Keith A. Frey

Patients' Perspectives on Ideal Physician Behaviors

We incorporated the views of patients to develop a comprehensive set of ideal physician behaviors. Telephone interviews were conducted in 2001 and 2002 with a random sample of 192 patients who were seen in 14 different medical specialties of Mayo Clinic in Scottsdale, Ariz, and Mayo Clinic in Rochester, Minn. Interviews focused on the physician-patient relationship and lasted between 20 and 50 minutes. Patients were asked to describe their best and worst experiences with a physician in the Mayo Clinic system and to give specifics of the encounter. The interviewers independently generated and validated 7 ideal behavioral themes that emerged from the interview transcripts. The ideal physician is confident, empathetic, humane, personal, forthright, respectful, and thorough. Ways that physicians can incorporate clues to the 7 ideal physician behaviors to create positive relationships with patients are suggested.

Preconception Healthcare: What Women Know and Believe

Objectives: The objectives of this study were to determine if women realize the importance of optimizing their health prior to a pregnancy, whether the pregnancy is planned or not; and to evaluate their knowledge level and beliefs about preconception healthcare. Additionally, we sought to understand how and when women wanted to receive information on preconception health. Methods: A survey study was performed using consecutive patients presenting to primary care practices for an annual well-woman exam. Patients were recruited based on appointment type and willingness to complete the survey at the time of their appointment, but prior to being seen by the physician. Results: A total of 499 women completed the survey. Nearly all women (98.6%) realized the importance of optimizing their health prior to a pregnancy, and realized the best time to receive information about preconception health is before conception. The vast majority of patients surveyed (95.3%) preferred to receive information about preconception health from their primary care physician. Only 39% of women could recall their physician ever discussing this topic. The population studied revealed some significant knowledge deficiencies about factors that may threaten the health of mother or fetus. Conclusions: A majority of women do understand the importance of optimizing their health prior to conception, and look to their Primary care physician as their preferred source for such information. Study participants demonstrated deficiencies in their knowledge of risk factors that impact maternal and fetal health suggesting that physicians are not addressing preconception healthcare during routine care.

The clinical content of preconception care: preconception care for men.

Little attention has been given to mens preconception health and health care. This paper reviews the key elements of an approach to optimizing the preconception health status of men. Preconception care for men is important for improving family planning and pregnancy outcomes, enhancing the reproductive health and health behaviors of their female partners, and preparing men for fatherhood. Most importantly, preconception care offers an opportunity, similar to the opportunity it presents for women, for disease prevention and health promotion in men. Currently, no consensus exists on service delivery of preconception care for men--who should provide preconception care to whom, where, when, and how, and there are significant barriers to this care including the organization, financing, training, and demand. Finally, much more research on the content and how to effectively market and implement preconception care for men is needed.

The 'Collaborative Care' curriculum: an educational model addressing key ACGME core competencies in primary care residency training.

Aim  The ‘Collaborative Care’ curriculum is a 12‐month senior resident class project in which one evidence‐based clinical guideline is designed, implemented and evaluated in our residency practice. This curriculum specifically addresses three of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies: Practice‐Based Learning and Improvement, Interpersonal and Communication Skills and System‐Based Practices. Additionally, the project enhances the quality of patient care within the model family practice centre in a family practice residency.

Knowledge and attitudes regarding preconception care in a predominantly low-income Mexican American population

OBJECTIVE The objective of the study was to determine knowledge and attitudes regarding preconception care in a low-income Mexican American population. STUDY DESIGN This was a cross-sectional survey of 305 reproductive-age women at an urban public hospital. RESULTS The sample was mostly Hispanic (88%) and pregnant (68%); 35% had not completed high school. Eighty-nine percent agreed that improving preconception health benefits pregnancy. Seventy-seven percent expressed some interest in preconception health care with the obstetrics gynecology office at the preferred location. The average knowledge of preconception care score was 76% (higher score more favorable). Areas of higher knowledge included the effects on pregnancy of folic acid; alcohol use; substance use; and verbal, physical, and sexual abuse; lower knowledge was found for the effects of cat litter and fish products. CONCLUSION There was interest in preconception education and agreement that preconception health has a positive effect on pregnancy. Fewer respondents agreed that it had a good effect than a suburban sample in the same region (89% vs 98%).

