Julia E. Connelly

The prevalence of mental disorders in rural office practice.

AbstractOBJECTIVE: To determine the prevalence of mental disorders in rural primary care office practice. DESIGN: Patient interview; chart review. SETTING: Two rural primary care office practices. PATIENTS: Three hundred-fifty scheduled or walk-in patients age 18 years or older. MEASUREMENTS: Medical Outcomes Study 36-Item Short-Form Health Survey (MOS SF-36), the Primary Care Evaluation of Mental Disorders (PRIME-MD), physical health using Greenfield’s index of coexistent disease (ICED), and health care utilization using the number of office visits and total office and laboratory charges six months before until six months after the interview. RESULTS: Of these patients 34% met criteria for one or more of the 18 mental disorders evaluated by the PRIME-MD; 19% met criteria for specific disorders according to criteria from theDiagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R). Mood disorders were most common (21.7%), followed by anxiety disorders (12.3%), somatoform disorders (11.1%), probable alcohol abuse or dependence (6.0%), and eating disorders (2.0%). By logistic regression, there was an association of age, sex, race (black), and education with lower prevalence of various mental disorder categories. Even after adjustment for demographic variables and physical health (ICED score), those with PRIME-MD diagnoses had significantly lower function as measured by the eight MOS SF-36 scales and higher utilization of office services (p<.001). CONCLUSIONS: The prevalence of mental disorders in rural primary care office practice is as high as in urban office practice.

Healthy patients who perceive poor health and their use of primary care services

Objective:To determine what proportion of patients who have poor health perceptions are physically healthy and to explore why some patients perceive a healthy state while others perceive illness.Design:A prospective consecutive series of office patients completed the Rand Corporation’s General Health Perceptions Questionnaire, and their physicians rated their physical health. Their use of health care services was determined for the following 12 months.Setting:A rural teaching office practice.Patients:Of 243 adult patients asked to complete the questionnaire, 32 were excluded, for dementia (8), illiteracy (4), illness (8), incomplete questionnaires (6), and other reasons (6). 208 patients (86%) formed the final study group.Measurements and main results:62 of 208 patients had poor health perception scores. 39 of the 62 were rated by physicians as physically healthy and were not statistically different in physical health ratings or numbers of prescribed medications from the 146 patients who had higher health perception scores. However, these 39 patients had significantly more health-related worry, acute pain, and depression than did the other 146 patients. They also made more office visits and telephone calls and had higher total primary care charges.Conclusions:This study suggests that 21% of adult primary care patients (39 of 208) have health perceptions lower than expected for their levels of physical health. These low health perceptions are correlated with increased emotional distress and higher utilization of health care resources. Strategies to identify these patients and interventions to improve their views of their health could reduce utilization.

The Medical School's Mission and the Population's Health

Abstract ▪ A conference organized by the Royal Society of Medicine Foundation was attended by 37 participants from Canada, the United Kingdom, the United States, and Australia. The discussants revi...

Home visits in a rural office practice : clinical spectrum and effect on utilization of health care services

Objective:To describe the clinical features of home visits and their role in continuity of care, costs, and benefits in a rural office practice.Design:Prospective study of all home visits performed during a 26-month period.Setting:A general medicine teaching office practice located in rural Virginia.Patients:All persons to whom home visits were made during the study period.Main results:138 home visits were made to 47 patients who had a mean age of 73.2 years. Home visits accounted for 1.4% of patient encounters in the practice, required a mean of 7.1 miles of one-way travel and a mean of 48 minutes, including travel time, to complete, and generated

The Avoidance of Human Suffering

36 in income per visit. Most patients (27 of 47) were not permanently homebound. Reasons for patients’ being homebound were grouped into six categories (acute illness, frail elderly, terminal illness, advanced chronic disease, neurologic problem, and miscellaneous reasons). The reasons for visits were grouped into four categories (acute self-limited illness, exacerbation of chronic disease, routine follow-up of chronic disease, and psychosocial problem). Physicians judged that 80% of home visits represented appropriate use of their services. In addition, 46% of home visits made an emergency room visit unnecessary, and 9% made a hospital admission unnecessary. At the time of 75% of home visits, physicians reported personal benefits of making the visit.Conclusions:Home visits have an important role in the care of ambulatory as well as permanently homebound patients. While physicians judged most home visits to be appropriate and personally beneficial, these visits required more time and generated less revenue than did office visits for comparable problems. Because home visits generated as well as prevented the use of medical services, their impact on the overall cost of medical care in this setting is unclear.

Restoring Balance to Internal Medicine Training: The Case for the Teaching Office Practice

Suffering is frequent among patients, and it is common for physicians to attempt to avoid contact with individuals who are dying, debilitated, or in pain. Both patients and physicians are harmed when this happens: patients feel abandoned, resulting in unnecessary suffering, and physicians miss moments of meaning and renewal through direct connection. Ernest Gaines’s novel A Lesson Before Dying is not a medical story, yet one character, Grant Wiggins, behaves like a physician when he tries to avoid direct, personal contact with Miss Emma, a community member who is suffering. This novel illuminates the tendency of human beings (including physicians) to try to avoid suffering, and the realization of this tendency can provide opportunities for ongoing medical education to help students, residents, and faculty members recognize their discomfort about suffering and learn to address it appropriately.

The reasons patients request “checkups”

Medical residents require an experience beyond the tertiary care hospital to understand many aspects of contemporary medical practice and to make informed career choices. To provide this balanced training, the University of Virginia has operated for 10 years an internal medicine teaching office practice to provide an outpatient experience similar to private practice. It allows residents to work closely with general internal medicine faculty and introduces them to the knowledge and skills necessary to establish and manage a successful practice. The curriculum of the 10 week rotation includes patient care in the office and by telephone, nursing home and home visits, tutorials and seminars on primary care and office management topics, and training in the use of microcomputers. A survey of 46 (92%) of the first 50 residents completing the rotation revealed that the content of the rotation was valuable, the rotation substantially influenced career choices, and the rotation helped provide a balanced view of internal medicine practice.

Redefining the Mission of the Medical School

When patients request checkups, physicians may assume it is for detection of asymptomatic disease. However, such patients may have other, covert reasons for seeking medical care which might not be addressed by a periodic health examination. The authors interviewed 38 consecutive patients who requested a new appointment at an academic, hospital-based general medical practice, and said the appointment was for a checkup and not an acute problem. Health screening was the principal reason for requesting evaluation of only 24% of patients. Fifty-two per cent had two or more reasons: psychosocial problems, health concerns, or symptoms. Psychosocial problems, with and without other problems, were the reason 45% of patients requested checkups. Physicians should be alert to the various reasons why patients request checkups, and not assume that a periodic health examination alone is an appropriate response.

Paternalism and the Physician's Conscience

Organizational and institutional turbulence and shrinking academic budgets are buffeting medical schools in both industrialized and developing countries. Current political and public scrutiny is focused on escalating health care expenditures and on the large unexplained variations within and among countries in the rates for use of services and the appropriateness of many interventions.

Literature and Medicine: Contributions to Clinical Practice

Excerpt To the editor: I read Dr. Thomasmas article (1) with skepticism. All models for the doctor-patient relationship are shortsighted as they do not acknowledge systems of relationships beyond ...