasing the use of pulmonary function testing, and using effective counseling and patient education strategies.