Initial Evaluation and Management of Infertility by the Primary Care Physician

Infertility is a common condition seen in primary care practices. Infertility is defined as 1 year of unprotected intercourse during which a pregnancy is not achieved. in the United States, 15% to 20% of all couples are infertile, with higher rates seen in older couples. The causes of infertility include abnormalities of any portion of the male or female reproductive system. The female partner usually presents initially for an infertilty problem, often in the context of an annual well-women examination. The primary care physician who provides such preventive care can initiate the diagnostic evaluation and can treat some causes of infertility.

Tricyclic Antidepressant Use and Risk of Fractures: a Meta-Analysis of Cohort and Case-Control Studies

Because studies of the association between tricyclic antidepressant (TCA) treatment and risk of fracture have shown inconsistent findings, we sought to assess whether people who take TCAs are at increased risk of fracture. Relevant studies published by June 2012 were identified through database searches of Scopus, MEDLINE, EMBASE, PsycINFO, ISI Web of Science, and WorldCat Dissertations and Theses from their inception, and manual searching of reference lists. Only original studies that examined the association between TCA treatment and risk of fracture were included. Two investigators independently conducted literature searches, study selection, study appraisal, and data abstraction using a standardized protocol. Disagreements were resolved by consensus. Twelve studies met inclusion criteria. Because of the heterogeneity of these studies, random‐effects models were used to pool estimates of effect. Overall, TCA use was associated with significantly increased fracture risk (relative risk [RR], 1.45; 95% confidence interval [CI], 1.31–1.60; p < 0.001). Increased fracture risk associated with TCA use was also observed in studies that adjusted for bone mineral density (RR, 1.54; 95% CI, 1.24–1.90; p < 0.001) or depression (RR, 1.49; 95% CI, 1.28–1.67; p < 0.001). Strength of association with TCA exposure duration ≥6 weeks (RR, 1.13; 95% CI, 1.00–1.28) was substantially weaker than association with TCA exposure duration <6 weeks (RR, 2.40; 95% CI, 1.41–4.08). Prior TCA exposure had no significant effect on fracture risk (RR, 1.04; 95% CI, 0.86–1.26; p = 0.70). After accounting for publication bias, we found the overall association between TCA use and fracture risk to be slightly weaker (RR, 1.36; 95% CI, 1.24–1.50) but still significant (p < 0.001). Findings of this meta‐analysis indicate that treatment with TCAs may convey an increased risk of fracture, independent of depression and bone mineral density.

Male reproductive health and infertility.

Primary care physicians have an essential role and opportunity in positively impacting the reproductive health of men. Although men are less likely than women to consistently seek preventive services, an office visit for any reason should be seen as an opportunity to introduce the idea of reproductive health. Additionally, primary care physicians can and should initiate the diagnostic workup for infertile couples in their practices. The initial assessment for the male partner consists of a thorough history and physical examination and appropriate laboratory tests, including a semen analysis.

The Well-Man Visit: Addressing a Man's Health to Optimize Pregnancy Outcomes

Male health and health care before conception has received little attention by many physicians. Only recently has the importance of the health of men before conception been explored. The benefits of preconception care are important, including ensuring that all pregnancies are planned and wanted, improving the mans genetic and biologic contributions to the pregnancy, improving reproductive health and outcomes for female partners, improving the mans capacity for and understanding of parenthood, and enhancing the mans overall health through access to primary care.

The Patient-Centered Medical Home and Preconception Care: An Opportunity for Internists

The patient-centered medical home is defined by the American College of Physicians as a comprehensive approach for delivering medical care to patients. Internists have the role of caring for patients from adolescence through adulthood and have the opportunity to deliver preconception care. Preconception care is the promotion of the health and well-being of a woman and her partner before pregnancy. The goal is to improve pregnancy-related outcomes through interventions that occur before conception and before the patient would ordinarily seek prenatal care. Using the model of the patient-centered medical home, internists can provide comprehensive preconception care to improve the health of women before pregnancy and thus to decrease the risk of adverse pregnancy outcomes.